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11  y  , 

THE 


DISEASES  OF  INFANCY 
AND   CHILDHOOD 


FOR   THE    USE   OF   STUDENTS 
AND    PRACTITIONERS   OF   MEDICINE 


BY 

L.    EMMETT   HOLT,  M.  D.,  LL  D. 

PROFESSOR  OF  DISEASES  OF  CHILDREN  IN  THE  COLLEGE  OF  PHYSICIANS  AND  SURGEONS 
(COLUMBIA  university),   NEW  YORK  ;    ATTENDING  PHYSICIAN  TO  THE  BABIES' 
AND  FOUNDLING  HOSPITALS,   NEW  YORK  ;    CONSULTING  PHYSICIAN  TO 
THE   NEW    YORK    INFANT    ASYLUM,   LYING-IN    HOSPITAL,   ORTHO- 
PEDIC,  AND  HOSPITAL  FOR  THE  RUPTURED  AND  CRIPPLED 


WITH  TWO  HUNDRED  AND   TWENTY-FIVE  ILLUSTRATIONS 
INCLUDING  NINE  COLOURED  PLATES 


SECOND  EDITION 
REVISED  AND  ENLARGED 


NEW    YORK 

D.    APPLETON    AND    COMPANY 

I  902 


Copyright,  1897.   1902 
Bv  D.   APPLETON  AND   COMPANY 


Published  August,  1902 


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TO 
VIRGIL   P.    GIBNEY,   M.  D.,   LL.  D., 

CLINICAL   PROFESSOR   OF   ORTHOPEDIC    SURGERY   IX   THE   COLLEGE   OF    PHYSICIAXS 

AND   SURGEONS   (COLUMBIA   UNIVERSITY),   NEW   YORK  ;   SURGEON-IN-CHIEF 

TO    THE    HOSPITAL    FOR    THE    RUPTURED    AND    CRIPPLED, 

THIS  VOLUME   IS  INSCRIBED 

AS   A   TRIBUTE   TO   HIS   PERSONAL   WORTH   AND   HIGH    PROFESSIONAL   ATTAINMENTS, 
AND   IN   GRATEFUL    REMEMBRANCE   OF   MANY   ACTS   OF   KINDNESS, 

BY  THE   AUTHOR. 


PEEFACE   TO   THE   SECOND   EDITION. 


The  rapid  advances  of  medicine  have  rendered  necessary  a  general 
revision  of  this  work,  which  has  been  carried  out  without  any  impor- 
tant change  in  the  general  arrangement.  Nearly  every  chapter  has 
been  subjected  to  careful  revision  and  many  of  the  chapters  have  been 
rewritten.  As  in  the  former  edition,  the  aim  has  been  to  supply  the 
every-day  needs  of  the  physician  who  practises  among  children  and 
the  student  who  expects  to  do  so.  If  rather  more  space  than  usual  has 
been  given  to  pathology  and  the  description  of  lesions,  it  is  because 
such  knowledge  is  essential  to  a  proper  understanding  of  symptoms 
and  diagnosis.  Realizing  from  his  own  experience  the  great  value  of 
post-mortem  observations  in  connection  with  clinical  work,  the  author 
has  introduced  rather  freely  drawings  and  photographs  of  pathological 
conditions,  with  the  thought  that  they  may,  in  some  measure,  supply 
the  lack  of  these  to  the  student. 

The  charts,  diagrams,  and  tables  inserted  will,  it  is  hoped,  con- 
tribute materially  to  the  clearness  and  vividness  of  the  clinical  de- 
scriptions. 

The  purpose  has  been  not  to  include  a  discussion  of  topics  which 
are  fully  treated  in  text-books  upon  general  medicine  nor  to  deal  with 
surgical  topics  more  than  in  their  medical  aspects. 

Upon  no  subject  has  our  knowledge  increased  so  much  of  late  as 
that  of  milk  and  infant  feeding.  These  chapters  have  been  entirely 
rewritten  and  much  new  material  added.  The  introduction  of  illus- 
trative weight  charts  will,  it  is  believed,  add  to  the  clearness  of  the 
discussion  of  this  subject. 

Nearly  all  the  illustrations  in  the  l)ook  are  from  original  sources; 
where  they  have  been  borrowed,  due  credit  has  been  given.    A  number 


vi  PREFACE  TO  THE  SECOND   EDITION. 

of  the  old  ones  have  been  replaced  by  new  ones,  and  in  all  twenty-one 
additional  illustrations  have  been  introduced. 

The  author  is  much  indebted  for  valuable  assistance  in  this  edition 
to  his  associates,  Dr.  L.  E.  La  Fetra  and  Dr.  John  Howland,  to  Dr. 
Louise  Cordes  for  suggestions  relating  to  the  chapters  upon  tbe  blood, 
to  Dr.  Martha  Wollstein  for  the  arrangement  of  much  pathological  ma- 
terial from  the  records  of  the  Babies'  Hospital,  and  to  his  brother.  Dr. 
N.  Curtice  Holt,  for  the  revision  of  the  proof  sheets  of  the  entire  book. 

14  West  Fifty-fifth  Street, 
New  York. 


TABLE   OF  CONTENTS. 


PAET  I. 


1. — Hygiene  and  General  Care  of  Infants  and  Young  Children  .  .  1 
Care  of  the  newly-born  child;  bathing;  clothing;  care  of  the  eyes;  care  of 
the  mouth  and  teeth ;  care  of  the  skin ;  care  of  the  genital  organs ;  vaccina- 
tion ;  training  to  proper  control  of  rectum  and  bladder ;  general  hygiene  of 
the  nervous  system ;  sleep ;  exercise ;  airing :  the  nursery ;  the  nurse ;  the 
amount  of  air  space  required  by  infants ;  the  care  of  premature  and  delicate 
infants ;  incubators  ;  the  feeding  of  the  premature  infant. 

11. — Growth  and  Development  of  the  Body .15 

Weight;  height;  growth  of  extremities  as  compared  with  the  trunk;  the 
head ;  the  chest ;  the  abdomen ;  muscular  development ;  development  of  spe- 
cial senses  ;  speech  ;  dentition. 

III. — Peculiarities  of  Disease  in  Children     ....  .        .      30 

Etiology ;  symptomatology  and  diagnosis ;  pathology ;  prognosis  and  infant 
mortality ;  prophylaxis  ;  therapeutics. 

PAET  II. 

Section  I. — Diseases  of  the  Newly-Born. 
I. — Asphyxia 67 

II. — Congenital  Atelectasis .72 

III. — Icterus 75 

IV. — The  Acute  Infectious  Diseases  op  the  Newly-Born    ....      78 
The  acute  pyogenic  diseases ;  ophthaUnia  ;  tetanus ;  epidemic  ha^moglobinuria ; 
fatty  degeneration  of  the  newly- born;  pemphigus. 

V. — Hemorrhages .93 

Traumatic  or  accidental  haemorrhages ;  spontaneous  haemorrhages. 
VI. — Birth  Paralyses 105 

Cerebral  paralysis;  facial  paralysis;  paralysis  of  the  upper  extremity. 
VII. — Tumours  of  the  Umbilicus,  etc. Ill 

Umbilical   hernia;   mastitis;   intestinal   obstruction;    diaphragmatic   hernia; 

sclerema;  cedenia;  inanition  fever. 

Section  II. — Nutrition. 

I. — Introductory 122 

The  food  constituents  and  tlic  puqioses  they  subserve  in  nutrition. 


viii  TABLE   OF   CONTENTS. 

CHAPTER  PAGE 

II. — The  Infant's  Dietary 126 

Woman's  milk;  cow's  milk;  condensed  milk;  kumyss;  matzoon;  junket, 
curds  and  whey ;  beef  preparations ;  cereals ;  infant  food. 

III. — Infant  Feeding 164 

Choice  of  methods ;  breast  feeding  ;  maternal  nursing ;  wet-nursing  ;  weaning ; 
mixed  feeding  ;  artificial  feeding. 

IV. — Feeding  after  the  First  Year 216 

Healthy  infants  during  the  second  year;  difficult  cases  during  the  second 
year;  feeding  from  the  third  to  the  sixth  year:  feeding  during  acute  illness. 

V. — The  Derangements  of  Nutrition 224 

Acute  inanition ;  malnutrition ;  marasmus. 
VI. — Diseases  Due  to  Faulty  Nutrition 242 

Scorbutus ;  rickets. 

Section  III. — Diseases  of  the  Digestive  System. 

I. — Diseases  of  the  Lips,  Tongue,  and  Mouth 272 

Malformations;  diseases  of  the  lips;  diseases  of  the  tongue;  alveolar  abscess; 
difficult  dentition  ;  catarrhal  stomatitis  ;  herpetic  stomatitis ;  ulcerative  stoma- 
titis ;  thrush  ;  gonorrhoeal  stomatitis ;  syphilitic  stomatitis  ;  gangrenous  stoma- 
titis. 

IL — Diseases  of  the  Pharynx 291 

Acute  pliaryngitis ;  uvulitis ;  elongated  uvula;  retro-pharyugeal  abscess; 
adenoid  vegetations  of  the  vault  of  the  pharynx. 

III. — Diseases  of  the  Tonsils 305 

Croupous  tonsillitis;  ulcero-menibranous  tonsillitis;  follicular  tonsillitis; 
phlegmonous  tonsillitis ;  chronic  hypertrophy  of  the  tonsils. 

IV. — Diseases  of  the  (Esophagus 312 

Malformations  ;  acute  oesophagitis  ;  retro-cesophageal  abscess. 

V. — Diseases  of  the  Stomach 316 

Digestion  in  infancy ;  malformations  and  malpositions  of  the  stomach  ;  vomit- 
ing ;  cyclic  vomiting ;  gastralgia ;  acute  gastric  indigestion ;  acute  gastritis ; 
gastro-duodenitis ;  chronic  gastric  indigestion ;  dilatation  of  the  stomach ; 
ulcer  of  the  stomach  ;  tumours  of  the  stomach  ;  haemorrhage  from  the  stomach. 

VI. — Diseases  of  the  Intestines 347 

Malformations  and  malpositions  ;  diarrhoea ;  acute  intestinal  indigestion. 

VII. — Diseases  of  the  Intestines  (contmued) 357 

Acute  gastro-enteric  intoxication  ;  cholera  infantum. 
VIII. — Diseases  of  the  Intestines  (contimied)    .        .        .        .  ■     .        .        .    381 
Acute  colitis  and   ileo-colitis ;   chrome  ileo-colitis ;   amabic  colitis;  amyloid 
degeneration  of  the  intestines ;  tuberculosis  of  the  intestines  and  mesenteric 
lymph  nodes. 

IX. — Diseases  of  the  Intestines  (continued) 409 

Chronic  intestinal  indigestion;  intestinal  colic;  chronic  constipation;  intus- 
susception. 

X. — Diseases  of  the  Intestines  (continued) 434 

Appendicitis ;  intestinal  worms. 

XL— Diseases  of  the  Rectum 448 

Prolapsus  ani;  fissures  of  the  anus ;  proctitis;  iscliio-rectal  abscess;  lisemor- 
rhoids ;  incontinence  of  fteces. 
XII.— Diseases  of  the  Liver 454 

Icterus;  functional  disorders;  acute  yellow  atrophy;  congestion  of  the  liver; 
abscess  of  the  liver;  cirrhosis;  amyloid  degeneration;  fatty  liver;  hydatids; 
biliary  calculi. 


TABLE   OF  CONTENTS.  ix 

CHAPTER  PAGE 

XIII. — Diseases  of  the  Peritoneum 461 

Acute  peritonitis;  chronic  (non-tuberculous^  peritonitis;  tuberculous  peri- 
tonitis ;  ascites  ;  subphrenic  abscess. 

Section  IV.— Diseases  of  the  Respiratory  System. 

I. — Nasal  Cavities 474 

Acute  nasal  catarrh  ;  chronic  nasal  catarrh ;  chronic  rhinitis ;  membranous 
rhinitis;  epistaxis. 

II. — Diseases  of  the  Larynx 485 

Catarrhal  spasm  of  the  larynx;  acute  catarrhal  laryngfitis;  pseudo-mem- 
branous laryngitis;  intubation;  submucous  laryngitis;  chronic  laryngitis; 
new  growths ;  foreign  bodies  in  the  larynx. 

III. — Diseases  of  the  Lungs 505 

The  peculiarities  of  the  lungs  in  infancy  and  early  childhood  ;  acute  catarrhal 
bronchitis;  fibrinous  bronchitis;  chronic  bronchitis ;  reflex  cough  ;  asthma. 

IV. — Diseases  of  the  Lungs  {coiitinued) 523 

Pneumonia ;  acute  broncho-pneumonia. 

V. — Diseases  of  the  Lungs  {continued) 558 

Lobar  pneumonia ;  pleuro-pneumonia ;  hypostatic  pneumonia ;  chronic  bron- 
cho-pneumonia ;  gangrene  of  the  lungs ;  acquired  atelectasis ;  emphysema. 

VI. — Pleurisy 587 

Dry  pleurisy  ;  pleurisy  with  serous  eifusion  ;  empyema. 

Section  Y. — Diseases  op  the  Circulatory  Sy^stem. 
I. — Peculiarities  of  the  Heart  and  Circulation  in  Early  Life    ,        .    602 
II. — Congenital  Anomalies  of  the  Heart 606 

III. — Pericarditis 613 

Acute  pericarditis ;  chronic  pericarditis  with  adhesions. 

IV. — Endocarditis  and  Valvular  Disease 618 

Acute  simple  endocarditis  ;  malignant  endocarditis:  chronic  valvular  disease  ; 
myocarditis ;  antemic  murmurs  ;  functional  disorders  of  the  heart ;  diseases  of 
the  blood-vessels. 

Section  YI.— Diseases  of  the  Uro-Genital  System. 

I. — The  L'rine  in  Infancy  and  Childhood 638 

Functional  or  cyclic  albuminuria;  htematuria;  ha?moglobinuria  ;  glycosuria; 
pyuria;  lithuria;  indicanuria;  acetonuria — diacetonuria ;  anuria;  diabetes 
insipidus. 

II. — Diseases  of  the  Kidneys 650 

Malformations  and  malpositions;  uric-acid  infarctions;  acute  congestion  of 
the  kidneys;  chronic  congestion  of  the  kidneys;  acute  degeneration  of  the 
kidneys;  acute  diffuse  nephritis;  chronic  nephritis;  tuberculosis  of  the 
kidney;  malignant  tumours  of  the  kidney;  pyelitis — pyelo-cystitis ;  renal 
calculi;  traumatic  hydro-nephrosis :  perinephritis;  general  oedema  not  de- 
pendent on  renal  disease. 

III. — Diseases  of  the  Genital  Organs 679 

Malformations;  diseases  of  the  male  genitals;  diseases  of  the  female  genitals. 

IV. — Enuresis 688 

Vesical  spasm  ;  vesical  calculi. 


TABLE   OF  CONTENTS. 


Section  VII.— Diseases  of  the  Nervous  System. 

CHAPTER  PAGE 

I. — Introductory 695 

II. — General  and  Functional  Nervous  Diseases 697 

Convulsions  ;  epilepsy ;  tetany  ;  laryngismus  stridulus  ;  chorea  ;  other 
spasmodic  affections ;  hysteria ;  headaches ;  disorders  of  speech ;  disorders 
of  sleep ;  injurious  habits  of  infancy  and  childhood. 

III. — Diseases  op  the  Brain  and  Meninges 743 

Malformations;  pachymeningitis;  acute  meningitis;  tuberculous  meningitis; 
chronic  basilar  meningitis  in  infants ;  thrombosis  of  the  sinuses  of  the  dura 
mater;  cerebral  abscess ;  cerebral  tumour;  hydrocephalus:  infantile  cerebral 
paralysis ;  feeble-mindedness,  idiocy,  imbecility  ;  sporadic  cretinism  ;  insanity  ; 
the  stigmata  of  degeneration  ;  deaf-mutism. 

IV. — Diseases  op  the  Spinal  Cord    . 805 

Malformations ;  spinal  meningitis ;  myelitis ;  compression-myelitis ;  acute 
poliomyelitis ;  tumours  of  the  spinal  cord ;  syringo-myelia ;  Friedreich's 
ataxia  ;  Landry's  paralysis  ;  the  muscular  atrophies. 

V. — Diseases  of  the  Peripheral  Nerves 831 

Multiple  neuritis  ;  diphtheritic  paralysis ;  facial  paralysis. 


Section  VIII. — Diseases  of  the  Blood,  Lymph  Nodes,  Bones,  etc. 

I. — Diseases  of  the  Blood .    841 

Leucocytosis ;   simple  anaemia ;   chlorosis ;   pseudo-leukeemic    anaemia  of  in- 
fancy ;  pernicious  anaemia ;  leukaemia  ;  haemophilia ;  purpura. 

II. — Diseases  op  the  Lymph  Nodes 863 

Lymphatism ;    simple   acute    adenitis ;    simple   chronic   adenitis ;    syphilitic 
adenitis  ;  tuberculous  adenitis ;  Hodgkin's  disease. 

III. — Diseases  op  the  Spleen 878 

IV. — Diseases  op  the  Bones  and  Joints 881 

Acute   arthritis   of  infants ;   tuberculous   diseases   of  the   bones  and  joints ; 
syphilitic  diseases  of  bone. 

V. — Diseases  op  the  Skin 904 

Congenital   ichthyosis;    miliaria;    seborrhea;    eczema;    furunculosis ;    gan- 
grenous dermatitis;  impetigo  contagiosa ;  urticaria;  scabies;  tinea  tonsurans. 

VI. — Acute  Otitis 925 


Section  IX.— The  Specific  Infectious  Diseases. 

I. — Scarlet  Fever 935 

II. — Measles 958 

IIL— Rubella 974 

IV. — Varicella 977 

V. — Vaccinia — Vaccination 979 

VI.— Pertussis 990 

VII.— Mumps 997 

VIII.- Diphtheria 1000 

IX.— Typhoid  Fever     .        .        .        .        ; 1050 

X. — Tuberculosis 1058 


TABLE   OF   CONTENTS.  xi 

CHAPTER  PAGE 

XL — Syphilis IO94 

XII. — Influenza UU 

XIII.— Malaria 1119 

Section  X.— Other  General  Diseases. 

I. — Rheumatism 1129 

LI. — Diabetes  Mellitus II35 


LIST   OF  ILLUSTRATIONS. 


PLATES.  FACING 

PAGE 

I.    Chart  showing  by  months  the  mortality  of  New  York  city  for  the  dif- 
ferent ages  for  three  years 41 

II.     Meningeal  ht-eraorrhage  in  the  newly  born 106 

III.  Chart  showing  composition  of  various   infant   foods   compared   with 

woman's  milk 163 

IV.  Bone  in  rickets 253 

V.     Typical  rickets 256 

VI.     Deformity  of  the  chest  in  severe  rickets 259 

VII.     The  stomach  at  the  different  periods  of  infancy 317 

VIII.     Intestinal  bacteria,  and  lesions 364 

IX.    Extensive  superficial  ulceration  of  the  colon 385 

X.     Deep  follicular  ulcers  of  the  colon 386 

XL     Membranous  inflammation  of  the  ileum 388 

XII.  Chronic  hyperplasia  of   the  lymph  nodules  (solitary  follicles)  of  the 

colon 410 

XIII.  Acute  broncho-pneumonia 530 

XIV.  Acute  pleuro-pneumonia 576 

XV.     Chronic  bi'oncho-pneumonia 579 

XVI.     Acute  meningitis,  complicating  pleuro-pneumonia 752 

XVII.  The  blood  in  leukjemia  and  pernicious  anferaia        .....     842 

XVIII.  The  pathognomonic  sign  of  measles  (Koplik's  spots)        ....     970 

XIX.     The  diphtheritic  membrane 1015 

XX.     Diphtheria  bacilli  and  their  associates 1024 

XXI.  Tuberculosis  of  the  tracheo-bronchial  lymph  nodes          ....  1070 


ILLUSTRATIONS  IN  THE  TEXT. 

FIGURE  pjlGE 

1.  Incubator 12 

2.  Incubator,  sectional  view 13 

3.  4.  Scales 15 

5.  Weight  curve  for  the  first  twenty  days 16 

6.  Weight  curve  for  the  first  year 18 

7.  Skull,  showing  premature  ossification 23 

8.  Apparatus  for  albolene  spray 55 

9.  Nasal  syringe 56 

10.  Position  for  nasal  syringing 57 

xiii 


xiv  LIST  OF  ILLUSTRATIONS. 

FIGURE  PAGE 

11.  Croup  kettle 58 

12.  Vapourizer 59 

13.  Steam  atomizer 59 

14.  Oiled-silk  jacket 59 

15.  Apparatus  for  stomach-washing 60 

16.  Position  for  stomach-washing 61 

17.  Colon  of  a  child  six  months  old 64 

18.  Ribemont's  tube 71 

19.  Double  cephalhasmatoma,  infant  seven  days  old 96 

20.  Erb's  paralysis 110 

21.  Umbilical  tumours 112 

22.  Temperature  chart  in  inanition  fever 120 

23.  Human  milk,  colostrum  period 127 

24.  Human  milk,  later  period 127 

25.  Apparatus  for  examination  of  human  milk        .         .  ' 132 

26.  Feser's  lactoscope 145 

27.  Cooley  creamer,  cans 149 

28.  Arnold  sterilizer 152 

29.  Freeman  Pasteurizer 153 

30.  Weight  curve  of  nursing  and  artificial  feeding  compared         ....  166 

31.  Weight  curve  showing  effect  of  bad  nursing  and  good  feeding        .         .         .  171 

32.  Chart  showing  effect  of  pregnancy  on  weight  of  nursing  infant       .         .         .175 

33.  Weight  curve  of  infant  properly  weaned i        .  176 

34.  Percentage  of  fat  in  different  layers  of  milk 188 

35.  Chapin's  dipper  for  removing  upper  layers  of  milk 188 

36.  Weight  curve  of  bottle-fed  infant  for  first  six  months 193 

37.  Weight  curve  of  artificially  fed  infant,  showing  effect  of  beginning  with  too 

high  percentages 195 

38.  The  "  Materna  "  measuring  glass 201 

39.  Weight  chart  showing  the  effect  of  intelligent  care 204 

40.  Weight  curve  showing  the  advantage  of  temporarily  stopping  milk       .         .  212 

41.  Case  of  marasmus 338 

42.  Normal  bone 254 

43.  Rachitic  bone 255 

44.  Rachitic  skull,  inside  view 258 

45.  Rachitic  head 259 

46.  Rachitic  skull,  external  view       .        .                 260 

47.  Rachitic  thorax  in  outline 260 

48.  Rachitic  bow-legs 261 

49.  Rachitic  knock-knees 262 

50.  Rachitic  deformity  of  legs 263 

51.  Rachitic  bow-legs  in  outline 270 

52.  Epithelial  desquamation  of  the  tongue 275 

53.  Thrush 285 

54.  Cancrum  oris 290 

55.  Adenoid  vegetations,  natural  size 298 

56.  Chest  deformity  from  adenoid  vegetations  of  the  pharynx       ,         .         .        .  300 

57.  58.  Child  with  adenoid  vegetations,  before  and  after  operation       .         .         .  304 

59.  Dilatation  of  the  stomach 343 

60.  ]Malformations  of  the  rectum 347 

61.  Chart  showing  mortality  from  diarrha;al  diseases  in  New  York       .        .        .  349 


LIST   OF   ILLUSTRATIONS.  XV 

FIGURE  PAGE 

62.  Chart  showing  frequency  of  diarrhoeal  diseases 350 

63.  Weight  curve  showing  effect  of  acute  gastro-enteric  intoxication  during 

first  year 363 

64.  Temperature  chart  of  acute  intestinal  intoxication  with  fatal  re-infection    .  366 

65.  Acute  catarrhal  ileo-colitis,  superficial  type 383 

66.  Acute  catarrhal  ileo-colitis,  severe  foi-m 384 

67.  Follicular  ulceration  of  the  colon,  early  stage 386 

68.  Follicular  ulceration  of  the  colon,  later  stage 387 

69.  Membranous  colitis 389 

70.  Weight  curve  showing  loss  from  ileo-colitis 391 

71.  Temperature  chart  in  ileo-colitis 393 

72.  Temperature  chart  in  membranous  colitis 395 

73.  Temperature  chart  in  membranous  colitis,  long  case 396 

74.  Chronic  catarrhal  inflammation  of  the  ileum 401 

75.  Ileo-csecal  intussusception 425 

76.  77.  Mechanism  of  intussusception 426 

78.  Taenia  saginata 442 

79.  Taenia  solium 442 

80.  Taenia  cucumerina 443 

81.  Bothriocephalus  latus 443 

82.  Ascaris  lumbricoides 444 

88.  Oxyuris  vermicularis 446 

84.  Prolapsus  ani 449 

85.  O'Dwyer's  intubation  set 495 

86.  An  air  vesicle  in  broncho-pneumonia 524 

87.  An  air  vesicle  in  lobar  pneumonia 525 

88.  Broncho-pneumonia  with  thickened  bronchus 530 

89.  Broncho-pneumonia,  hemorrhagic  form 532 

90.  Broncho-pneumonia  with  emphysema 533 

91.  Broncho-pneumonia,  diffuse  purulent  infiltration 534 

92.  Persistent  broncho-pneumonia 536 

93.  Temperature  chart  in  mild  uncomplicated  broncho-pneumonia     .        .        •  541 

94.  Temperature  chart,  prolonged  course,  broncho-pneumonia    ....  542 

95.  Temperature  chart,  relapsing  broncho-pneumonia  .        .        .        .        .        .  542 

96.  Temperature  chart,  rapidly  fatal  broncho-pneumonia 542 

97-100.  Physical  signs  in  broncho-pneumonia .  544 

101.  Temperature  chart,  persistent  broncho-pneumonia 547 

102.  Temperature  chart,  broncho-pneumonia  following  pertussis  ....  548 

103.  Temperature  chart,  typical  lobar  pneumonia 564 

104.  Temperature  chart,  remittent  type,  lobar  pneumonia 564 

105.  Temperature  chart,  lobar  pneumonia,  subnormal  temperature  after  crisis-    .  565 

106.  Tem[)erature  chart,  abortive  pneumonia 565 

107-109.  Physical  signs,  lobar  pneumonia 569 

110.  Section  of  lung,  showing  distribution  of  fluid  in  chest 594 

111,  112.  Empyema  following  pneumonia 595 

113.  Deformity  after  old  empyema 600 

114.  Apparatus  for  inducing  lung  expansion  after  empyema         ....  601 

115.  Showing  normal  areas  of  cardiac  dulness 605 

116.  Congenital  cardiac  disease 607 

117.  Clubbing  of  fingers  in  congenital  cardiac  disease 610 

118.  Congenital  malformations  of  the  kidney  and  ureters 653 

2 


xvi  LIST   OF   ILLUSTEATIONS. 

FIGURE  PAGE 

119,  120.  Sarcoma  of  the  kidney  before  and  after  operation 669 

121.  Tetany 714 

122.  Spasmodic  torticollis 727 

123.  Meningocele 743 

124.  Encephalocele 743 

125.  Hydrencephalocele 743 

126.  Meningocele 743 

127.  Naso-frontal  meningocele 744 

128.  Tracing  of  respiration  in  tuberculous  meningitis 763 

129.  Temperature  chart  in  tuberculous  meningitis 763 

130.  Chronic  basilar  meningitis 766 

131.  Section  of  the  brain  in  hydrocephalus 780 

132.  Head  in  chronic  hydrocephalus,  globular  form 781 

133.  Head  in  chronic  hydrocephalus,  pyramidal  form 783^ 

134.  Brain,  showing  results  of  old  meningeal  hemorrhage,  lateral  view        .        .  786 

135.  Brain,  showing  results  of  old  meningeal  haemorrhage,  superior  view     .        .  787 

136.  Convulsions  in  infantile  cerebral  paralysis 788 

137.  Spastic  paraplegia 789 

138.  Contractures  following  infantile  cerebral  paralysis 793 

139.  Brain  in  idiocy 795 

140.  A  typical  cretin 798 

141-144.  Cretins,  showing  effect  of  thyroid  treatment 799 

145.  Spina  bifida,  meningocele  (partially  diagrammatic)        .         .         .        .        .  806 

146.  Spina  bifida,  meningocele,  case  of 806 

147.  Spina  bifida,  meningo-myelocele  (partially  .diagrammatic)      ....  807 

148.  Spina  bifida,  syringo-myelocele 80& 

149.  Spina  bifida,  sacral 808 

150.  Spina  bifida,  section  of  cord  in 809 

151.  Infantile  spinal  paralysis  of  lower  extremity 820 

152.  Infantile  spinal  paralysis  of  shoulder 821 

153.  3Iuscular  pseudo-hypertrophy .         .  830 

154.  Alcoholic  neuritis 833 

155.  Diphtheritic  paralysis 834 

156.  Facial  paralysis 839 

157.  Acute  suppurative  adenitis,  cervical 867 

158.  Acute  suppurative  adenitis,  inguinal 867 

159.  Chain  of  tuberculous  lymph  nodes  (posterior  cervical) 873 

160.  Cicatrices  following  tuberculous  adenitis 874 

161.  Section  of  the  spine  in  Pott's  disease 885 

162.  Hip-joint  disease 891 

163.  Tuberculous  dactylitis 896 

164.  Syphilitic  disease  of  the  radius  and  ulna 898 

165.  Syphilitic  disease  of  the  tibia 900 

166.  Syphilitic  disease  of  both  tibiae 901 

167.  Syphilitic  necrosis  of  the  tibia 902 

168.  Syphilitic  dactylitis 903 

169.  Congenital  ichthyosis 905 

170.  Temperature  chart,  acute  otitis  following  influenza 926 

171.  Temperature  chart,  acute  otitis,  early  paracentesis 927 

172.  Mastoid  abscess 930 

173.  Temperature  chart  in  scarlet  fever,  typical  curve 941 


LIST  OF  ILLUSTRATIONS. 


XVll 


FIGURE 

174.  Temperature  chart  in  scarlet  fever,  prolonged  course    . 

175.  Temperature  chart  in  complicated  scarlet  fever 

176.  Temperature  chart  in  fatal  septic  scarlet  fever 

177.  178.  Temperature  charts  in  measles,  typical  curve . 

179.  Temperature  chart  in  measles,  occasional  course    . 

180.  Temperature  chart  in  measles,  prolonged  course     . 

181.  182.  Temperate  charts  in  measles  complicated  by  pneumonia 

183.  Table  showing  protective  power  of  vaccination 

184.  Vaccination  vesicles,  normal 

185.  Vaccination  vesicles,  severe  course 

186.  Temperature  chart  in  pseudo-diphtheria 

187.  Temperature  chart  in  typhoid  fever,  short  course  . 

188.  Temperature  chart  in  typhoid  fever,  with  relapse  . 

189.  Tuberculous  broncho-pneumonia,  diffuse  consolidation  . 

190.  Cavity  from  tuberculous  broncho-pneumonia  . 

191.  A  tuberculous  nodule 

192.  Tuberculous  broncho-pneumonia,  early  stage . 

193.  Tuberculous  bronchial  lymph  nodes         .... 

194.  Temperature  chart  of  tuberculosis  following  measles 

195.  Temperature  chart  of  tuberculous  broncho-pneumonia,  general  tuberculoi 

196.  Temperature  chart  of  tuberculous  broncho-pneumonia  with  softening . 

197.  Syphilitic  scaling  in  an  infant 

198.  Syphilitic  notched  teeth 

199.  Syphilitic  teeth,  variously  deformed 

200.  Temperature  chart  of  severe  influenza  in  an  infant        .... 

201.  Temperature  chart  of  acute  broncho-pneumonia  complicating  influenza 

202.  Temperature  chart,  quotidian  intermittent  fever 

203.  Temperature  chart,  tertian  intermittent  fever 

204.  Temperature  chart  in  malaria,  irregular  type 


PAGE 

.  942 
.  943 
.  944' 
.  964 
.  964 
.  965 
.  966 
.  980 
.  982 
.  982 
.  1005 
.  1011 
.  1012 
.  1067 
.  1067 
.  1068 
.1069 
.  1071 
.  1080 
;is  1081 
.  1082 
.  1102 
.  1104 
.  1105 
.  1113 
.  1115 
.  1121 
.  1122 
.  1123 


THE  DISEASES  OF  INFANCY  AND  CHILDHOOD. 

PART  I. 


CHAPTER  I. 

HYGIENE  AND   GENERAL   CARE  OF  INFANTS  AND   YOUNG 

CHILDREN. 

The  physical  development  of  the  child  is  essentially  the  product  of 
the  three  factors — inheritance,  surroundings,  and  food.  The  first  of  these 
it  is  beyond  the  physician's  power  to  alter ;  the  second  is  largely  and  the 
third  almost  entirely  within  his  control,  at  least  in  the  more  intelligent 
classes  of  society.  These  two  subjects,  infant  hygiene  and  infant  feeding, 
are  the  most  important  departments  of  pediatrics. 

The  Care  of  the  Newly-Born  Child. — After  the  ligature  of  the  cord  the 
child  should  be  wrapped  in  a  thick  blanket  and  placed  in  a  warm  room. 
In  hospital  practice  the  eyes  should  be  cleansed  with  absorbent  cotton 
and  water  which  has  been  boiled,  and  then  two  or  three  drops  of  a  two- 
per-cent  solution  of  nitrate  of  silver,  after  Crede's  method,  instilled  into 
each  eye  by  means  of  a  glass  rod  or  eye-dropper.  In  private  practice  a 
saturated  solution  of  boric  acid  may  be  substituted,  unless  the  mother  has 
had  a  purulent  vaginal  discharge,  in  which  case  the  silver  solution  should 
always  be  used.  The  bath  should  now  be  given  in  a  warm  room  ;  the 
body  being  first  oiled  thoroughly  in  order  to  remove  the  vernix  caseosa 
and  then  washed  in  water  at  a  temperature  of  100°  F.  The  mouth  should 
be  cleansed  with  plain  tepid  water  and  a  soft  cloth,  and  no  violence  em- 
ployed. The  cord  may  be  covered  with  salicylic  acid  one  part  aud  starch 
nineteen  parts,  or  simply  with  subnitrate  of  bismuth,  and  wrapped  in 
sterile  gauze  or  surgeon's  lint.  The  abdomen  should  now  be  enveloped 
in  a  flannel  band,  eight  or  ten  inches  wide,  and  pinned  rather  snugly. 
Before  dressing  is  completed,  the  child  should  be  submitted  to  a  thorough 
examination  for  injuries  received  during  delivery,  congenital  deformities, 
also  as  to  the  condition  of  the  respiration,  circulation,,  etc. 

After  dressing,  the  child  should  be  placed  in  its  crib  and  covered  with 
blankets,  and  if  the  feet  are  cold,  or  the  fingers  and  lips  a  little  blue,  it 

1 


2  HYGIENE  AND  GENERAL  CARE  OF  INFANTS. 

should  be  surrounded  by  hot-water  bottles  covered  with  flannels,  and 
placed  near,  but  not  in  contact  with,  the  body.  The  crib  should  be  placed 
in  a  quiet,  darkened  room.  The  young  infant  should  not  occupy  the 
same  bed  as  the  mother,  unless  it  greatly  needs  the  warmth  of  her  body, 
other  means  of  artificial  heat  not  being  at  hand. 

The  cord  should  be  kept  dry  and  disturbed  as  little  as  possible  until 
it  falls  off.  Under  ordinary  circumstances  the  cord  separates  from  the 
fourth  to  the  seventh  day,  the  average  being  the  fifth  day.  The  stump 
should  then  be  covered  with  the  salicylic  acid  and  starch  powder,  and  a  pad 
of  sterile  gauze  about  one  fourth  of  an  inch  thick  and  two  inches  square 
applied  and  secured  in  position  by  means  of  the  abdominal  band.  The 
purpose  of  this  is  to  prevent  umbilical  hernia.  The  pad  should  be  con- 
tinued for  the  first  month.  The  use  of  stronger  antiseptic  dressings  than 
that  recommended  is  somewhat  objectionable,  since  it  preserves  the  cord 
too  long  and  delays  separation.  The  full  bath  should  not  be  given  until 
the  cord  has  separated. 

The  physician  should  always  see  to  it  that  the  infant  cries  enough  to 
keep  the  lungs  properly  expanded. 

The  question  of  food  for  the  newly-born  infant  is  considered  in  the 
■chapter  upon  infant  feeding. 

Bathing. — For  the  first  few  months  the  bath  should  be  given  at  98° 
'F.  The  room  should  be  warm,  preferably  there  should  be  an  open  fire. 
The  bath  should  be  short  and  the  body  dried  quickly,  without  too  vigor- 
ous rubbing.  The  addition  of  salt  to  the  bath  is  an  advantage  where  the 
skin  is  unusually  delicate  or  excoriations  are  present.  One  large  handful 
should  be  used  to  a  gallon  of  water.  By  the  sixth  month  the  temperature 
of  the  bath  for  healthy  infants  may  be  lowered  to  95°  F.,  and  by  the  end 
of  the  first  year  to  90°  F.  Older  children  who  are  healthy  should  be  sponged 
or  douched  for  a  moment  at  the  close  of  the  tepid  bath  with  water  at  65° 
or  70°  F.  During  childhood  the  warm  bath  is  preferably  given  at  night. 
In  the  morning  a  cold  sponge  bath  is  desirable.  This  should  be  given  in 
a  warm  room  and  while  the  child  stands  in  a  tub  partly  filled  with  warm 
water.  This  cold  sponge  should  last  but  half  a  minute,  and  be  followed 
by  a  brisk  rubbing  of  the  entire  body. 

In  some  young  infants  and  even  older  children  there  is  no  proper 
reaction  after  the  bath,  even  when  given  at  the  temperatures  mentioned; 
children  being  pale,  slightly  blue  about  the  lips  and  under  the  eyes.  All 
tub  bathing,  and  especially  all  cold  bathing,  should  then  be  stopped,  since 
a  continuance  can  only  be  a  drain  upon  the  child's  vitality. 

Clothing. — The  clothing  of  infants  should  be  light,  warm,  non-irri- 
tating to  the  skin,  and  loose  enough  to  allow  free  motion  of  the  extremi- 
ties; nor  should  bands  be  pinned  so  tightly  about  the  trunk  as  to  em- 
barrass the  movements  either  of  the  chest  or  of  the  abdomen.  The  chest 
should  be  covered  with  a  woollen  shirt,  high  in  the  neck  and  with  long 


BATHING— CLOTHING.  3 

sleeves.  All  petticoats  should  be  supported  from  the  shoulders  and  not 
from  waistbands.  Canton  flannel  and  stockinet  are  both  superior  as 
absorbents  to  the  more  commonly  used  linen  diapers.  Stockinet  has  the 
advantage  of  being  very  soft  and  pliable.  Care  should  be  given  that  in  in- 
fants the  feet  be  kept  warm.  If  the  circulation  is  very  poor,  a  bag  of  hot 
water  should  always  be  in  the  crib.  Cold  feet  are  responsible  for  many 
attacks  of  colic  and  indigestion. 

The  abdominal  band  is  usually  worn  during  infancy.  It  cannot  be 
considered  in  any  sense  a  necessity  after  the  first  few  months,  excepting 
in  cases  of  very  thin  infants  whose  supply  of  fat  in  the  abdominal  walls  is 
an  insufficient  protection  to  the  viscera.  For  the  first  few  weeks  a  band  of 
plain  flannel  is  to  be  preferred  ;  later,  a  knitted  band  with  shoulder-straps. 
The  fashion  of  low  neck  and  short  sleeves  for  infants  and  very  young 
children  has  fortunately  passed  away — let  us  hope,  never  to  return. 

During  the  summer  the  outer  clothing  should  be  light  and  the  under 
clothing  of  the  thinnest  flannel  or  gauze.  The  changes  in  the  tempera- 
ture of  morning  and  evening  may  be  met  by  extra  wraps.  The  custom  of 
allowing  young  children  to  go  with  legs  bare  has  many  enthusiastic  advo- 
cates ;  while  it  may  not  be  objectionable  during  the  heat  of  summer,  its 
advantages  at  any  season  are  very  questionable  in  a  changeable  climate 
like  that  of  New  York  or  the  Atlantic  coast.  Many  delicate  children  are 
certainly  injured  by  such  ill-advised  attempts  at  hardening. 

The  night  clothing  of  infants  should  be  similar  to  that  worn  during 
the  day,  but  should  be  loose,  the  material  being  of  the  lightest  flannel. 
The  night  clothing  for  older  children  should  consist  of  a  thin  woollen 
shirt  and  a  union  suit  with  waist  and  trousers,  and  in  some  cases  with 
feet,  if  there  is  a  tendency  to  get  outside  the  coverings.  The  common 
mistake  is  to  overload  all  children,  but  especially  infants,  with  covering  at 
night.  This  is  an  explanation  of  much  of  the  restless  sleep  which  is  seen 
particularly  in  delicate  children. 

Care  of  the  Eyes. — During  the  first  few  days  at  the  daily  bath,  the 
eyes  should  be  cleansed  with  a  saturated  solution  of  boric  acid.  They 
should  be  carefully  protected  from  too  strong  light  during  early  infancy. 
It  is  desirable  that  a  child  should  always  sleep  in  a  darkened  room. 

Care  of  the  Mouth  and  Teeth, — The  mouth  of  the  newly-born  infant 
should  be  gently  cleansed  at  each  morning  bath  with,  boiled  water  and 
a  soft  cloth.  On  the  first  appearance  of  thrush  the  mouth  should  be 
washed  after  every  feeding  with  a  solution  of  bicarbonate  of  soda  or  borax 
(twenty  grains  to  the  ounce).  Harm  is  often  done  by  the  use  of  too  much 
force  in  cleansing  the  mouth  of  a  young  infant. 

The  primary  teeth  as  well  as  those  of  the  permanent  set  should  receive 
daily  attention.  Too  often  they  are  neglected  altogether.  Dirty  teeth 
are  likely  sooner  or  later  to  become  carious ;  and  carious  teeth,  besides 
being  a  cause  of  bad  breath  and  neuralgia,  are  a  constant  menace  to  the 


4         HYGIENE  AND  GENERAL  CARE  OP  INFANTS. 

health  of  the  child,  since  they  may  harbour  infectious  germs  of  all  varie- 
ties.    Such  teeth  should  either  be  filled  or  removed. 

Care  of  the  Skin. — The  skin  of  a  young  infant  is  exceedingly  deli- 
cate, and  excoriations,  intertrigo,  and  eczema  are  of  very  common  occur- 
rence. These  conditions  are  much  easier  of  prevention  than  of  cure. 
The  first  essential  in  the  care  of  the  skin  is  cleanliness,  and  this  must  be 
secured  without  the  use  of  strong  soaps  or  too  much  rubbing.  Napkins 
must  be  removed  as  soon  as  soiled  or  wet.  Some  bland  absorbent  powder, 
like  starch,  talcum,  or  the  stearate  of  zinc,  should  be  used  in  all  the  folds 
of  the  skin,  in  the  neck,  in  the  axillge,  groins,  and  about  the  genitals,  and 
in  the  folds  of  the  thighs,  particularly  in  very  fat  infants.  If  plain  water 
produces  an  undue  amount  of  irritation,  the  salt  or  bran  bath  should  be 
employed. 

Care  of  the  Genital  Organs. — The  female  genitals  need  but  little 
attention  in  young  children,  excepting  as  to  cleanliness.  This  is  more 
often  neglected  in  older  children  than  in  infants.  Vulvo-vaginitis  is  very 
common  among  the  children  of  the  poorer  classes  where  cleanliness  is 
neglected. 

In  males  the  prepuce  should  receive  attention  during  the  first  few 
weeks  of  life.  If  the  foreskin  is  long  and  the  preputial  orifice  small, 
circumcision  should  invariably  be  done.  If  it  is  not  long,  but  is  only 
adherent,  these  adhesions  should  be  broken  up,  the  parts  thoroughly 
cleansed  and  the  foreskin  retracted  daily  until  there  is  no  disposition  to  a 
recurrence  of  the  adhesions.  These  operations  will  be  discussed  more  at 
length  in  a  subsequent  chapter.  The  only  thing  to  be  emphasised  in 
the  present  connection  is  that  the  prepuce  should  receive  proper  atten- 
tion in  early  infancy,  since  this  can  now  be  done  with  less  pain  and  dis- 
comfort to  the  child,  and  at  the  same  time  better  results  are  obtained. 
If  this  matter  is  neglected  during  infancy,  it  is  apt  to  be  overlooked  until 
harm  has  been  produced  by  local  or  reflex  irritation  which  phimosis  or 
adherent  prepuce  may  have  excited. 

Vaccination. — This,  although  considered  elsewhere,  should  be  men- 
tioned in  this  connection  as  among  the  things  requiring  the  physician's 
attention  during  the  first  months  of  life. 

Training  to  Proper  Control  of  Rectum  and  Bladder. — It  is  surpris- 
ing to  see  what  can  be  accomplished  by  intelligent  efEorts  at  training 
in  these  particulars.  An  infant  can  often  be  trained  at  three  months  to 
have  its  movements  from  the  bowels  when  placed  upon  a  small  cham- 
ber. This  not  only  saves  a  great  amount  of  washing  of  najDkins,  but 
there  is  soon  formed  a  habit  of  having  the  bowels  move  at  a  regular  time 
or  times  each  day.  The  infant  must  be  put  upon  the  chamber  soon  after 
its  feeding.  The  importance  of  training  young  children  to  regular  habits 
regarding  evacuations  from  the  bowels  can  hardly  be  overestimated.  It 
should  be  impressed  upon  every  mother  and  nurse  by  the  physician,  and 


SLEEP.  5 

especially  the  necessity  of  beginning  training  during  infancy.  Much  of 
course  will  depend  upon  the  food  and  the  digestion ;  but  habit  is  a  very 
large  factor  in  the  case. 

The  training  of  the  bladder  is  not  quite  so  important,  but  the  proper 
education  of  this  organ  adds  much  to  the  comfort  of  the  child  and  the  ease 
with  which  it  is  cared  for.  Before  the  end  of  the  first  year  most  intelli- 
gent children  can  be  trained  to  indicate  a  desire  to  empty  the  bladder. 
Many  mothers  and  nurses  succeed  in  training  children  so  well  that  by  the 
tenth  or  eleventh  month  napkins  are  dispensed  with  during  the  day. 
On  the  other  hand,  it  is  very  common  to  see  children  of  two  and  even  two 
and  a  half  years  still  wearing  napkins  because  of  the  lack  of  proper  train- 
ing. Before  it  has  reached  the  latter  age  a  healthy  child  should  go  from 
10  P.  M.  until  morning  without  emptying  the  bladder.  The  annoyance 
and  discomfort  from  the  neglect  of  early  training  in  this  particular  are 
very  great.  Night  feeding  is  responsible  for  much  of  the  difficulty  expe- 
rienced in  training  children  to  hold  the  water  during  the  night. 

General  Hygiene  of  the  Nervous  System. — Great  injury  is  done  to 
the  nervous  system  of  children  by  the  influences  with  which  they  are 
surrounded  during  infancy,  especially  during  the  first  year.  The  brain 
grows  more  during  the  first  two  years  than  in  all  the  rest  of  life.  Normal 
healthy  development  of  the  nervous  centres  demands  quiet,  rest,  peaceful 
surroundings,  and  freedom  from  everything  which  causes  excitement  or 
undue  stimulation. 

The  steadily  increasing  frequency  of  functional  nervous  diseases  among 
young  children  is  one  of  the  most  powerful  arguments  for  greater  atten- 
tion by  physicians  to  the  subject  of  the  hygiene  of  the  nervous  sys- 
tem during  infancy.  Most  parents  err  through  ignorance.  Playing  with 
young  children,  stimulating  to  laughter  and  exciting  them  by  sights, 
sounds,  or  movements  until  they  shriek  with  apparent  delight,  may  be  a 
source  of  amusement  to  fond  parents  and  admiring  spectators,  but  it  is 
almost  invariably  an  injury  to  the  child.  This  is  especially  harmful  when 
done  in  the  evening.  It  is  the  plain  duty  of  the  physician  to  enlighten 
parents  upon  this  point,  and  insist  that  the  infant  shall  be  kept  quiet,  and 
that  all  such  playing  and  romping  as  has  been  referred  to  shall,  during 
the  first  year  at  least,  be  absolutely  prohibited. 

Sleep. — The  sleep  of  the  newly-born  infant  is  profound  for  the  first 
two  or  three  days  and  under  normal  conditions  almost  continuous.  In 
the  case  of  prolonged  or  tedious  labor,  or  where  from  any  cause  undue 
compression  has  been  exerted  upon  the  head,  it  may  approach  the  con- 
dition of  semi-coma  for  twenty-four  or  forty-eight  hours.  This  may  be  so 
deep  as  to  excite  apprehensions  of  serious  brain  lesions.  If,  however,  there 
are  associated  with  it  no  convulsions  and  no  rigidity,  this  early  stupor 
usually  passes  away  on  the  second  or  third  day. 

The  sleep  of  early  infancy  is  quiet  and  peaceful,  but  not  very  deep  after 


6  HYGIENE   AND    GENERAL   CARE   OP  INFANTS. 

the  first  month.  After  the  third  3'ear  the  heavy  sleep  of  childhood  is 
commonly  seen.  A  healthy  infant  during  the  first  few  weeks  sleeps  from 
twenty  to  twenty-two  hours  out  of  the  twenty-four,  waking  only  from 
hunger,  discomfort,  or  pain.  During  the  first  six  months  a  healthy  infant 
will  usually  sleep  from  sixteen  to  eighteen  hours  a  day,  the  waking  pe- 
riods being  only  from  half  an  hour  to  two  hours  long.  At  the  age  of  one 
year  most  infants  sleep  from  fourteen  to  fifteen  hours,  viz.,  from  eleven 
to  twelve  hours  at  night,  and  two  or  three  hours  during  the  day,  usually 
in  two  naps.  When  two  years  old  usually  thirteen  to  fourteen  hours' 
sleep  are  taken  ;  eleven  or  twelve  hours  at  night  and  one  or  two  hours 
during  the  day,  generally  in  a  single  nap.  At  the  age  of  four  years  chil- 
dren require  from  eleven  to  twelve  hours'  sleep.  It  is  always  desirable, 
and  in  most  cases  with  regularity  it  is  possible,  to  keep  up  the  daily  nap 
until  children  are  four  years  old.  From  six  to  ten  years  the  amount  of 
sleep  required  is  ten  or  eleven  hours,  and  from  ten  to  sixteen  years  nine 
hours  should  be  the  minimum. 

Training  in  proper  habits  of  sleep  should  be  begun  at  birth.  From 
the  outset  an  infant  should  be  accustomed  to  being  put  into  its  crib  while 
awake  and  to  go  to  sleep  of  its  own  accord.  Rocking  and  all  other  habits 
of  this  sort  are  useless  and  may  even  be  harmful.  An  infant  should  not 
be  allowed  to  sleep  on  the  breast  of  the  nurse,  nor  with  the  nipple  of  the 
bottle  in  its  mouth.  Other  devices  for  putting  infants  to  sleep,  such  as 
allowing  the  child  to  suck  a  rubber  nipple  or  anything  else,  are  positively 
injurious.  If  such  means  of  inducing  sleep  are  resorted  to  the  infant  soon 
acquires  the  habit  of  not  sleeping  without  them.  I  have  known  of  one 
instance  where  the  habit  of  rocking  during  sleep  was  continued  until  the 
child  was  two  years  old ;  the  moment  the  rocking  was  stopped  the  infant 
would  wake,  and  in  consequence  this  practice  was  continued  by  the  de- 
voted but  misguided  parents,  A  quiet,  darkened  room,  a  warm  and  com- 
fortable bed,  an  appetite  satisfied,  and  dry  napkins  are  all  that  are  needed 
to  induce  sleep  in  a  healthy  child. 

The  periods  of  sleep  in  young  infants  are  usually  from  two  to  three 
hours  long,  with  the  exception  of  once  or  twice  in  the  twenty-four  hours, 
w^hen  a  long  sleep  of  five  or  six  hours  occurs.  The  purpose  of  training 
is  to  have  the  child  take  this  long  sleep  at  night.  The  habit  of  regular 
sleep  is  best  established  by  wakening  the  infant  regularly  every  two  or 
two  and  a  half  hours  during  the  day  for  feeding,  and  allowing  it  to  sleep 
as  long  as  possible  during  the  night.  This  training  goes  hand-in-hand 
with  regular  habits  of  feeding.  Such  habits  are  easily  formed  if  the  plan 
be  systematically  followed  from  the  outset. 

By  the  fifth  month  all  feeding  between  10  p.  m.  and  7  a.  m.  should  be 
discontinued.  If  this  is  done  most  infants  can  be  trained  by  this  time  to 
sleep  all  night.  If  the  room  is  lighted,  and  the  child  taken  from  the  crib 
or  rocked  or  fed  as  soon  as  it  wakens  at  night,  there  is  no  such  thing  as 


EXERCISE.  Y 

the  formation,  of  good  habits  of  sleep.  Eegularity  in  sleep  and  feeding 
not  only  make  the  care  of  young  infants  very  much  easier,  but  they  are  of 
a  good  deal  of  importance  for  the  health  of  the  child. 

The  causes  of  disturbed  or  irregular  sleep  in  young  infants  are  mainly 
two — hunger  and  indigestion.  In  nursing  infants  it  is  usually  the  for- 
mer ;  in  those  artificially  fed  usually  the  latter.  Sleeplessness  from  hun- 
ger is  often  seen  in  children  who  are  nursed  thirty  or  forty  minutes  and 
then  fall  asleep,  but  wake  in  fifteen  or  twenty  minutes  crying  and  fretful. 
After  being  quieted  they  may  fall  asleep  again  for  half  an  hour,  but  wake 
at  short  intervals.  The  peaceful  sleep  of  two  or  three  hours  which  should 
follow  a  proper  feeding  is  never  seen.  With  this  restlessness,  in  indiges- 
tion other  signs  are  usually  present,  such  as  bad  stools,  stationary  weight, 
■etc.  The  disturbed  sleep  due  to  overfeeding  shows  itself  by  much  the 
same  symptoms,  excepting  that  the  first  sleep  after  the  meal  is  usually 
longer. 

Exercise. — This  is  no  less  important  in  infancy  than  in  later  child- 
hood. An  infant  gets  its  exercise  in  the  lusty  cry  which  follows  the  cool 
sponge  of  the  bath,  in  kicking  its  legs  about,  waving  its  arms,  etc.  By 
these  means  pulmonary  expansion  and  muscular  development  are  in- 
creased and  the  general  nutrition  promoted.  An  infant's  clothing  should 
be  such  as  not  to  interfere  with  its  exercise.  Confinement  of  the  legs 
should  not  be  permitted.  In  hospital  practice  I  have  often  had  a  chance 
-to  observe  the  bad  results  which  follow  when  very  young  infants  are 
allowed  to  lie  in  the  cribs  nearly  all  the  time.  Little  by  little  the  vital 
processes  fiag,  the  cry  becomes  feeble,  the  weight  is  first  stationary,  then 
there  is  a  steady  loss.  The  appetite  fails  so  that  food  is  at  first  taken 
without  relish,  then  at  times  altogether  refused;  later,  vomiting  ensues 
and  other  symptoms  of  indigestion.  This,  in  many  cases,  is  the  begin- 
ning of  a  steady  downward  course  which  goes  on  until  a  condition  of  hope- 
less marasmus  is  reached.  Such  infants  must  be  taken  up  every  few 
hours  and  carried  about  the  wards ;  the  position  should  be  frequently 
changed,  and  general  friction  of  the  entire  body  employed  at  least  twice  a 
day.  Every  means  must  be  made  use  of  to  stimulate  the  vital  activity. 
The  value  of  systematic  attention  to  these  matters  cannot  be  overestimated 
in  hospitals  for  infants.  Infants  who  are  old  enough  to  creep  or  stand 
usually  take  sufficient  exercise  unless  they  are  restrained.  At  this  age 
they  should  be  allowed  to  do  what  they  are  eager  to  do.  Every  facility 
should  be  afforded  for  using  their  muscles.  Exercise  may  be  encouraged 
by  placing  upon  the  floor  in  a  warm  room  a  mattress  or  a  thick  "  com- 
fortable," and  allowing  the  infant  to  roll  and  tumble  upon  it  at  will.  A 
large  bed  may  answer  the  same  purpose. 

In  older  children  every  form  of  out-of-door  exercise  should  be  encour- 
aged— ball,  tennis,  and  all  running  games,  horseback  riding,  the  bicycle, 
tricycle,  swimming,  coasting,  and  skating.     Up  to  the  eleventh  year  no 


8  HYGIENE   AND   GENERAL   CARE  OF  INFANTS. 

difference  need  be  made  in  the  exercise  of  the  two  sexes.  Companion* 
ship  is  a  necessity.  Children  brought  up  alone  are  at  a  great  disadvantage 
in  this  respect,  and  are  not  likely  to  get  as  much  exercise  as  they  require. 
The  amount  of  exercise  allowed  delicate  children  should  be  regulated 
with  some  degree  of  care.  It  may  be  carried  to  the  point  of  moderate 
muscular  fatigue,  but  never  to  muscular  exhaustion.  The  latter  is  partic- 
ularly likely  to  be  the  case  in  competitive  games. 

Exercise  should  have  reference  to  the  symmetrical  development  of  the 
whole  body.  In  prescribing  it  the  specific  needs  of  the  individual  child 
should  be  considered.  By  carefully  regulated  exercises  very  much  may  be 
done  to  check  such  deformities  as  round  shoulders  and  slight  lateral  cur- 
vature of  the  spine,  and  also  to  develop  narrow  chests  and  feeble  thoracic 
muscles.  For  purposes  like  these,  gymnastics  are  exceedingly  valuable  to 
supplement  out-of-door  exercise,  but  they  can  never  take  their  place. 

There  are  two  important  points  with  reference  to  exercise  indoors : 
First,  the  playroom  should  be  cool — from  60°  to  65°  F. ;  never  above 
this  'point.  Secondly,  during  all  active  exercise  the  clothing  should  be 
loose  and  light,  so  as  to  allow  the  freest  possible  motion  of  the  body. 

Airing. — In  summer  there  can  be  no  possible  objection  to  a  young 
infant  being  allowed  out  of  doors  at  the  end  of  the  first  week.  It  should 
be  kept  in  the  open  air  as  much  as  possible  during  the  day.  In  the  fall 
and  spring  this  should  not  be  permitted  until  the  child  is  at  least  a  month, 
old,  and  then  only  when  the  out-of-door  temperature  is  above  60°  F. 
During  its  outing  the  head  should  be  protected  from  the  wind  and  the 
eyes  from  the  sun.  The  duration  of  the  outing  at  first  should  be  only  fif- 
teen or  twenty  minutes,  the  time  being  gradually  lengthened  to  two  or 
three  hours.  The  child  should  be  gradually  accustomed  to  changes  of 
temperature  in  the  room  by  opening  wide  the  windows  for  a  few  min- 
utes each  day  even  before  it  is  taken  out  of  doors,  the  child  being  dressed 
meanwhile  as  for  an  outing.  In  the  case  of  children  born  late  in  the 
fall  or  in  the  winter  this  means  of  giving  fresh  air  may  be  advantageously 
begun  at  one  month  and  followed  throughout  the  first  winter.  It  is  only 
necessary  in  all  such  cases  that  the  changes  be  made  very  gradually 
both  as  to  the  length  of  the  airing  and  to  the  temperature.  The  great 
advantage  of  this  plan  over  that  more  commonly  followed  of  keeping 
young  infants  closely  housed  for  the  first  six  months  in  case  they  are  born 
in  the  fall  or  early  winter,  I  can  positively  affirm  from  quite  a  wide  obser- 
vation of  both  methods.  It  is  a  matter  of  very  serious  importance  that 
every  infant  be  furnished  an  abundance  of  pure  fresh  air  in  winter  as  well 
as  in  summer.  When  the  plan  above  outlined  is  carefully  and  judiciously 
followed,  the  tendency  to  catarrhal  affections  instead  of  being  increased  is 
thereby  greatly  lessened. 

When  four  or  five  months  old,  there  is  no  reason  why  a  healthy  child 
should  not  go  out  of  doors  on  pleasant  days  if  the  temperature  is  not 


NURSERY.  9 

below  20°  F.  While  there  is  a  prejudice  on  the  part  of  many  mothers 
and  some  physicians  against  a  child's  sleeping  out  of  doors  in  cold 
"weather,  it  is  a  practice  which  I  have  always  urged  upon  mothers,  and 
liave  never  seen  followed  by  any  but  the  most  beneficial  results.  The 
days  of  all  others  when  infants  and  very  young  children  should  not  be 
out  of  doors  are  when  there  are  high  winds,  especially  those  from  the 
northeast,  an  atmosphere  of  melting  snow,  and  during  severe  storms. 
Delicate  infants  must  of  course  be  more  carefully  guarded  during  the 
cold  season.  With  most  of  these  the  plan  of  house-airing  is  all  that 
should  be  attempted. 

Nursery. — This  should  be  the  sunniest  and  best-ventilated  room  in 
the  house.  It  is  the  physician's  duty  to  see  that  proper  attention  is  paid 
to  the  hygiene  of  the  room  in  which  the  child  spends  at  least  four-fifths 
of  its  time  during  the  first  year,  and  two-thirds  of  its  time  during  the 
first  two  or  three  years  of  life.  Sunlight  is  absolutely  indispensable. 
Sunny  rooms  always  contain  less  organic  matter  and  less  humidity,  and 
hence  a  room  upon  the  north  side  of  the  house  should  always  be  avoided, 
preferably  one  in  the  second  story  should  be  chosen.  Nothing  which  can 
in  any  way  contaminate  the  air  of  the  room  should  be  allowed.  There 
should  be  no  dr3dng  of  clothes  or  of  napkins,  and  no  plumbing.  No  food 
should  be  allowed  to  stand  about  the  room.  The  gas  should  not  be 
allowed  to  burn  at  night;  a  small  wax  night-light  furnishes  all  that  is 
needed  in  the  nursery.  If  possible  the  heat  should  be  from  an  open  fire ; 
the  next  best  thing  is  the  Franklin  radiator.  Nothing  in  the  room  is 
worse  than  steam  heat  from  a  radiator  unless  it  be  a  gas  stove  which 
under  no  circumstances  should  be  allowed,  excepting  possibly  for  a  few 
minutes  each  morning  during  the  bath. 

The  temperature  of  the  room  during  the  day  should  be  70°  F.,  but 
better  68°  than  72°  F.  It  is  important  that  every  nursery  should  have  a 
thermometer,  and  that  this  and  not  the  sensations  of  the  nurse  should  be 
the  guide.  It  is  almost  invariably  true  that  the  nursery  is  overheated. 
Often  no  other  explanation  can  be  found  for  chronic  indigestion  and  fall- 
ing weight  excepting  a  nursery  whose  habitual  temperature  ranges  from 
75°  to  80°  F.  At  night  for  the  first  few  months  the  temperature  should 
not  be  allowed  to  fall  below  65°  F.  After  the  first  year  the  night  tem- 
perature may  fall  to  60°  or  even  50°  F. 

Free  ventilation  without  draughts  is  an  absolute  necessity.  This  is 
best  accomplished  by  ventilators  in  the  windows,  of  which  there  are  many 
excellent  devices  sold  in  the  shops.  While  the  child  is  absent  from  the 
room  the  windows  should  be  widely  opened  and  free  airing  of  the  nursery 
accomplished.  The  room  sliould  always  be  thoroughly  aired  at  night  be- 
fore the  child  is  ]nit  to  bed.  Tlie  window  may  be  kept  open  even  in  the  first 
year,  unless  the  temperature  out  of  doors  is  below  35°  F.  After  the  first 
year  the  window  may  be  open,  unless  the  outside  temperature  is  as  low  as 


10  HYGIENE   AND   GENERAL   CARE   OF   INFANTS. 

20°  F.  If  the  window  is  open  the  door  of  the  nursery  should  be  closed, 
that  currents  of  air  may  be  avoided.  The  ventilation  by  means  of  an  open 
fire  is  the  most  efficient. 

The  furniture  of  the  nursery  should  be  as  simple  as  possible,  heavy 
hangings  should  be  positively  forbidden,  and  upholstered  furniture  used 
only  to  a  small  extent.  Floors  covered  by  large  rugs  are  much  more  clean- 
ly than  carpets,  and  hence  are  to  be  preferred. 

The  child,  whenever  it  is  possible,  should  have  a  separate  bed;  and 
so  should  the  newly-born  infant,  in  order  to  prevent  the  danger  of  over- 
lying by  the  mother,  which  among  the  lower  classes  is  a  frequent  cause  of 
death,  and  also  to  avoid  the  danger  of  too  frequent  night  nursing,  which  is 
injurious  alike  to  mother  and  child.  Separate  beds  for  older  children  will 
prevent  the  spread  of  many  forms  of  infection  from  the  diseased  child  to 
the  healthy.  The  cradle  for  infants  should  be  one  which  does  not  rock,  in 
order  that  this  unnecessary  and  vicious  practice  should  not  be  carried  on. 
The  mattress  should  be  of  hair  and  quite  firm.  The  pillow  should  be 
small;  in  the  summer,  hair  pillows  are  an  advantage  but  not  a  neces- 
sity. The  position  of  the  child  during  sleep  should  be  changed  from 
time  to  time  from  one  side  to  the  other  and  then  to  the  back.  Atten- 
tion to  all  these  details  should  not  be  beneath  the  physician's  notice,  since 
the  violation  of  these  plain  rules  of  hygiene  is  at  the  bottom  of  many 
of  the  milder  disorders  and  even  of  some  of  the  more  serious  diseases  seen 
in  infancy. 

The  Nurse. — The  nurse  of  a  young  child  should  be  healthy,  young 
or  in  middle  life,  free  from  tuberculous  or  syphilitic  taint,  and  from  ca- 
tarrhal affections  of  the  nose  and  throat.  She  should  be  neat  in  habit, 
of  quiet  disposition,  and,  most  of  all,  she  should  be  a  person  of  intelli- 
gence. 

The  Amount  of  Air  Space  required  by  Infants. — The  nursery  should 
always  be  as  large  a  room  as  jDOSsible.  One  of  the  reasons  why  young 
infants  do  so  badly  in  institutions  is  because  of  overcrowding.  In  a 
well-ventilated  ward  there  should  be  allowed  to  each  infant  at  least  1,000 
cubic  feet  for  the  best  results.  Children  over  two  years  old  are  not  so 
sensitive  to  their  surroundings,  and  may  thrive  in  wards  where  only  700 
or  800  cubic  feet  are  allowed  to  each  child. 


THE   CARE   OF   PREMATURE   AND   DELICATE   INFANTS. 

Infants  born  before  term,  and  some  exceedingly  delicate  ones  which  are 
born  at  full  term,  require  very  special  and  particular  care.  The  vitality  is 
so  feeble  in  these  children  that  if  they  are  handled  in  the  ordinary  way 
they  survive  at  most  but  a  few  weeks.  The  symptom  which  indicates  that 
such  special  care  is  necessary  is  most  of  all  the  weight  of  the  child.  Either 
congenital  feebleness  or  prematurity  may  be  assumed  in  most  of  the  chil- 


THE  CARE  OF   PREMATURE  AND  DELICATE  INFANTS.  H 

dren  weighing  less  than  four  pounds ;  also  if  the  length  of  the  body  is  less 
than  nineteen  inches.  In  these  children  all  the  organs  are  likely  to  be 
imperfectly  developed  and  they  are  not  ready  for  their  work.  Especially 
is  this  true  of  the  lungs  and  of  the  organs  of  digestion. 

The  clinical  picture  presented  by  these  cases  is  quite  characteristic. 
The  body  is  limp ;  the  skin  very  soft  and  delicate  and  almost  transparent ; 
the  cry,  a  low  feeble  whine  not  unlike  the  mew  of  a  kitten ;  the  respira- 
tory movements,  extremely  irregular,  sometimes  scarcely  perceptible  for 
several  seconds ;  the  movements  of  the  extremities  infrequent  and  never 
vigorous.  The  general  appearance  is  one  of  torpor.  The  muscles  of  the 
mouth  and  cheek  and  tongue  may  lack  the  requisite  force  for  sucking, 
so  that  this  is  practically  impossible,  and  even  deglutition  is  slow,  difficult, 
and  prolonged.  It  is  difficult  to  maintain  the  normal  body  temperature ; 
unless  closely  watched  this  may  fall  far  below  the  normal,  and  may  rise 
quite  as  much  above  it  with  the  use  of  too  much  artificial  heat.  I  once 
saw  a  fluctuation  of  13°  F.  occur  in  a  few  hours  from  such  causes.  All  the 
symptoms  mentioned  vary  much  according  to  the  degree  of  prematurity. 
In  the  management  of  these  cases  there  are  two  problems  to  be  solved : 
the  first  to  maintain  the  animal  heat,  the  second  to  nourish  the  infant. 
Difficult  as  it  always  is  to  rear  a  premature  infant,  these  difficulties  are 
much  increased  in  cases  where  proper  means  are  not  adopted  immediately 
after  birth.  The  loss  which  these  children  sustain  during  the  first  few 
days  is  in  very  many  cases  so  great  that  subsequent  measures,  however 
well  carried  out,  are  futile.  The  heat-producing  power  is  so  feeble  that 
the  body  temperature  quickly  falls  below  normal  unless  artificial  heat  is 
constantly  used.  The  effect  of  cold  upon  these  delicate  infants  is  very 
serious,  and  not  only  growth  but  even  life  depends  upon  maintaining  the 
body  temperature  steadily  and  uniformly.  Their  extreme  susceptibility 
is  something  which  it  is  difficult  for  one  to  appreciate  who  has  not  had 
experience  in  these  cases. 

One  of  the  simplest  means  of  maintaining  the  temperature  is  to  oil 
the  skin  and  then  roll  the  entire  body  in  cotton  batting,  no  clothing  ex- 
cepting the  diaper  being  used.  The  body  should  then  be  wrapped  in 
two  or  three  blankets  and  surrounded  by  bottles  or  rubber  bags  con- 
taining hot  water.  The  room  temperature  should  be  kept  about  80°  F. 
These  means  are  usually  sufficient  in  infants  of  four  pounds  or  over,  but 
in  those  much  under  this  weight  this  is  not  enough.  Where  cotton  is 
used  it  should  be  changed  only  once  in  two  or  three  days,  excepting  about 
the  buttocks.  If  absorbent  cotton  be  used  in  tin's  region  instead  of  cotton 
batting,  the  napkin  may  be  dispensed  with  altogether.  This  cotton  may 
be  changed  as  often  as  it  is  soiled  by  the  discharges.  These  children 
should  not  be  bathed,  but  the  skin  should  be  kept  in  a  healthy  condition 
by  rubbing  with  sweet  oil  once  in  two  or  three  days. 

Incubators. — In  infants  born  before  the  end  of  the  seventh  month, 
and  some  even  later  than  this,  the  animal  heat  can  seldom  be  properly 


12 


HYGIENE  AND  GENERAL  CARE  OF  INFANTS. 


maintained  h\  the  means  described.  For  such  cases  an  incubator  should 
be  employed. 

The  essential  things  in  an  incubator  are  means  of  maintaining  a  uni- 
form temperature  and  efficient  ventilation ;  since  the  dangers  of  infection 
are  great,  absolute  cleanliness  is  indispensable.  The  temperature  for  the 
youngest  and  most  delicate  infants  should  be  from  90°  to  95°  F. ;  for 
those  somewhat  older  and  stronger,  from  85°  to  90°  F.  Ventilation  is 
much  more  easily  secured  when  the  air  admitted  to  the  incubator  is  con- 
siderably below  these  figures,  or  not  above  60°  or  65°.  The  incubator 
should  therefore  stand  in  a  large  cool  room  or  communicate  with  the.  out- 
side air.  A  thermostat  attachment  is  a  great  advantage:  as  is  also  fil- 
tration of  the  air  through  cotton.  Metal  construction  allows  greater 
cleanliness  and  more  complete  disinfection.  The  incubator  of  Lion 
(Mce)  seems  to  fulfil  all  these  requirements  better  than  any  other  yet 
constructed.  On  account  of  the  difficulties  and  dangers  inherent  in 
small  incubators,  Escherich  *  has  devised  an  "  incubator  room  "  in  which 
several  infants  can  be  accommodated.  It  is  four  by  eight  and  a  half  feet, 
and  six  feet  high.  The  nurse  can  enter  this,  and  thus  the  removal  of  the 
child  for  feeding  or  any  other  purpose  is  avoided.  Better  results  are 
claimed  to  have  been  obtained  than  by  the  small  apparatus. 

A  simple  incubator  can  be  constructed  of  wood,  with  which  good  re- 
sults can  be  obtained ;  but  it  requires  great  care  to  ventilate  and  to  keep 


Fig.  1. — Incubator. 

clean.  A  modification  of  Tarnier's  incubator,  devised  by  Dr.  E.  J.  She- 
row  and  myself,  is  shown  in  Figs.  1  and  2.  It  is  thirty  inches  long, 
twenty  inches  wide,  and  twenty  inches  high.  The  openings  for  fresh  air 
should  be  two  upon  either  side,  each  at  least  three  inches  in  diameter; 
the  slide  permits  one  or  both  to  be  open.     The  sponge  moistens  the  air. 

*  Shaw,  Albany  Medical  Annals,  September,  1900. 


THE  CARE   OP   PREMATURE  AND  DELICATE  INFANTS.  13 


Its  construction  is  made  clear  by  the  illustration.  The  infant  lies  upon  a 
bed  of  cotton  or  a  soft  pillow,  and  should  be  lightly  clothed,  a  shirt  and 
napkin  being  generally  sufficient.  It  is  disturbed  as  little  as  possible.  It 
should  be  removed  only  for  feeding  and  weighing,  and  for  cleaning  the 


i 


Glaus  Cover 


Air  Exit 


^m. 


m 


Fig.  2.— Section  of  incubator,  showing  construction. 

incubator.  The  feeding  can  in  many  instances  be 
done  by  simply  sliding  the  glass  cover.  The  cotton 
bed  should  be  renewed  every  two  days  at  least ;  and 
the  skin  may  be  kept  clean  with  cotton  and  oil.  It  is  necessary  to  watch 
not  only  the  temperature  of  the  incubator,  as  registered  by  a  thermometer 
beside  the  baby,  but  the  baby's  rectal  temperature  should  be  taken  every 
few  hours;  fluctuations  between  97-5°  and  100-5°  F.  are  unimportant. 
If  the  variations  are  much  wider,  the  temperature  of  the  apparatus  should 
be  modified  accordingly. 

Every  incubator  baby  requires  close  and  constant  attention,  and  re- 
sults depend  upon  nothing  so  much  as  the  intelligence  and  watchfulness 
of  the  nurse.  Unless  skilled  attendance  is  possible,  the  results  without 
the  inculjator  may  be  better  than  with  it.  Since  no  system  of  ventilation 
can  be  absolutely  depended  upon,  whenever  possible  a  cylinder  of  oxygen 
should  be  at  hand,  for  use  in  the  attacks  of  asphyxia  or  cyanosis  which 
so  often  occur. 

The  feeding  of  the  premature  infant  is  not  less  important  than  the 
heat  and  ventilation.  Few  infants  under  eight  and  a  half  months  will 
take  the  breast.  Most  of  those  over  seven  months  will  suck  from  a  bottle 
if  the  nipple  is  small  and  soft.  The  feeder  suggested  by  Eotch,  which 
is  in  principle  only  a  large  medicine  dropper,  works  very  well  for  many 
cases.  A  few  must  be  fed  by  gavage.  Feeding  slionld  always  be  slowly 
done;  if  rapidly  taken,  some  of  the  food  is  likely  to  be  regurgitated,  and 
this  regurgitation  may  produce  attacks  of  asphyxia  or  even  aspiration- 
piKMUiionia.  'I'lic  (|ii;intity  of  food  and  the  frequency  of  feeding  will 
depend  ui)on  the  size,  age,  and  vigour  of  the  child.  At  first  only  one 
or  two  drachms  should  be  given,  and  repeated  every  hour ;  later,  as  much 
3 


14 


HYGIEN^E  AND   GENERAL   CARE   OF  INFANTS. 


as  half  an  ounce  every  hour;  and,  finally,  when  the  child  has  reached 
what  would  be  full  term,  from  one  to  two  ounces  may  be  given  every 
two  hours.  Artificial  feeding  I  have  not  found  very  satisfactory  with 
premature  infants.  In  some  of  the  larger  and  more  vigorous,  milk 
modified  according  to  the  directions  given  in  the  chapter  on  Infant  Feed- 
ing gives  good  results;  but  for  the  weaker  and  smaller  children  good 
breast  milk  is  essential.  For  the  first  twenty-four  hours,  ordinarily 
nothing  is  given  except  warm  water  or  a  4-per-cent  solution  of  milk 
sugar,  one  or  two  drachms  every  four  hours.  When  two  days  old,, 
breast  milk  may  be  given  diluted  with  an  equal  quantity  of  the  sugar  solu- 
tion, in  all  two  or  three  drachms  every  hour.  The  proportion  of  milk 
may  be  gradually  increased  until  at  the  end  of  two  or  three  weeks  it  is 
given  undiluted,  the  guide  to  increasing  it  being  the  condition  of  the 
infant's  digestion.  The  breast  milk  selected  should  be  that  of  a  woman 
whose  own  child  is  at  least  ten  days  old.  The  premature  baby  may  take 
its  mother's  breast  wholly  or  in  part  as  soon  as  it  is  sufficiently  strong 
to  nurse.  But  for  two  or  three  weeks  it  is  almost  always  necessary  to 
have  the  breast  of  another  woman  to  draw  upon. 

The  results  with  premature  babies  will  depend  very  much  upon  how 
soon  after  birth  they  receive  proper  care.  Where  one  is  expected,  an 
incubator  should  be  in  readiness,  so  that  the  child  can  be  put  into  it  at 
once  or  as  soon  as  it  is  breathing  properly.  If  the  incubator  is  not  em- 
ployed until  the  child  is  several  days  old  and  is  losing  rapidly,  the  chances- 
are  poor.  Another  factor  of  importance  already  mentioned  as  greatly 
affecting  results  is  the  constant  attention  of  a  nurse  who  has  had  expe- 
rience in  cases  of  this  kind.  The  age  and  vigour  of  the  infant  are  of  the 
greatest  importance  in  estimating  the  chances  of  survival.  The  follow- 
ing table  gives  Tarnier's  statistics,  showing  the  percentage  of  premature 
infants  saved  during  a  period  of  five  years  without  the  incubator,  and 
during  the  succeeding  five  years  with  the  incubator ;  also  the  percentage 
saved  at  the  Sloane  Hospital  (Wew  York),  as  published  by  Voorhees :  * 


Age. 


Born  at  6    months. 

"   "  n 

"     "  8 


Tarnier  saved 
without  incu- 
bators. 


0-0 
21-5 
39-0 
54-0 

78-0 
88-0 


Tarnier  saved 
with  incubator. 


16-0 
36-6 
49-8 
77-0 
88-8 
96-0 


Voorhees 
saved  with 
incubators. 


22-0 
41-0 
75-0 
70-0 


Voorhees  saved 
excluding  cases 

dying  a  few 
hours  after  birth. 


66-0 
71-0 
89-0 
91-0 


Eesults  will  improve  with  the  experience  of  the  physician  in  the  feed- 
ing and  care  of  these  very  sensitive  patients.  Much  is  yet  to  be  learned 
about  them. 


*  Archives  of  Paediatrics,  May,  1900. 
ture  Babies  in  Incubators. 


An  excellent  article  on  the  Care  of  Prema- 


CHAPTER   IL 

GROWTH  AND  DEVELOPMENT  OF  THE  BODY. 

Obseevations  upon  growth  and  development  are  of  the  utmost  im- 
portance during  infancy  and  childhood.  Only  by  this  means  are  very 
many  diseases  detected  in  their  incipiency.  Early  recognition  carries 
with  it  in  most  cases  the  possibility  of  checking  such  pathological  pro- 
cesses, as,  if  allowed  to  go  on,  may  affect  the  health  not  only  in  infancy 
but  even  throughout  life. 

By  familiarity  with  what  is  normal,  detection  of  the  abnormal  soon 
becomes  easy.  Investigation  in  regard  to  these  subjects  should  be  made  a 
part  of  the  physical  examination  of  every  child. 

WEIGHT. 

The  weight  of  the  infant  is  the  best  means  we  have  to  measure  its 
nutrition.  It  is  as  valuable  a  guide  to  the  physician  in  infant  feeding  as 
is  the  temperature  in  a  case  of  continued  fever.  Although  the  weight  is 
not  to  be  taken  as  the  only  guide  to  the  child's  condition,  it  is  of  such 


Fig.  3. 


Fig.  4. 


importance  that  we  cannot  afford  to  dispense  with  it  during  the  first  two 
years.  It  is  a  great  advantage  to  keep  up  regular  observations  during 
childhood. 

Weekly  weighings  should  be  made  for  the  first  six  months,  bi-weekly 
for  the  rest  of  the  first  year,  and  monthly  during  the  second  year.  Deli- 
cate children  should  be  weighed  even  more  frequently.  Satisfactory  scales 
of  moderate  price  for  domestic  use  are  those  known  in  the  shops  as  the 
"Universal  Family  Scales."     (Fig.  3).     These  weigh  up  to  twenty-four 

15 


16 


GROWTH  AND  DEVELOPMENT. 


pounds  and  indicate  ounces.  For  hospital  use  and  for  very  fine  observa- 
tions more  accurate  scales  are  needed.  In  Fig.  4  are  shown  the  scales  I 
employ ;  they  weigh  up  to  sixty-one  pounds  and  indicate  half  ounces.* 

Weight  at  Birth. — The  following  figures  are  taken  consecutively  in 
nearly  equal  proportion  from  the  records  of  the  Nursery  and  Child's 
Hospital,  the  Sloane  Maternity,  and  the  New  York  Infant  Asylum,  and 
include  only  full-term  children  : 

Average  weight  of  568  females 7-16  lbs.  (3,260  grammes). 

590  males 7-55    "   (3,400        "        ). 


1,158  infants 7-35    "   (3,330 


)• 


Weight  Curve  during  the  First  Few  Weeks.  —  The  accompanying 
chart  represents  the  variations  in  weight  for  the  first  twenty  days.  These 
observations  were  made  upon  one  hundred  healthy,  nursing  infants,  fifty 

males  and  fifty  fe- 
males, at  the  Nursery 
and  Child's  Hospi- 
tal. The  children 
were  weighed  daily 
during  the  period 
of  observation.  The 
average  weight  at 
birth  was  7' 1  pounds. 
The  curve  shows  a 
very  marked  loss  of 
weight  on  the  first ' 
day  and  a  slight  loss 
on  the  second  day, 
the  lowest  point  be- 
ing touched  at  the 
beginning  of  the 
third  day ;  but  from 
this  time  there  was 
a  steady  gain.  The 
average  initial  loss 
in  these  cases  was 
ten  ounces,  being  in  each  sex  exactly  eleven  per  cent  of  the  body  weight. 
In  eight  hundred  and  thirty-five  cases,  however,  including  those  above 
mentioned,  the  average  loss  was  nine  and  a  half  ounces.  The  loss  of  the 
first  days  is  chiefly  due  to  the  discharge  of  the  meconium  and  urine,  but  is 
in  part  from  the  excess  of  tissue  waste  over  the  nutriment  derived  from 
the  breasts.     After  the  third  day,  coincident  with  an  abundant  secretion 


Name, - Date  of  Birth........ ......189 

Gms. 

Lbs. 

1 

2 

3 

i 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

4420 
iSlO 
i200 
4080 
3970 
3850 
3740 
3030 
3510 
3400 
3290 
3180 
3060 
2940 
2830 
2720 
2610 
2490 
2380 

9U 

9K 

914 

» 

&'A 

8M 

8 

7U 

TA 
7 

(,% 
S'A 

6Ji 
6 

5% 
5A 

,— 

^ 

-^ 

-^ 

v^ 

'^ 

^ 

,— ' 

--- 

K-' 

\ 

^ 

^ 

N 

^ 

^ 

N 

— ' 

^ 

i       1 

Fig.  5.— Weight  curve  of  the  first  twenty  days. 


*  These  are  made  by  the  Howe  Scale  Company. 


WEIGHT   CURVE   OF   THE   FIRST   YEAR.  17 

of  milk,  there  is  a  steady,  daily  increase  in  weight.     If  the  milk  is  very 
scanty  or  is  wanting  altogether,  the  loss  in  weight  continues. 

The  birth-weight  of  nursing  children  who  thrive  normally  is  regained 
on  the  average  on  the  tenth  day.  The  most  frequent  deviation  from  the 
normal  curve  consists  in  a  continued  loss  or  stationary  weight  after  the 
third  day.  This  may  be  due  to  acute  illness,  such  as  bronchitis,  diarrhoea, 
pyajmia,  or  haemorrhage,  but  in  the  majority  of  cases  there  is  a  disturbance 
of  nutrition  from  improper  or  insufficient  food.  This  is  quite  as  likely  to 
be  the  case  in  nursing  infants  as  in  those  who  are  artificially  fed.  Under 
these  circumstances  the  loss  may  continue  indefinitely,  and  it  may  be  slow 
or  rapid  according  to  the  character  of  the  nursing  or  feeding. 

The  weight  curve  of  infants  who  are  artificially  fed,  even  though  they 
are  strong  and  vigorous  and  the  feeding  properly  done,  rarely  follows  for 
the  first  month  the  same  lines  as  that  of  nursing  infants.  We  usually 
see  an  initial  loss  which  is  about  the  same  as  in  nursing  infants,  then  a 
period  of  nearly  stationary  weight  lasting  from  one  to  two  weeks.  xA.fter 
this  the  steady  regailar  gain  begins,  and  is  quite  eqnal  to  that  of  nursing 
infants.  This  period  of  stationary  weight  is  to  be  expected  while  the 
infant  is  becoming  accustomed  to  his  new  food.  The  chief  danger  at  this 
time  is  that  the  physician,  because  there  is  no  gain,  may  be  led  to  increase 
either  the  strength  or  the  quantity  of  the  food  so  rapidly  as  to  upset  the 
child's  digestion. 

There  are  cases  in  which  aii  excessive  loss  of  weight  during  the  first 
three  or  four  days  is  associatcd^with  an  elevation  of  temperature,  but 
without  any  other  evident  signs  of  disease.  Both  the  fever  and  the  rapid 
loss  in  weight  are  to  be  looked  upon  as  due  to  the  same  cause — inani- 
tion. This  will  be  more  full}^  considered  in  the  chapter  devoted  to  that 
subject. 

Excessive  loss  in  weight  during  the  first  few  days  from  any  cause 
whatsoever,  seriousl)^  handicaps  an  infant  during  the  first  weeks  of  its 
life.  The  great  importance  of  this  has  not  been  sufficiently  appreciated. 
Loss  in  weight  after  the  third  day  is  an  indication  for  food  in  addition 
to  tliat  derived  from  the  breast. 

Weight  Curve  of  the  First  Year. — The  curve  of  the  accompanying 
cliart  is  made  up  from  complete  weight  charts  ol'  one  hundred  hoaltliy 
nursing  infants  who  were  thriving  and  weighed  every  week,  and  the  in- 
complete eliarts  of  about  three  hundred  otlier  inl'nnts.  There  ai'c  repre- 
sented in  round  numbers  about  ton  thousand  observations  on  ohildi-en 
under  one  year.  The  period  of  most  rapid  increase  is  dui'ing  flu-  first 
three  months.  It  is  slowest  from  the  sixth  to  the  ninth  month.  This  curve 
is  not  to  be  regarded  as  a  normal  line,  like  th?  normal  lin(^  of  the  tem]iera- 
ture  chart,  but  as  an  average  line.  An  iDlniil  wlio  is  ;i(  hitih  n  ]iound 
aijove  the  average  may  keep  this  distance  above  \\\v  line  for  the  whole 


18 


GROWTH  AND  DEVELOPMENT. 


year ;  another  weighing  one  pound  less  than  the  average  may  be  as  far 
below  it.  Grirls  throughout  the  year  are  on  the  average  half  a  pound 
lighter  than  boys.  No  single  child  exactly  follows  the  line  all  the  way, 
but  it  is  surprising  to  see  how  close  to  it  a  very  large  number  of  the  cases 
come. 

In  artificially-fed  infants — provided  the  feeding  is  properly  done — the 
curve  does  not  differ  essentially  from  that  of  breast-fed  infants,  excepting 


JVame, 

WEIGHT  CHART 
...Date;  of  Bir 

fh 

r 

Rn 

•'                                               -^          1 

E 
o 

-Q 

-J 

MONTH  OF  AGE. 

123456          78          9        10        11      12 

10890 
10130 
9980 
9530 
9070 
8620 
8160 
7710 
7260 
6800 
6350 
6900 
5M0 
4990 
45i0 
4080 
3630 
3180 
2720 
2270 

24 
23 
22 
21 
20 
19 
18 
17 
16 
15 
14 
13 
12 
11 
10 
9 
8 
7 
6 
5 

1 

1 

^ 

^ 

'^ 

^'i 

■ 

1 

_ 

„.., 

"^ 

1 

L.- 

^^ 

^ 

^^ 

,' 

y 

t> 

z' 

/ 

/ 

/ 

/ 

/ 

/ 

/ 

y 

V 

J 

,  1 

1 

{ 

1 

1 

1 

_ 

1 

J 

1, 

Fig.  6. — The  weight  curve  of  the  first  year. 

in  the  slower  gain  of  the  first  month,  although  this  difference  is  usually 
made  up  before  the  sixth  month  is  reached.  (See  also  Figs.  30  and  36.) 
At  the  end  of  the  first  year  the  average  child  weighs  nearly  three  times 
as  much  as  at  birth.  Perfect  health  during  the  first  year  is  consistent 
only  with  a  steady  gain  in  weight.  A  child  may  not  always  gain  rapidly, 
but  it  should  gain  steadily,  and  if  it  does  not,  something  is  wrong.  All 
the  conditions  surrounding  the  infant  should  be  investigated,  but  espe- 
cially the  food.  One  should  not  be  satisfied  unless  the  average  weekly 
gain  during  the  first  six  months  is  at  least  four  ounces.  In  the  second 
six  months  it  may  be  slightly  less.  It  may  be  taken  as  a  rule  that  a  child 
who  gains  regularly  in  weight  is  thriving;  an  exception  must,  however, 
be  made  in  the  case  of  some  infants  who  are  fed  chiefly  upon  carbo- 
hvdrate  foods. 


THE  WEIGHT  OF  OLDER  CHILDREN. 


19 


Weight  from  the  Second  to  the  Fifth  Year.— Comparatively  few  obser- 
yations  have  been  published  upon  the  weight  during  this  period.  From 
three  hundred  and  seventy-two  personal  observations  it  appears  that  the 
gain  is  about  six  pounds  during  the  second  year,  about  four  and  a  half 
during  the  third  year,  and  about  four  pounds  during  the  fourth  year :  the 
actual  weights  are  given  in  the  large  table  (page  20).  During  this  period 
the  gain  is  rarely  steady  even  in  the  second  year.  With  most  children  it 
is  slowest  or  the  weight  is  stationary  in  the  summer  months,  while  the 
most  rapid  increase  is  usually  seen  in  autumn.  Throughout  this  period 
the  girls  gain  in  about  the  same  ratio  as  boys,  but  remain  on  the  average 
nearly  one  pound  lighter.  During  almost  every  illness,  no  matter  of  what 
character,  the  gain  in  weight  ceases,  and  usually  there  is  a  loss,  the  rapid- 
ity and  extent  of  which  are  somewhat  proportionate  to  the  severity  of  the 
attack ;  but  it  is  always  much  more  rapid  in  diseases  of  the  digestive  tract 
than  in  any  other  form  of  illness. 

Weight  of  Older  Children. — The  weights  given  in  the  table  of  children 
from  five  to  fourteen  years  are  from  Bowditch.  Observations  were  made 
upon  children  of  American  parentage  in  the  public  schools  of  Boston — 
upon  4,327  boys  and  3,681  girls.*  It  is  to  be  remembered  that  these 
weights  include  the  ordinary  clothing,  while  those  below  five  years  are 
without  clothing,  f 

The  slowest  gain  is  from  the  fifth  to  the  eighth  year,  when  it  is  about 
four  pounds  a  year.  From  the  eighth  to  the  eleventh  year  it  rises  to  about 
six  pounds  a  year.  Up  to  the  eleventh  year  the  two  sexes  gain  in  about 
the  same  ratio.     From  the  eleventh  to  the  thirteenth  year  the  girls  gain 


*  W.  T.  Porter  has  published  (1894)  observations  made  upon  14,744  children  of  Amer- 
ican parentage  in  the  public  schools  of  St.  Louis.  His  figures  show  quite  a  variation 
from  those  of  Bowditch,  and  are  as  follows  : 


boys'  weight. 

GIRLS-   WEIGHT. 

Age. 

Kilos. 

Pounds. 

Kilos. 

Pounds. 

6  years  

19-66 
21-67 
23-91 
26-08 
28-49 
31-26 
33-45 
35-96 
40-34 
47-25 
52-10 

43-2 

47-7 
52-6 
57-4 
62-7 
68-8 
73-6 
79-1 
88-7 
103-9 
114-6 

18-76 
20-82 
22-71 
25-07 
27-43 
29-93 
33-17 
38-29 
43-12 
46-90 
50-06 

41-3 

7     "       

45-8 

8     "     

50-0 

9     "       

55-1 

10     "       

60-3 

11     "       

65-8 

12     "     

73-0 

13     "     

84-2 

14     "     

94-9 

15     "     

103-2 

16     "     

110-1 

\  The  average  weight  of  the  ordinary  house  clothing  of  school  children,  according 
to  Bowditch,  is  at  five  years  2-8  pounds  for  both  sexes ;  at  seven  years,  3-5  for  both 
sexes  ;  at  ten  years.  5-7  pounds  for  boys  and  4-5  pounds  for  girls ;  at  thirteen  years,  7-4 
pounds  for  boys  and  5-6  pounds  for  girls ;  at  sixteen  year.s,  9-7  pounds  for  boys  and  8-1 
pounds  for  girls.     This  must  be  deducted  from  weights  given  to  obtain  the  net  weight. 


20 


GROWTH   AND   DEVELOPMENT. 


much  more  rapidly,  passing  the  boys  for  the  first  time  and  maintaining 
this  lead  until  the  fifteenth  year,  when  again  the  boys  pass  them. 

Table   showing    Weight,   Height,   and   Circumference   of   the  Head   and 
Chest  from  Birth  to  the  Sixteenth  Year* 


Age. 


Birth 

6  months  . 
12  months. 
18  months. 

2  years 

3  years 

4  years 

5  years. . . . , 

6  years 

7  years 

8  years 

9  years 

10  years.. .  . 

11  years. . .  . 

12  years.. .  . 

13  years. . .  . 

14  years. . . . 

15  years.. . . 

16  years. . .  . 


Sex. 


Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 


Pounds.       Kilos. 


7-55 

7-16 

160 

15-5 

20-5 

19-8 

22-8 
22-0 

2G  5 

25-5 

31-2 

30-0 

350 

34-0 

41  2 

39-8 

45  1 

43-8 

49-5 

48-0 

54-5 

52-9 

60  0 

57-5 

66-6 

64-1 

72  4 

70-3 

79-8 
81-4 

88-3 
91-2 

99-3 

100-3 

110-8 

108-4 

123  7 

113-0 


3-43 

3  26 

7  26 

7-03 

9  29 

8-84 

10-35 

9-98 

12  02 

11-56 

14  14 

13-60 

15-87 

15-41 

18-71 

18-06 

20  48 

19-87 

22-44 

21-78 

24  70 

24-01 

26-58 

26-10 

30  22 

29-07 

32  83 

31-87 

36-21 

36-90 

40  04 

41-36 

45  03 

45-50 

50-26 

49-17 

56-09 

51-24 


Inches.       Cm 


20  6 

20-5 

25  4 

25-0 

290 

28-7 

30  0 

29-7 

5 

5 

35  0 

35-0 

38  0 

38-0 


32 

32' 


41 

41 


44  1 

43-6 

46-2 

45-9 

48-2 
48-0 

501 

49-6 

52  2 

51-8 

54  0 

53-8 

55-8 
57-1 


58 
58 


610 

60-3 

63  0 

61-4 

65-6 

61-7 


52  5 

52-2 

64-8 

63-6 

73-8 
73-2 

76-3 

75-6 

82-8 
82-8 


89 
89 


96-7 

96-7 

1060 

105-3 

112-0 

110  9 


117 

116' 


122-3 

122-1 

127-2 

126-0 

132  6 

131-5 

137-2 

136-6 

141-7 

145-2 

147  7 

149-2 

155  1 

153-2 

159-9 

155-9 

166-5 

156-7 


Inches.     Cm 


13.4 

13-0 

16  5 

16-1 

18-0 

17-4 

18  5 

18-0 

190 

18-5 

20  1 

19-8 

20  7 

20-5 

21-5 

21-0 

23  2 

22-8 

23-7 

23-3 

24  4 

23-8 

25  1 

24-5 

25-8 
24-7 

26  4 

25-8 

27-0 

26-8 

27-7 

28-0 

28-8 
29-2 


300 

30-3 

31  2 

30-8 

34.2 

33-2 

42-0 

41-0 

45-9 

44-4 

47-1 

45-9 

48  4 

47-0 

511 

50-5 

52-8 
52-2 

54-8 
53-5 

59-1 

58-3 

60-6 

59-5 

62-2 

60-8 

63  9 

62-5 

65  6 

63-0 

67-2 

65-8 

68-8 
68-3 

70-6 

71-3 

73  3 

74-1 

76  6 

76-8 

79  2 

78-8 


Inches.       Cm 


13-9 

13-5 

17-0 

16-6 

180 

17-6 

18-5 

18-0 

18-9 

18-6 

19-3 

19-0 

19  7 

19-5 

20  5 

20-2 


210 

20-7 


21-8 

21-5 


35  5 

34-5 


43 

42- 


45-9 

44-6 

47-1 

45-9 

48-2 
47-2 

490 

48.4 

50.3 

49.6 

52.2 

51.3 


53-5 

52-8 


55  6 

54-8 


*  The  recently  published  observations  of  Boas  (Science,  April  12,  1895)  upon  4,319 
children  over  six  years  old  show  that  first  born  exceed  later  children  both  in  height 
and  weiffht. 


GROWTH   OF  THE   EXTREMITIES.  21 

HEIGHT. 

The  figures  showing  the  height  at  different  ages  are  given  in  the  fore- 
going table.  Tlie  measurements  of  infants  at  birth  are  taken  in  about 
equal  numbers  from  the  records  of  the  New  York  Infant  Asylum  and 
the  Sloane  Maternity  Hospital.     They  were  made  upon  full-term  infants. 

Average  length  of  231  males 20-61  inches  (52-5  cm.) ; 

211  females 20-47      "       (52-2     "); 

«  "         442  infants 20-54      "       (52-35  "  ). 

The  most  rapid  gain  in  length  is  in  the  first  year.  During  this  period 
the  child  grows  on  an  average  a  little  over  eight  inches  (21  cm.).  This 
gain  is  usually,  but  not  always,  proportionate  to  the  increase  in  weight. 
During  the  second  year  the  average  increase  is  three  and  a  half  inches  (9 
cm.).  From  this  time  on  the  rate  of  increase  is  quite  uniform  in  both 
sexes  until  the  eleventh  year,  it  being  between  two  and  three  inches  a 
year. 

After  the  eleventh  year  in  girls  and  the  twelfth  in  boys  the  growth  is 
much  more  rapid.  In  height  the  girls  exceed  the  boys  at  the  twelfth  and 
thirteenth  years  for  the  only  time  in  their  growth. 

In  the  figures  given  in  the  preceding  table  those  of  five  years  and  over 
are  taken  from  Bowditch,*  the  observations  being  made  upon  the  same 
children  as  those  whose  weights  were  taken.  The  observations  from  six 
months  to  four  years  inclusive  are  from  original  sources,  and  are  drawn 
from  about  five  hundred  cases.  The  height  much  more  than  the  weight 
of  children  is  modified  by  hereditary  infiuences. 

Rachitic  children  during  infancy  and  early  childhood  are,  as  a  rule, 
shorter  than  others,  I  have  frequently  measured  such  children  during 
the  third  year  who  were  six  inches  below  the  average  for  that  age.  The 
effect  of  malnutrition  upon  the  length  of  the  body  is  much  less  than  on 
the  weight. 

GROWTH  OF  THE  EXTREMITIES  AS  COMPARED  WITH  THE  TRUNK. 

At  birth  the  trunk  is  relatively  long  and  the  extremities  short.  Sub- 
sequently the  growth  of  the  extremities  is  much  more  rapid  than  that  of 
the  trunk.  Thus  I  have  found  at  birth  the  length  of  the  lower  ex- 
tremities (measuring  from  the  anterior  superior  spine  of  the  ilium  to  the 
sole  of  the  foot)  to  be  forty-three  per  cent  of  the  length  of  the  body ;  at 
five  years,  fifty-four  per  cent,  and  at  sixteen  years  sixty  jier  cent.  The 
above  figures  are  from  one  hundred  and  fifty  observations,  which,  although 
not  numerous  enough  for  exact  percentages,  are  still  sufficient  to  give  a 

*  According  to  the  observations  of  Porter,  the  St.  Louis  chiklren  reach  a  given 
height  on  the  average  about  one  your  later  than  Boston  sclioul  cliiklron. 


22  GROWTH  AND   DEVELOPMENT. 

very  good  idea  of  the  general  relation  of  the  length  of  the  extremities  to 
that  of  the  body  as  a  whole. 

THE  HEAD. 

Circumference. — The  average  circumference  of  the  head  at  birth  in 
four  hundred  and  forty-six  full-term  infants  taken  in  about  equal  num- 
bers from  the  Sloane  Maternity  Hospital  and  Xew  York  Infant  Asylum 
was  as  follows  : 

Average  circumference  of  the  head,  231  males. .   13-90  inches  (35 "5  cm.); 

"      215  females.  13-52      "      (34-5    "  ); 

Total 446  infants.  18 -71      "      (35-0     "  ). 

The  occipito-frontal  measurement  has  been  the  one  taken. 

The  growth  of  the  head  is  most  rapid  during  the  first  year,  the  in- 
crease being  about  four  inches  (10  cm.).  During  the  second  year  the 
increase  is  about  one  inch  (2-5  cm.).  From  the  second  to  the  fifth  year 
the  growth  is  slower,  being  only  about  one  and  a  half  inches  (4  cm.)  for 
the  three  years.  After  the  fifth  year  the  increase  in  the  circumference 
of  the  head  is  very  slow,  as  shown  by  the  preceding  table. 

Closure  of  the  Sutures. — The  main  sutures  of  the  cranium  are  not 
commonly  ossified  before  the  end  of  the  sixth  month,  and  very  fre- 
quently some  mobility  may  be  detected  at  the  end  of  the  ninth  month. 
Distinct  separation  of  the  cranial  bones  after  birth  is  abnormal.  It  is 
most  frequently  seen  in  premature  and  in  syphilitic  infants,  but  rarely 
in  this  country  as  the  result  of  congenital  rickets. 

Closure  of  the  Fontanels.— The  posterior  fontanel  is  usually  obliter- 
ated by  the  end  of  the  second  month.  The  anterior  fontanel  under 
normal  conditions  closes  on  an  average  at  about  the  eighteenth  month. 
The  usual  variations  are  between  the  fourteenth  and  the  twenty-second 
months.  At  the  end  of  the  first  year  the  fontanel  should  be  about  one 
inch  in  diameter.  An  open  fontanel  at  the  end  of  the  second  year  may 
always  be  considered  abnormal.     Eickets  is  the  usual  explanation. 

The  closure  of  the  fontanel  is  not  always  early  in  well-nourished  chil- 
dren, nor  is  it  always  delayed  in  those  suffering  from  malnutrition.  It 
often  happens  that  in  a  child  with  marked  evidences  of  malnutrition  the 
fontanel  at  ten  or  twelve  months  is  nearly  or  quite  closed  and  the  sutures 
firmly  ossified.  In  such  children  the  head  is  usually  small,  and  the  early 
closure  is  partly  due  to  the  slow  growth  of  the  brain.  On  the  other  hand, 
it  is  sometimes  the  case  that  in  stout,  well-nourished  children  the  fontanel 
may  remain  open  until  nearly  the  end  of  the  second  year,  although  the 
child  presents  every  evidence  of  perfect  nutrition  and  no  signs  of  rickets. 
This  may  be  due  to  the  fact  that  the  brain  has  grown  with  more  than 
usual  rapidity.  When,  however,  there  is  any  great  disproportion  between 
the  size  of  the  head  and  the  development  of  the  rest  of  the  body,  or  when 


SHAPE   OF   THE   HEAD.  23 

the  circumference  of  the  head  exceeds  very  much  the  figures  given  in  the 
table  above,  either  rickets  or  hydrocephalus  should  be  suspected. 

Shape  of  the  Head. — The  deformity  which  results  from  compression 
during  labour  usually  disappears  by  the  end  of  the  first  month.  During 
the  first  year  the  head  often  becomes  flattened  at  the  occiput  in  conse- 
quence of  the  child's  lying  too  much  upon  the  back.  This  is  easily 
remedied  by  changing  its  position.     A  slight  obliquity  of  the  head  may 


Fig.  7. — Premature  ossification  of  the  sagittal  suture.     Dealh  at  .-ix  \veoks. 

result  from  a  habitual  position  during  nursing  or  sleep.  A  marked  de- 
gree of  obliquity  is  sometimes  congenital,  but  usually  disappears  by  the 
fifth  or  sixth  year. 

The  other  abnormities  in  the  shape  of  the  head  are  chiefly  due  to 
rickets  and  hydrocephalus,  more  rarely  to  congenital  malformations  of 
the  brain.     They  will  be  considered  in  the  chapter  devoted  to  these  topics. 

Premature  ossification  of  the  sutures  of  the  cranium  occasionally  gives 
rise  to  a  very  striking  deformity  of  the  head.  I  liave  seen  two  cases 
of  such  deformity  from  prenuiture  ossification  of  the  sagittal  suture. 
The  heads  in  both  cases  were  very  narrow  and  long  in  the  antero-poste- 
rior  diameter.     The  forehead  was  narrow,  prominent,  and  slightly  pro- 


24  GROWTH   AND  DEVELOPMENT. 

jecting.  The  illustration  on  page  23  (Fig.  7)  shows  the  skull  of  one  of 
these  cases.  There  is  a  complete  obliteration  of  the  sagittal  suture.  In 
this  case  there  was  a  wide  separation  of  the  sutures  at  the  junction  of 
the  parietal  and  temporal  bones. 

THE  CHEST. 

The  figures  showing  the  circumference  of  the  chest  at  the  different 
periods  of  childhood  are  given  on  page  20.  The  measurements  up  to 
and  including  five  years  are  from  personal  observations,  those  from  the 
sixth  to  the  sixteenth  are  taken  from  Porter,  and  are  drawn  from  obser- 
vations on  31,371  school  children.  The  measurement  of  the  chest  is  that 
taken  midway  between  full  inspiration  and  expiration,  and  at  the  level  of 
the  nipples. 

In  the  newly-born  child  the  antero-posterior  and  the  transverse  diame- 
ters of  the  chest  are  nearly  the  same.  As  age  advances,  the  transverse- 
diameter  increases  very  much  more  rapidly,  so  that  the  outline  of  the 
chest  gradually  assumes  an  elliptical  shape,  which  it  maintains  during- 
childhood. 

At  birth,  the  circumference  of  the  chest  is  about  one  half  inch  less 
than  that  of  the  head,  but  throughout  infancy  the  two  measurements 
are  nearly  the  same.  It  is  not  until  the  third  year  that  the  average  cir- 
cumference of  the  chest  exceeds  that  of  the  head.  According  to  Uffel- 
mann,  the  circumference  of  the  head  and  the  chest  are  the  same  until 
the  twenty-first  month  in  a  robust  child,  and  until  two  and  a  half  years- 
in  an  average  child.  The  chest  measurement  in  infants  is  alwa3^s  much 
modified  by  the  amount  of  fat ;  but,  after  making  due  allowance  for  this,. 
a  large  chest  always  indicates  a  robust  child  and  a  small  chest  a  delicate 
one.  If  at  any  age  the  circumference  of  the  child's  chest  is  found  to  be 
below  the  average,  means  should  be  taken,  by  gjannastics  and  other- 
wise, to  develop  it. 

Deformities  of  the  thorax  result  chiefiy  from  rickets,  sometimes  from 
empyema,  emphysema,  and  cardiac  disease ;  in  older  children,  from  lat- 
eral curvature  of  the  spine,  or  from  Pott's  disease.  A  peculiar  deformity,, 
usually  congenital,  but  sometimes  rachitic,  is  the  funnel-shaped  chest,  the 
Trichter-brust  of  the  Germans.  It  consists  in  a  deep  pit-like  central 
depression  at  the  lower  end  of  the  sternum.     It  is  usually  permanent. 

THE  ABDOMEN. 

Throughout  infancy  the  circumference  of  the  abdomen  is,  as  a  rule,, 
about  the  same  as  that  of  the  chest.  At  the  end  of  the  second  year 
the  measurements  of  the  head,  chest,  and  abdomen  are  very  often  identi- 
cal ;  after  this  time  the  chest  measurement  increases  much  more  rapidly 
than  the  other  two.     Marked  enlargement  of  the  abdomen  is  seen  in. 


DEVELOPMEXT   OF  THE   SPECIAL  SENSES.  25 

many  varieties   of   chronic   intestinal   disorders.      It   is,   however,   most 
marked  in  the  tympanites  which  so  constantly  accompanies  rickets. 

MUSCULAR   DEVELOPMEXT. 

The  first  voluntary  movements  are  usually  in  the  fourth  month,  when 
the  infant  deliberately  attempts  to  grasp  some  object  placed  before  it. 
During  the  fourth  month,  as  a  rule,  the  head  can  be  held  erect  when  the 
trunk  is  supported.  In  many  infants  this  is  possible  in  the  early  part 
of  the  third  month.  At  seven  months  a  healthy  child  is  usually  able  to 
sit  erect  and  support  the  trunk  for  several  minutes. 

In  the  ninth  or  tenth  month  are  usually  seen  the  first  attempts  to  bear 
the  weight  ujDon  the  feet.  At  ten  or  eleven  months  a  child  stands  with 
slight  assistance.  The  first  attempts  at  walking  are  commonly  seen  in 
the  twelfth  or  thirteenth  month.  The  average  age  at  which  children 
walk  freely  alone  has  been,  in  my  experience,  the  fourteenth  or  fifteenth 
month.  Quite  wide  variations  are  seen  in  healthy  children.  Very  much 
depends  upon  the  surroundings.  I  have  known  infants  to  walk  at  ten 
months  and  many  others  not  until  seventeen  or  eighteen  months,  although 
showing  no  evidences  of  disease,  and  although  their  development  had  not 
been  retarded  by  previous  illness.  A  very  marked  difference  is  seen  in 
different  families  of  children  with  respect  to  the  time  of  walking. 

The  physician  is  often  consulted  because  of  backward  muscular  devel- 
opment, most  frequently  because  the  child  is  late  in  walking.  General 
malnutrition,  or  any  other  severe  or  prolonged  illness,  may  postpone  for 
several  months  this  or  any  of  the  other  functions  mentioned.  When 
there  is  no  such  explanation  of  the  backwardness,  a  child  who  does  not 
hold  up  its  head,  sit  alone,  or  make  efforts  to  stand  or  walk  at  the  proper 
time,  should  be  submitted  to  a  careful  examination  for  a  cerebral  or  spinal 
paralysis,  but  especially  for  rickets  which  is  the  most  frequent  explanation 
of  the  symptoms. 

Contrivances  for  teaching  infants  to  walk  are  unnecessary,  and  tlieir 
effect  may  even  be  injurious.  An  infant  should  be  allowed  the  greatest 
possible  freedom  in  the  use  of  its  limbs.  It  should  not  be  restrained- 
from  walking  when  inclined  to  do  so,  nor  continually  urged  to  walk  when 
no  voluntary  attempts  are  made.  Nothing  short  of  mechanical  restraint 
will  prevent  a  healthy  child  from  walking  or  standing  when  it  is  strong 
enough  to  do  so. 

DEVELOPMENT   OP   THE   SPECIAL  SENSES.* 

Sight. — The  newly-born  infant  avoids  the  light.  Its  pupils  contract 
in  a  light  room,  and  if  a  bright  light  is  brought  before  the  eyes  they 

*  For  many  of  the  facts  in  this  paragraph  I  am  indebted  to  Preyer's  The  Senses 
and  the  Will,  American  edition,  1888,  D.  Appleton  &  Co, 


26  GROWTH  AND   DEVELOPMENT. 

close.  During  the  first  few  weeks  the  infant  indicates  by  every  sign  that 
excessive  light  is  unpleasant.  As  early  as  the  sixth  day  the  eyes  will 
sometimes  follow  a  light  in  the  room,  and  the  child  may  even  turn  the 
head  for  this  purpose.  The  muscles  of  the  eyes  of  the  newly-born  infant 
act  irregularly  and  not  in  harmony.  Co-ordinate  action  for  general  pur- 
poses is  not  established  until  about  the  end  of  the  third  month.  Even 
after  this  time  inco-ordinate  action  is  occasionally  seen.  The  eyelids  also 
move  irregularly,  and  are  often  partly  separated  during  sleep.  The  cornea 
is  but  slightly  sensitive  during  the  first  weeks.  In  Prej^er's  child  it  was 
not  until  the  third  month  that  the  lids  closed  when  the  water  in  the  bath 
touched  the  lashes  or  the  cornea.  The  recognition  of  objects  seen  is  usu- 
ally evident  in  the  sixth  montii. 

It  is  important  that  the  room  in  which  the  newly-born  child  is  placed 
should  be  darkened,  and  that  for  the  first  few  weeks  the  eyes  should  be 
protected  against  strong  light. 

Hearing. — For  the  first  twenty-four  hours  after  birth  infants  are 
deaf.  This  deafness  sometimes  persists  for  several  days.  It  is  believed 
to  be  due  to  absence  of  air  from  the  middle  ear  and  to  swelling  of  the 
mucous  membrane  which  lines  the  tympanum.  With  the  movements  of 
respiration,  air  gradually  finds  its  way  into  the  middle  ear,  and  the  swell- 
ing subsides  during  the  first  few  days.  After  this  the  hearing  gradually 
improves,  and  during  the  early  months  of  life  it  is  very  acute.  The  child 
starts  at  the  slamming  of  a  door,  and  even  moderately  loud  noises  will 
waken  it  from  sleep.  By  the  end  of  the  second  month  it  will  sometimes 
turn  its  head  in  the  direction  from  which  the  sound  comes,  and  by  the 
end  of  the  third  month  this  will  usually  be  done.  Demme  found,  in 
observations  upon  one  hundred  and  fifty  infants,  that  the  voices  of  parents 
were  recognised  on  an  average  at  three  and  a  half  months. 

Not  only  are  the  ears  unusually  sensitive  to  sound  in  infancy,  but 
the  impression  produced  upon  the  brain  is  often  marked — very  loud 
sounds  causing  great  fright,  and  sometimes  even,  it  is  reported,  convul- 
sions. 

Touch. — Tactile  sensibility  is  present  at  birth,  but  is  not  highly  devel- 
oped except  in  the  lips  and  tongue,  where  it  is  very  acute  for  the  obvious 
necessity  of  sucking.  After  the  third  month  it  is  fairly  acute  over  the 
surface  of  the  body  generally.  Two  especially  sensitive  areas,  according 
to  Preyer,  are  the  forehead  and  external  auditory  meatus. 

Sensibility  to  painful  impressions  is  present  in  early  infancy,  but  very 
dull  as  compared  with  later  childhood. 

Temperature  is  also  distinguished.  This  recognition  is  especially 
acute  in  the  tongue.  A  young  infant  is  often  seen  to  refuse  to  take 
the  bottle  because  the  milk  is  only  a  few  degrees  too  cold  or  too 
warm. 

The  localization  of  sensory  impressions  comes  later,  probably  not  much 


DENTITION.  27 

before  the  middle  of  the  sixth  month,  aud  is  very  imperfect  throughout 
the  first  year. 

Taste. — This  is  highly  developed,  even  from  birth.  According  to  the 
experiments  of  Kussmaul,  the  ability  to  distinguish  sweet,  sour  and  bit- 
ter, exists  in  the  newly-born  child — sweet  exciting  sucking  movements, 
and  bitter,  grimaces.  A  young  infant  detects  with  surprising  accuracy 
the  slightest  variation  in  the  taste  of  its  food,  and  the  smallest  difference 
is  often  enough  to  cause  it  to  refuse  its  bottle  altogether.  Sweet  sub- 
stances are  always  easily  administered,  and  in  combination  with  sirups 
even  very  bitter  substances  can  be  given ;  but  to  aromatic  powders  and 
elixirs  it  usually  objects. 

Smell. — Observations  upon  the  sense  of  smell  in  newly-born  infants 
are  few  and  not  altogether  conclusive.  Kroner's  exjDeriments  appear  to 
show  that  smell  is  present  in  the  newly  born.  It  has  been  noted  to  be 
especially  acute  in  infants  born  blind.  The  sense  of  smell  is  developed 
much  later  than  the  other  senses.  Detection  of  fine  differences  in  odours 
is  not  acquired  until  quite  late  in  childhood. 

SPEECH. 

There  is  a  very  wide  variation  in  children  with  reference  to  the  time 
of  development  of  the  function  of  speech.  Girls,  as  a  rule,  talk  from  two 
to  four  months  earlier  than  boys.  Towards  the  end  of  the  first  year  the 
average  child  begins  with  the  words  "  papa,"  "  mamma."  By  the  end  of 
the  second  year  it  is  able  to  put  words  together  in  short  sentences  of  two 
or  three  words.  Progress  in  speech  from  this  time  is  very  rapid,  each 
month  showing  great  improvement.  Names  of  persons  are  commonly  first 
acquired,  then  the  names  of  objects.  Next  to  this  the  verbs  are  learned, 
and  then  adverbs  and  adjectives.  Conjunctions,  preiDositions,  and  articles 
follow  in  order,  and  last  of  all  the  personal  pronouns. 

If  a  child  of  two  years  makes  no  attempt  to  speak,  some  mental  defect 
may  usually  be  inferred. 

DENTITION. 

The  teeth  are  enclosed  at  birth  in  dental  sacs  which  are  situated  in  the 
gums.  Above,  they  are  covered  by  the  submucous  connective  tissue  and 
the  mucous  membrane ;  below,  the  dental  sacs  rest  in  depressions  in  the 
alveolar  process  of  the  jaw.  The  tooth  grows  in  length  mainly  as  the 
result  of  the  calcification  of  its  roots,  and  being  thus  fixed  below,  it  pushes 
upward  towards  the  mucous  membrane.  This  growth  undoubtedly  goes 
on  steadily  from  birth  until  the  tooth  pierces  the  gum. 

The  deciduous  or  milk  teeth  are  twenty  in  number.  The  time  at 
which  they  appear  is  subject  to  considerable  variation  even  under  normal 
conditions.  The  following  is  the  order  and  the  average  time  of  appearance 
of  the  different  teeth  : 


28  GROWTH   AND  DEVELOPMENT. 

(1)  Two  lower  central  incisors 6  to    9  months. 

(2)  Four  upper  incisors 8  "  12        " 

(3)  Two  lower  lateral  incisors  and  four  anterior  molars.  12  "  15        " 

(4)  Four  canines 18  "  24       " 

(5)  Four  posterior  molars 24  "  30        " 

At  1    year  a  child  should  have 6  teeth. 

At  li  "  "  "  "  "    12     " 

At  2    years       "  "         "    16     " 

At  2i     "  "  "         "    ..20     " 

Quite  wide  variations  on  both  sides  of  the  average  are  common,  and 
are  not  always  easy  of  exj)lanation.  In  many  cases  it  seems  to  be  a  family 
idiosyncrasy,  since  in  the  different  members  of  a  family  the  teeth  are 
apt  to  appear  at  about  the  same  time.  I  know  one  family  in  which  no 
less  than  three  members  of  three  successive  generations  were  born  with 
teeth,  and  in  most  of  the  other  members  the  first  teeth  appeared  in  the 
third  or  fourth  month.  The  order  in  which  the  teeth  appear  is  much 
miore  regular  than  the  time  of  their  appearance.  The  order  given  above 
corresponds  with  that  stated  by  most  observers,  although  some  writers 
have  made  different  statements,  placing  the  lower  before  the  upper  lateral 
incisors. 

The  teeth  may  pierce  the  gum  without  any  local  manifestations.  Very 
frequently,  however,  just  before  a  tooth  comes  through  there  is  noticed  a 
moderate  swelling  and  redness  of  the  mucous  membrane  of  the  gum  over- 
lying it,  and  to  a  slight  degree  this  may  affect  the  general  mucous  mem- 
brane of  the  mouth.  This  condition  may  be  accompanied  by  a  little  fret- 
fulness  and  increased  salivation,  or  both  of  these  may  be  entirely  wanting. 
These  symptoms  usually  disappear  when  the  tooth  has  pierced  the  gum. 
The  symptoms  of  difficult  dentition  will  be  discussed  in  connection  with 
Diseases  of  the  Mouth. 

Infants  may  be  born  with  teeth ;  this  is,  however,  an  exceedingly  rare 
occurrence.  It  is  almost  invariably  one  of  the  lower  central  incisors  that 
is  present.  In  case  this  interferes  with  nursing,  or  if  it  is  very  loosely 
attached  to  the  gum,  it  should  be  extracted,  but  under  other  circumstances 
it  should  be  allowed  to  remain,  since,  if  it  is  removed,  a  second  tooth  is 
not  likely  to  appear  in  its  place  in  the  first  set.  It  is  not  at  all  uncommon 
for  the  first  teeth  to  appear  in  the  fourth  mouth.  Such  teeth,  in  my 
experience,  do  not  usually  differ  in  character  from  those  appearing  later, 
unless  they  are  in  children  who  are  syphilitic.  Syphilitic  children  are 
rather  prone  to  early  dentition,  and  under  such  circumstances  rapid  and 
early  decay  is  likely  to  take  place.  Nursing  infants  are,  as  a  rule,  a  little 
earlier  in  their  dentition  than  those  artificially  fed. 

Delayed  dentition  is  usually  due  to  rickets.  However,  in  many  healthy 
infants  no  teeth  appear  before  the  tenth  month ;  and  I  have  occasionally 
seen  the  first  ones  at  thirteen  months  in  those  who  seemed  perfectly 
healthy  and  showed  no  other  evidence  of  rickets.     On  the  other  hand,  it 


DENTITION.  29 

is  by  no  means  invariable  that  dentition  is  late  in  rachitic  children. 
The  latest  dentition  is  seen  in  cases  of  cretinism.  In  such  children  it 
is  not  rare  for  the  first  teeth  to  appear  as  late  as  the  eighteenth  month. 
I  have  seen  one  child  two  years  old  with  but  two  teeth.  As  a  rule,  den- 
tition and  ossification  of  the  bones  of  the  head  go  on  in  a  correspond- 
ing ]uanner ;  where  one  is  early  the  other  is  likely  to  be  rapid,  and  con- 
versely. 

Provided  an  infant  is  well  nourished  and  thrives  properly  for  the  first 
six  or  eight  months,  the  eruption  of  the  teeth  is  likely  to  go  on  steadily 
after  this  time,  even  though  the  child  may  later  have  chronic  indigestion 
or  suffer  from  extreme  malnutrition  from  any  cause  excepting  rickets. 
If,  however,  the  symptoms  of  malnutrition  date  from  birth,  dentition  is 
almost  invariably  delayed.  It  is  often  a  matter  of  very  great  surprise  to 
see  children  who  are  markedly  emaciated  as  a  result  of  chronic  indiges- 
tion or  ileo- colitis  and  yet  go  on  cutting  their  teeth  regularly.  I  have 
under  observation  at  the  present  time  a  delicate  infant  of  sixteen  months, 
whose  body  length  is  twenty-eight  inches  and  whose  weight  is  less  than 
nineteen  pounds — almost  exactly  what  they  were  eight  months  ago — and 
yet  he  has  now  thirteen  good  teeth. 

Eruption  of  the  Permanent  Teeth.— The  first  to  appear  are  the  first 
molars,  which  usually  come  in  the  sixth  year,  and  hence  the  name  six- 
year-old  molars,  which  is  applied  to  them.  These  appear  posterior  to  the 
second  molars  of  the  first  set.  The  following  table  from  Forchheimer 
gives  the  average  time  of  the  appearance  of  the  second  teeth  : 

First  molars 6  years. 

Incisors 7  to    8      " 

Bicuspids ^ 9  "  10      " 

Canines 12  "  14      " 

Second  molars 12  "  15      '" 

Third  molars 17  '•  25      " 

The  order  of  appearance,  therefore,  leaving  out  the  first  molars,  is 
essentially  the  same  as  that  of  the  first  set.  The  permanent  teeth,  with 
the  exception  of  the  molars,  take  the  place  of  the  corresponding  deciduous 
teeth.  As  they  grow  and  push  upward  they  cause  atrophy  of  the  roots  of 
the  first  teeth,  and  gradually  cut  otf  their  blood  supply,  so  that  they 
loosen  and  fall  out. 

The  place  of  dentition  as  an  etiological  factor  in  the  diseases  of  in- 
fancy will  be  considered  in  the  chapter  on  DiflScult  Dentition. 


CHAPTEE   III. 

PECULIARITIES  OF  DISEASE  IN  CHILDREN. 

In  many  particulars  disease  in  children  differs  from  that  of  later  life. 
These  differences  relate  to  etiology,  pathology,  symptomatology,  diagno- 
sis, and  prognosis.  The  greatest  contrast  to  adult  life  is  presented  by  in- 
fancy and  early  childhood.  After  seven  years,  children  in  their  diseases 
resemble  adults  more  than  they  do  infants. 

ETIOLOGY. 

1.  Inheritance  is  an  important  factor.  The  disease  most  frequently 
transmitted  directly  is  syphilis.  Occasionally  tuberculosis  and  other  in- 
fectious diseases  have  been  conveyed  "directly  from  the  mother  to  the 
child.  In  cases  where  no  distinct  disease  is  transmitted,  children  may 
inherit  from  parents  constitutional  tendencies,  or  a  diathesis  which  may 
manifest  itself  in  infancy,  or  in  some  cases  not  until  later  childhood. 
Under  this  head  we  may  place  the  influence  of  rheumatism,  gout,  the 
various  neuroses,  and  possibly  alcoholism  and  insanity.  In  consequence 
of  these  conditions  in  parents,  the  child  may  inherit  no  definite  disease, 
but  simply  a  vitiated  constitution. 

2.  Malformations  must  be  considered,  particularly  in  the  first  two 
years  of  life.  The  most  important  of  these,  from  a  medical  standpoint, 
are  those  of  the  heart,  brain,  and  kidney.  The  various  malformations  of 
the  mouth,  nose,  bladder,  rectum,  and  genital  organs  belong  more  particu- 
larly to  the  domain  of  surgery. 

3.  The  Diseases  or  Accidents  Connected  with  Birth. — Some  of  these  are 
distinctly  traumatic,  like  the  meningeal  hsemorrhages.  A  very  large  class 
are  the  infectious  processes  in  the  newly  born.  Infection  usually  takes 
place  through  the  umbilical  wound,  more  rarely  through  the  skin  or 
mucous  membranes.  This  class  includes  pyasmia,  with  its  varied  lesions 
in  the  brain,  lungs,  and  serous  membranes,  erysipelas,  ophthalmia,  and 
tetanus.  In  the  class  of  infectious  diseases  may  also  be  included  many  of 
the  varieties  of  pulmonary  and  intestinal  diseases  in  the  newly  born,  and 
probably  also  some  of  the  hemorrhagic  affections. 

4.  Conditions  Interfering  with  Proper  Growth  and  Development. — 
These  are  among  the  largest  etiological  factors  in  the  diseases  of  infancy. 
They  are  improper  food  or  feeding,  unhygienic  surroundings,  and  neglects 

30 


SYMPTOMATOLOGY   AND   DIAGNOSIS.  3^ 

These  may  cause  specific  diseases,  like  rickets  or  scurvy,  or  may  lead  to  a 
condition  of  general  malnutrition  or  marasmus.  In  this  way  they  become 
most  important  predisposing  factors,  in  infancy,  to  the  acute  diseases  of 
the  gastro-enteric  tract,  and  later  in  childhood,  to  functional  nervous  dis- 
eases. 

5.  Infection. — This  has  already  been  mentioned  as  an  important  factor 
in  diseases  of  the  newly  born.  The  number  of  diseases  in  later  life  di- 
rectly traceable  to  this  is  very  large,  and  is  constantly  increasing.  Under 
this  head  should  be  included  not  only  the  well-known  classes  of  infectious 
and  contagious  diseases,  but  also  a  very  large  number  of  varieties  of  infec- 
tion which  as  yet  have  not  been  differentiated,  and  the  nature  of  which 
is  but  imperfectly  understood. 

SYMPTOMATOLOGY  AND   DIAGNOSIS. 

In  older  children  the  symptoms  of  disease  are  very  much  the  same  as 
in  adults,  and  similar  methods  of  examination  may  be  employed.  What 
is  really  peculiar  to  children  belongs  especially  to  the  first  three  years  of 
life,  before  speech  has  developed.  During  this  period  the  chief  and  al- 
most the  sole  reliance  of  the  physician  must  be  upon  the  objective  signs 
of  the  disease.  It  is  not  so  much  that  diseases  in  early  life  are  peculiar, 
as  that  the  patients  themselves  are  peculiar. 

Two  fundamental  facts  are  always  to  be  kept  in  mind  :  First,  that  the 
common  pathological  processes  are  comparatively  few,  being  chiefly  of 
the  gastro-enteric  tract,  the  lungs,  and  the  brain,  but  that  the  variations 
in  clinical  types  are  almost  endless;  the  second  is,  that  in  infants,  on 
account  of  the  susceptibility  of  the  nervous  system,  functional  derange- 
ments are  often  accompanied  by  very  grave  symptoms,  and  may  even 
prove  fatal  in  twelve  or  twenty-four  hours,  or  there  may  be  speedy  and 
complete  recovery  after  very  alarming  symptoms.  In  many  of  these 
cases  the  symptoms  are  so  indefinite  that  an  exact  diagnosis  is  impossible 
during  life,  and  even  the  autopsy  may  throw  but  little  light  upon  them. 

At  the  bedside  it  is  of  great  assistance  to  the  physician  if  he  can  keep 
in  mind  the  most  frequent  forms  of  acute  disease  that  are  likely  to  be 
met  with.  In  the  first  group,  including  those  which  are  very  common, 
may  be  placed  acute  indigestion  and  ileo-colitis,  bronchitis,  pneumonia, 
pharyngitis,  and  tonsillitis;  in  the  second  group,  including  those  which 
are  not  quite  so  common,  may  be  placed  otitis  and  the  acute  infectious 
diseases — measles,  scarlet  fever,  diphtheria,  influenza,  and  malaria;  in 
the  third  group,  including  the  rarer  forms  of  acute  disease — meningitis, 
tuberculosis,  rheumatism,  and  diseases  of  the  kidneys.  Under  all  circum- 
stances, the  season,  and  the  nature  of  the  prevailing  epidemic,  if  one 
exists,  are  to  be  considered. 

In  the  examination  of  a  sick  infant  quite  a  different  method  is  to  be 
followed  from  that  pursued  with  adults.  Much  information  is  to  be  gained 


32  PECULIARITIES   OF   DISEASE   IN   CHILDREN. 

from  a  history  carefully  taken  from  an  intelligent  mother  or  nurse,  and 
much  more  from  a  close  observation  of  the  child,  whether  asleep  or 
awake,  quiet  or  crying. 

The  History. — The  points  to  be  most  carefully  investigated  will  vary 
somewhat  with  the  nature  of  the  illness.  If  the  disturbance  is  one  of 
nutrition,  the  minutest  details  relating  to  the  character  and  preparation 
of  the  food  from  birth  up  to  the  present  illness  must  be  considered ;  also 
the  progress  of  dentition,  and  whether  this  has  been  easy  or  difficult.  All 
facts  relating  to  the  child's  growth  and  development  are  significant — the 
period  when  it  was  able  to  sit  alone,  stand  and  walk,  and  its  weight. 
Every  previous  illness  should  be  investigated  as  to  its  nature,  duration, 
and  severity,  especially  the  eruptive  fevers,  the  diseases  of  the  lungs 
and  the  digestive  tract.  All  the  facts  relating  to  the  present  illness 
should  then  be  brought  out — the  exact  time  and  mode  of  onset,  the 
presence  or  absence  of  fever,  the  amount  of  food  taken,  the  existence  of 
cough  or  hoarseness,  the  evidences  of  pain,  such  as  restlessness  or  scream- 
ing, the  character  of  the  sleep,  the  condition  of  the  bowels,  the  amount 
of  urine  passed,  and  the  frequency  of  micturition.  In  every  case  the  phy- 
sician should  inspect  for  himself  the  child's  napkins,  and  never  trust  to 
the  statements  of  the  mother  or  nurse  with  regard  to  the  character  of  the 
faecal  discharges  or  the  urine.  The  question  of  exposure  to  any  conta- 
o-ious  disease  should  also  be  considered. 

In  chronic  diseases  it  is  of  special  importance  to  investigate  the  sub- 
ject of  heredity,  from  manifestations  of  disease  both  in  the  parents  and  in 
other  children  of  the  family.  This  is  most  important  with  reference  to 
syphilis  and  tuberculosis.  The  character  of  the  labour  should  be  in- 
quired into,  whether  it  was  difficult,  prolonged,  or  instrumental. 

Inspection. — What  is  learned  by  the  inspection  of  a  sick  child  will 
depend  almost  entirely  upon  the  powers  of  observation  of  the  physician. 
One  accustomed  to  bring  out  the  patient's  symptoms  by  questions  is  de- 
decidly  at  a  loss  to  know  how  to  proceed  in  the  case  of  a  sick  infant. 
With  time,  patience  and  method  very  much  that  is  important  and  exact 
can  be  determined.  In  fact,  the  diagnosis  of  disease  in  infancy,  instead 
of  being,  as  is  often  supposed,  a  matter  of  extreme  difficulty  or  impossi- 
bility, becomes  with  experience  quite  as  easy  as  among  adults. 

In  acute  disease  when  the  child  is  asleep  or  quiet  the  following 
points  should  be  noted  : 

1.  Posture — whether  the  child  lies  upon  the  back,  the  side,  or  the 
face ;  whether  there  is  opisthotonos,  or  a  general  flexion  of  all  the  limbs. 

2.  Character  of  the  sleep — whether  it  is  quiet  and  peaceful  or  dis- 
turbed ;  whether  there  is  constant  tossing  about,  grinding  of  the  teeth, 
etc. 

3.  Respiration — whether  it  is  regular,  or  irregular.  This  can  be  deter- 
mined only  by  careful  observation  for  some  minutes.     It  should  be  noted 


INSPECTION.  33 

whether  it  is  rapid,  or  slow,  easy,  natural,  and  quiet,  or  whether  there  is 
Basal  obstruction  with  snoring  and  mouth-breathing  due  to  tonsillitis, 
diphtheria,  scarlet  fever,  or  adenoid  vegetations  of  the  pharynx.  The 
best  evidence  of  dyspnoea  is  the  recession  of  the  supraclavicular  and 
suprasternal  regions,  the  sinking  in  of  the  intercostal  spaces,  sometimes 
with  lateral  recession  of  the  chest  walls.  There  is  usually  present  active 
dilatation  of  the  nostrils. 

4.  Pulse — whether  it  is  rapid  or  slow,  full  and  strong  or  soft  and  com- 
pressible. The  frequency  of  the  pulse  in  infancy  is  of  much  less  impor- 
tance than  the  force  and  rhythm.  A  slow,  irregular  pulse  is  always  sig- 
nificant, and  should  suggest  meningitis ;  an  irregular  pulse,  when  rapid, 
has  no  special  significance. 

5.  Skin — whether  it  is  dry  and  hot,  or  covered  with  perspiration.  The 
existence  of  pallor,  general  cyanosis,  or  blueness  of  the  lips  and  finger 
nails  should  be  noted ;  also  the  circulation  in  tlie  extremities,  whether 
they  are  warm,  or  cold  and  clammy. 

6.  Facial  expression — whether  this  is  calm  and  peaceful,  drawn  and 
anxious,  intelligent  or  stupid,  and  whether  the  features  are  contracted 
from  time  to  time  as  if  from  pain. 

7.  Cough — whether  this  is  frequent,  difficult,  or  severe. 

8.  Cry :  Since  this  is  the  chief  means  by  which  the  infant  expresses 
discomfort  or  displeasure,  it  becomes  exceedingly  important  but  not  always 
easy  to  determine  whether  an  infant  cries  from  pain,  discomfort,  hunger, 
temper,  or  from  habit.  In  very  many  instances  the  cry  under  these  con- 
ditions is  so  characteristic  that  one  who  is  familiar  with  the  child's 
language  readily  divines  what  is  wrong.  It  is  something  which  should 
never  be  disregarded,  even  though  it  may  be  the  only  obvious  symptom. 
Tears  are  not  seen  until  the  second  month,  so  that  their  absence  before 
that  time  is  not  to  be  taken  as  an  evidence  that  the  cry  is  not  from  pain. 

The  cry  of  hunger  is  apt  to  be  interrupted  by  vigorous  sucking  of  the 
fingers.  It  is  not  usually  sharp  and  piercing,  like  the  cry  of  pain,  but  it 
is  a  worrying,  fretful  cry.  It  ceases  immediately  when  the  hunger  lias 
been  satisfied. 

The  cry  of  indigestion  is  often  mistaken  for  that  of  hunger,  but  in 
such  cases,  although  crying  may  cease  for  a  few  minutes  after  taking  food, 
from  the  temporary  relief  which  this  gives,  it  is  likely  soon  to  return  with 
unabated  vigour.  Under  such  circumstances  a  frequent  repetition  of 
feeding  or  nursing  should  never  be  allowed,  although  very  often  this  is 
just  what  is  done. 

The  character  of  the  cry  of  pain  will  depend  somewhat  upon  the  se- 
verity of  the  pain.  When  it  is  acute  like  that  of  colic  or  ear-ache,  it  may 
be  sharp  and  piercing,  and  accompanied  by  contraction  of  the  features, 
drawing  up  of  llic  Ic-s.  and  other  evident  signs  of  distress.  The  child 
falls  aslccii  oiilv  when  rxhauslcd.and  soon  wakes,  nl'ion  with  a  scream.  In 


34  PECULIAEITIES   OF   DISEASE   IX   CHILDEEX. 

pain  of  less  severity  there  is  usually  moaning,  but  rarely  a  sharp  cry.  In- 
fants cry  not  only  from  pain  but  from  every  sort  of  discomfort — wet 
diapers,  cold  feet,  a  cramped  position,  uncomfortable  clothing,  pins,  also 
if  they  are  tired  or  sleepy,  and  from  a  great  many  other  minor  causes. 
The  more  delicate  a  child  the  more  readily  it  cries  from  any  cause. 

The  cry  of  weakness  and  exhaustion  is  quite  characteristic.  It  may  be 
noticed  in  a  great  variety  of  conditions.  It  is  usually  a  low,  feeble  whine 
or  moan,  often  nearly  constant,  except  when  the  child  is  asleep. 

The  cry  of  temper  is  not  generally  heard  before  the  fifth  month.  It 
is  usually  accompanied  by  stiffening  of  the  body,  throwing  back  of  the 
head,  and  sometimes  by  vigorous  kicking.  It  is  loud,  violent,  and  often 
prolonged. 

The  cry  of  habit  is  one  of  the  most  difficult  to  recognise.  These  habits 
are  formed  by  indulging  infants  in  various  ways.  Some  children  cry  to 
be  held,  some  to  be  carried,  some  to  be  rocked,  some  for  a  light  in  the 
nursery,  some  for  a  rubber  nipple  or  some  other  thing  to  suck.  The 
extent  to  which  this  kind  of  crying  may  be  indulged  in,  even  by  very 
young  infants,  is  surprising,  and  it  explains  much  of  the  crying  of  early 
childhood.*  The  fact  that  the  cry  ceases  immediately  when  the  child 
gets  what  it  wants  is  diagnostic  of  the  cry  from  habit.  The  only  success- 
ful treatment  of  such  cases  is  to  allow  the  child  to  "  cry  it  out "  once  or 
twice,  and  then  the  habit  is  broken.  Of  course,  before  such  a  procedure 
is  allowed  to  go  on.  one  must  be  well  assured  that  the  cry  is  from  this 
cause  and  no  other. 

There  are  some  diseases  in  which  the  cry  is  sufficiently  characteristic 
to  be  of  diagnostic  importance.  Thus  we  hear  the  short,  catchy,  sup- 
pressed cry  of  pneumonia,  the  sharp  nocturnal  cry  of  tuberculous  menin- 
gitis and  of  chronic  bone  disease,  the  moan  of  chronic  indigestion  and 
acute  intestinal  diseases,  the  hoarse  nasal  cry  of  hereditary  syi^hilis,  and 
the  feeble  whine  of  marasmus  and  of  atelectasis. 

9.  The  nervous  condition  m&j  be  one  of  undue  excitement,  and  it  may 
be  difficult  to  tell  whether  this  is  from  fright  at  the  approach  of  a  stranger 

*  On  admission  to  the  Babies'  Hospital  very  young  infants  almost  invariably  cry  a 
great  deal  for  the  first  two  days.  It  being  against  the  rules  to  take  such  children  from 
their  cribs  and  hold  them  to  quiet  their  crying,  they  soon  cease  the  habit,  and  give  no 
further  trouble,  crying  subsequently  only  from  the  usual  causes. 

Dr.  J.  S.  Thacher  relates  an  experience  which  illustrates  to  what  extent  this  habit 
may  be  formed  in  infants  of  only  a  few  weeks.  In  a  hospital  ward  under  his  care, 
containing  fifteen  or  twenty  mothers  and  newly-born  infants,  one  of  the  women  was 
seriously  ill,  and  was  so  annoyed  by  the  crying  of  the  infants  that  they  were  allowed  to 
be  taken  from  their  cribs  and  held  or  carried  as  soon  as  crying  from  any  cause  began. 
After  several  days  the  patient  was  removed  from  the  ward,  and  for  the  nest  two  or 
three  days  the  crying  in  the  ward  was  enough  to  drive  one  distracted  ;  but  the  mothers 
were  forbidden  to  quiet  the  infants  by  taking  them  up.  and  after  two  or  three  days' 
discipline  the  crying  ceased  and  peace  and  order  were  again  restored. 


THE   PHYSICAL  EXAMINATION.  35 

or  from  disease.  More  significant  is  a  condition  of  apatlu'  and  dulness 
and  general  relaxation  in  which  no  resistance  whatever  is  made  to  the  ex- 
amination. Such  symptoms  always  indicate  either  extreme  prostration 
or  brain  disease.  A  child  may  cry  from  pain  or  from  fright.  General 
hj'persesthesia  is  common  in  meningitis.  Soreness  of  the  legs  only,  sug- 
gests in  an  infant,  scurvy  ;  in  an  older  child,  rheumatism  or  joint  disease. 

10.  The  condition  of  the  imiyils  should  be  observed,  whether  con- 
tracted or  dilated,  and  the  nature  of  the  response  to  light ;  also  the  pres- 
ence of  corneal  ulcers  and  the  interstitial  keratitis  so  frequent  in  heredi- 
tary syphilis.  The  thin  mucous  film  seen  over  the  cornea  always  indicates 
grave  prostration,  and  often  approaching  death. 

11.  The  lymph  glands  of  the  neck  should  be  noted :  as  when  swollen 
they  may  indicate  scarlet  fever,  diphtheria,  or  simple  acute  inflammation. 

12.  The  presence  or  absence  of  nasal  discharge  should  be  determined, 
and  also,  if  possible,  its  character.  In  acute  disease  this  suggests  diph- 
theria, scarlet  fever,  or  influenza;  if  it  is  chronic,  adenoid  growths  of 
the  pharynx,  or  syphilis. 

13.  The  appearance  of  the  mucous  membrane  of  the  mouth,  teeth,  and 
gums  may  often  be  ascertained  by  watching  the  child  while  it  is  crying. 
It  should  be  noted  whether  the  tongue  is  dry  or  moist,  also  whether  thrush 
is  present,  or  any  other  form  of  stomatitis.  The  condition  of  the  gums 
may  be  observed,  whether  congested  or  swollen  or  haemorrhagic  as  in 
scurvy,  and  also  the  number,  position,  and  character  of  the  teeth.  The 
general  colour  of  the  mucous  membrane  may  be  significant,  as  in  cases  of 
cyanosis. 

Very  much  can  be  learned  in  acute  illness  by  simply  watching  atten- 
tively a  sick  child  for  a  few  minutes,  studying  the  foregoing  points  in 
order.  By  such  observation  and  a  carefully  obtained  history  of  the  ill- 
ness an  experienced  physician  can  often  make  a  very  probable  diag- 
nosis without  further  examination  ;  the  latter,  however,  should  never  be 
omitted. 

The  Physical  Examination. —  Temjjerattire.  The  first  step  should  gen- 
erally be  to  ascertain  whether  or  not  there  is  fever.  For  this  one  should 
never  fall  into  the  habit  of  trusting  to  his  sense  of  touch,  for  it  is  often 
very  misleading.  Only  the  rectal  temperature  in  infants  is  to  be  de- 
pended upon,  since  axillary  temperatures  are  untrustworthy,  and  those  in 
the  mouth  difficult  to  obtain. 

Immediately  after  birth  the  temperature  of  the  child  is  about  the  same 
as  that  of  the  mother,  or  a  little  higher.  It  falls  from  1°  to  3°  F.  in  the 
course  of  the  first  few  hours,  under  the  influence  of  the  bath  and  radiation 
from  the  skin  during  dressing.  Very  soon  it  again  rises  to  98-5°  or  99°  F,, 
near  which  point,  under  normal  conditions,  it  remains  during  the  first 
months  of  life,  and  in  fact  throughout  childhood. 

From  a  large  number  of  personal  observations  upon  healthy  infants  I 


36  PECULIARITIES   OF   DISEASE   IN   CHILDREN. 

have  found  that  the  rectal  temperature  under  normal  conditions  usually 
varies  between  98°  and  99  -5°  F. ;  occasionally  the  range  may  be  as  wide  a* 
97  -5°  to  100  -5°  F.  in  apparently  perfect  health.  The  heat-regulating  cen- 
tre in  the  brain  acts  only  imperfectly  in  the  young  infant,  and  very  slight 
causes  are  enough  to  disturb  the  temperature.  When  the  heat  equilibri- 
um has  once  been  disturbed,  slight  fluctuations  may  continue  for  some 
time  after  the  cause  has  been  removed. 

The  temperature  in  infants  is  always  higher  than  from  corresponding- 
causes  in  adults.  Moreover,  ver}'  high  temperatures  may  be  met  with  in 
cases  not  at  all  serious,  and  not  infrequently  when  no  explanation  can  be 
found  even  after  the  most  thorough  examination.  In  such  cases  the  tem- 
perature very  often  does  not  remain  at  a  high  jDoint  for  more  than  a  few 
hours.  It  is  a  continuous  high  temperature  rather  than  a  single  rise 
which  is  significant  of  disease  in  infancy.  Xothing  is  more  perplexing  to 
the  young  practitioner  than  the  frequency  with  which  a  high  tempera- 
ture is  seen  in  infants  in  cases  of  comparatively  mild  illness.  AV'hile  a 
valuable  guide  in  diagnosis,  the  temperature  alone  must  not  be  depended 
upon  in  early  life,  nor  should  its  significance  be  measured  by  the  adult 
standards. 

It  is  very  common  in  chronic  wasting  diseases,  in  delicate  infants  and 
in  those  prematurely  born,  to  find  the  temperature  one  or  two  degrees 
below  the  normal ;  95°  and  96°  F.  are  of  almost  daily  occurrence  in  hos- 
pitals. In  one  premature  infant  the  temperature  on  admission  was  93° 
F.  The  feeble  heat-producing  power  of  these  infants,  and  the  rapid  ra- 
diation from  their  bodies  because  of  the  absence  of  subcutaneous  fat,  make 
the  temperature  a  very  important  matter  in  their  nutrition.  Daily  ob- 
servations should  be  made  with  the  thermometer,  just  as  in  cases  of  high 
temperature. 

Some  very  puzzling  and  apparently  alarming  temperatures  are  seen 
in  infants  as  a  result  of  the  application  of  artificial  heat.  In  one  of  my 
patients,  an  infant  two  days  old,  a  temperature  of  107°  F.  was  caused 
by  the  close  proximity  of  two  large  hot-water  bags  placed  in  the  baby's 
basket.  The  younger  and  feebler  the  child  the  more  readily  are  such 
temperatures  produced.  Those  of  premature  infants  have  already  been 
mentioned.  This  cause  must  be  carefully  eliminated  in  cases  where 
unusually  high  temperatures  appear  after  surgical  operations  or  unex- 
pectedly under  other  conditions. 

For  the  purpose  of  making  a  systematic  routine  examination  of  the 
entire  body,  the  child's  clothing,  with  the  exception  of  the  napkin,  should 
be  removed,  and  the  child  laid  upon  the  nurse's  lap  on  a  blanket.  The 
sMii  may  now  be  inspected  for  eruptions,  and  it  is  important  that  the 
entire  body  be  examined.  Xext  the  general  nutrition  of  the  patient 
should  be  observed — whether  it  is  emaciated  or  avoII  nourislied. 

The  }iead  should  be  examined  to  see  whetlier  the  sutures  are  ossified 


THE    PHYSICAL   EXAMINATION.  37 

or  unnaturally  open  ;  whether  the  fontanel  has  closed,  or,  if  open,  whether 
it  is  depressed  or  bulging. 

The  details  regarding  physical  examination  of  the  lungs  are  discussed 
in  the  introductory  chapter  of  the  section  devoted  to  pulmonary  diseases. 
In  the  auscultation  of  the  heart,  it  should  be  remembered  that  under 
two  years  of  age  loud  murmurs  are  almost  invariably  of  congenital  ori- 
gin, that  soft  murmurs  are  frequently  functional,  and  that  acquired  or- 
ganic heart  disease  is  extremely  rare  until  after  the  third  year. 

In  the  examination  of  the  abdomen  there  should  be  noted  the  pres- 
ence or  absence  of  tympanites  or  abdominal  tenderness,  whether  general 
or  localized,  and  the  existence  of  retraction  of  the  abdominal  walls  as  in 
meningitis.  The  size  and  position  of  the  liver  and  spleen  are  best  de- 
termined by  palpation.  The  lower  border  of  the  liver  is  usually  slightly 
below  the  free  border  of  the  ribs.  If  the  spleen  can  be  easily  felt  below 
the  ribs,  it  is  as  a  rule  enlarged.  If  it  can  not  be  felt  in  a  satisfactory  ex- 
amination, it  is  not  sufficiently  enlarged  to  be  of  any  diagnostic  impor- 
tance. It  should  be  remembered  that  both  liver  and  spleen  may  be  dis- 
placed downward  in  rickets  from  contraction  of  the  chest,  giving  the 
appearance  of  slight  enlargement  when  they  are  normal  in  size.  In  acute 
disease  a  large  spleen  suggests  malaria,  typhoid,  or  tuberculosis ;  in 
chronic  disease,  malaria,  syphilis,  leukaemia,  or  anaemia. 

Examination  of  the  urine  should  not  be  forgotten.  The  staining  of 
the  napkin  may  give  information  regarding  the  discharge  of  crystalline 
uric  acid  or  of  concentrated  urine.  For  other  purposes  the  urine  must  be 
collected.  This  is  often  difficult.  The  most  satisfactory  method  I  have 
found  is,  in  male  infants,  to  tie  a  condom  over  the  penis ;  in  female  in- 
fants, to  put  a  small  cup  over  the  vulva  inside  the  napkin.  In  those  who 
are  a  year  old  the  urine  may  readily  be  collected  by  putting  the  child 
upon  the  chamber  every  few  minutes.  It  is  important  not  to  overlook 
phimosis  or  balanitis  in  the  male  or  vulvo-vaginitis  in  the  female,  since 
these  conditions  may  not  only  give  rise  to  local  but  even  to  general 
symptoms. 

A  careful  inspection  of  the  moulli  and  tliroat  should  never  be  (»iiiittcd 
in  any  acute  illness,  no  matter  what  the  other  symptoms  are ;  l)ut  usually 
this  had  better  be  deferred  until  the  last.  For  this  are  required  a  good 
light  and  a  quick  glance.  In  the  pharynx  or  on  the  hard  palate  one  may 
find  the  first  local  symptom  of  scarlet  fever :  on  the  inside  of  the  cheeks 
the  earliest  evidence  of  measles  in  the  form  of  Koplik's  spots.  Diphtheria 
mav  exist  without  pseudo-membrane,  and  marked  general  redness  may 
be  due  to  scarlet  fever,  influenza,  or  simple  pharyngitis. 

In  chronic  disease  a  somewhat  different  method  of  examination  may 
be  followed.  The  most  important  diseases  because  most  often  met  with 
in  infancy  are,  in  the  first  phice,  those  which  are  connected  with  nuiri- 


38  PECULIARITIES  OF   DISEASE   IN  CHILDREN. 

tion,  chronic  disturbances  of  the  gastro-enteric  tract,  rickets,  and  scurvy; 
secondly,  syphilis,  tuberculosis,  chronic  diseases  of  the  lungs,  diseases  of 
the  blood,  the  bones,  the  kidney,  and  the  heart. 

In  the  examination,  the  general  development  of  the  child  should  be 
considered.  Its  height,  weight,  circumference  of  head,  chest,  and  ab- 
domen should  be  taken  and  these  compared  with  the  average  for  the 
child's  age.  The  condition  of  the  tissues  should  be  noted,  whether  firm, 
soft,  or  flabby ;  the  ligaments,  whether  relaxed  or  not ;  the  presence  of 
bony  deformities ;  also  the  existence  of  pallor,  cyanosis,  and  cachexia,  and 
the  general  nutrition.  It  should  then  be  determined  whether  the  child 
has  for  its  age  a  sufiicient  muscular  development,  as  shown  by  sitting, 
standing  or  walking.  Its  speech,  hearing,  sight,  general  intelligence  and, 
finally,  its  mental  disposition  should  be  investigated. 

In  the  local  examination  special  attention  should  be  given  to  the  shape 
of  the  skull,  the  condition  of  the  sutures,  the  size  and  shape  of  the  fon- 
tanel, and  the  progress  of  dentition.  It  should  be  noted  whether  there 
are  glandular  swellings  in  the  neck  or  in  different  parts  of  the  body ;  also 
hypertrophied  tonsils  or  adenoids.  Finally,  there  should  follow  a  thor- 
ough examination  of  the  heart,  lungs,  liver,  spleen,  blood,  urine,  bones, 
spine,  and  joints.  The  same  order  need  not  be  followed  in  every  case, 
but  the  examination  should  always  be  thorough,  and  with  the  body 
stripped.  Unless  this  is  done,  serious  deformities  are  often  entirely  over- 
looked, and  an  erroneous  diagnosis  made. 

In  children  who  are  old  enough  to  answer  questions  the  same  method 
may  be  pursued  as  in  an  adult  examination.  An  important  thing  in 
dealing  with  children  is  a  gradual  approach,  first  winning  the  confidence 
of  the  child  and  diverting  its  attention  from  the  real  purpose  in  view ; 
secondly,  the  avoidance  of  every  rough  examination  which  might  by  any 
chance  produce  pain ;  and,  finally,  deferring  until  the  end  of  the  ex- 
amination the  inspection  of  the  throat,  which  must  frequently  be  done 
forcibly,  and  is  sure  to  interrupt  any  further  chance  of  intimacy.  With 
time  and  patience  almost  everything  mentioned  in  the  above  category 
can  be  satisfactorily  investigated. 

PATHOLOGY. 

The  pathological  processes  which  result  from  intra-uterine  disease  and 
those  which  are  connected  with  delivery  are  peculiar  to  early  life.  They 
have  already  been  referred  to  in  the  section  on  etiology.  Of  the  processes 
of  early  life  which  begin  after  birth,  the  first  in  frequency  are  those  of 
the  mucous  membranes  resulting  from  the  various  forms  of  infection. 
In  summer,  it  is  the  stomach  and  intestines,  which  suffer  chiefly ;  in 
winter,  the  respiratory  tract. 

The  serous  membranes  are  rarely  the  seat  of  primary  inflammation. 
The  pleura  is   seldom  the  seat   of  jarimary  disease,  but  very  often   in- 


PATHOLO(iY. 


39 


volved  secondarily  to  disease  of  the  lung  itself.  Affections  of  the  peri- 
cardium and  peritona3um  are  quite  rare.  Meningitis  is  fairly  common 
both  in  the  simple  and  the  tuberculous  form. 

Diseases  of  the  lymph  nodes  (lymphatic  glands)  play  an  important 
part  in  connection  with  the  acute  diseases  of  the  mucous  membranes,  with 
many  affections  of  the  skin  and  even  of  the  viscera.  Acute  infection  tends 
to  excite  suppurative  inflammation,  particularly  in  infants ;  a  less  active 
process  leads  to  chronic  hyperplasia  in  the  mesenteric,  mediastinal,  and 
cervical  glands,  in  the  tonsils,  adenoid  tissue  of  the  pharynx,  etc.  The 
lymph  nodes  in  the  neck  and  thorax  are  frequently  the  earliest  seat  of 
tuberculous  deposits,  and  in  very  many  cases  they  are  the  foci  from  which 
secondary  infection  of  the  lungs,  brain,  or  joints  may  occur. 

Of  the  visceral  inflammations  *  those  of  the  lungs  are  the  most  com- 

*  The  following  table  gives  in  a  general  way  a  very  good  idea  of  the  relative  fre- 
quency of  diseases  of  the  different  organs  in  infancy.  It  is  based  upon  seven  hundred 
and  twenty-six  consecutive  autopsies  in  the  New  York  Infant  Asylum,  extending  over 
a,  period  of  eight  years  during  my  connection  with  that  institution.  More  than  one  half 
of  the  autopsies  I  made  personally.  Of  these  children  seventy-two  per  cent  were 
under  one  year,  twenty-five  per  cent  between  one  and  two  years,  and  only  three  per 
cent  were  over  two  years.  The  institution  does  not  receive  infants  under  one  month, 
hence  the  absence  of  lesions  peculiar  to  the  newly  born : 

Table  showing  principal  lesions  in  seven  hundred  and  twenty-six 
consecutive  autopsies  in  the  Neiv  York  Infant  Asylum. 
Lungs  : 

Pneumonia — Primary 139 

Complicating  other  acute  infectious  diseases 112 

Complicating  other  conditions 71 

Noted  to  be  present  in 322 

Pleurisy —      No  case  uncomplicated  with  disease  of  lungs. 

Empyema 5 

Serous  pleurisy 1 

Dry  pleurisy  in  nearly  all  the  severe   cases  of  pneu- 
monia. 

Atelectasis  (congenital) 6 

Pulmonary  abscess  (always  with  pneumonia) 7 

Pulmonary  gangrene  (always  with  pneumonia) 2 

Pulmonary  tuberculosis 06 

Mouth  : 

Noma , 1 

Peritonxi'tim  : 

Acute  peritonitis  (localized  2,  with  acute  pneumonia  and  pleurisy  2)..       4 
Kidneys : 

Acute  nephritis  (complicating  scarlet  fever  4,  diphtheria  1,  pneumonia 
4,  measles  1,  pertussis  1,  ileo-colitis  2,  pyonephrosis  1,  apparently 

primary  5) 19 

Malformations  of  the  kidney 7 


40  PECULIARITIES   OP  DISEASE   IN   CHILDREN. 

mon,  it  being  rare  to  find  the  lungs  normal  at  autopsy  after  any  acute 
infectious  disease  which  has  lasted  a  week.  Up  to  the  third  or  fourth 
year  of  life  the  heart  usually  escapes.  In  older  children  it  may  be 
involved,  as  in  adults,  in  the  rheumatic  diseases.  The  liver  and  spleen 
are  not  often  the  seat  of  organic  disease  in  early  life,  nor  is  serious  disease 
of  the  kidney  likely  to  be  met  with  excepting  in  connection  with  scarlet 
fever.  Organic  disease  of  the  brain  itself  is  rare,  as  is  also  organic  dis- 
ease of  the  spinal  cord,  with  the  exception  of  poliomyelitis.  Chronic  dis- 
eases of  the  different  viscera  are  decidedly  rare,  excej)t  when  resulting- 
from  acute  processes.  Diseases  of  the  bones  and  joints  are  common,  and 
of  extreme  importance.  They  are  usually  of  tuberculous,  less  frequently  of 
syphilitic,  origin.  Diseases  of  the  blood  are  quite  common,  but  as  3'et 
but  little  understood.  New  growths  are  rare.  The  parts  most  frequently 
the  seat  are  the  kidney  and  the  bones.  Disorders  of  nutrition  are  ex- 
tremely common  and  of  great  importance,  particularly  rickets  and  scurvy. 

PROGNOSIS   AND   INFANT   MORTALITY. 

The  younger  the  patient  the  worse  the  prognosis  in  all  the  diseases  of 
childhood.  This  is  in  consequence  of  the  feeble  resistance  of  the  infan- 
tile organism  to  all  diseases,  particularly  those  which  are  of  an  acute 
nature.  On  the  other  hand,  the  rapid  metabolism  of  childhood  makes 
it  possible  for  many  conditions  of  an  organic  natui-e  to  disapj)ear  with 
time,  or,  as  the  phrase  is,  to  be  "  outgrown,"  provided  the  patient  can 
be  so  placed  that  the  general  nutrition  can  be  carried  to  the  highest 
point. 

The  accompanying  chart  (Plate  I)  shows  the  mortality  of  ISTew  York 
city    by   months  during  the  three  years  from    1890    to    1892,  inclusive,. 

Stomach  and  Intestines  : 

Acute  ileo-colitis,  with  or  without  gastritis 116 

Acute  gastritis  (without  intestinal  lesions) None 

Acute  diarrhoeal.  disease  (without  gross  lesions) 72 

Intussusception 1 

Heart  : 

Pericarditis  (all  with  acute  pneumonia) 3 

Congenital  malformations 3 

Acute  or  chronic  endocarditis None 

Brain  : 

Acute,  simple,  or  purulent  meningitis  (7  with  pneumonia,  2  cerebro- 
spinal)        14 

Tuberculous  meningitis 11 

Acute  encephalitis 1 

Chronic  pachymeningitis 5 

Chronic  simple  meningitis 1 

Chronic  hydrocephalus 3- 

There  were  twenty-six  deaths  from  marasmus  without  gross  lesions. 


PLATE    I. 


LJ                         1 

( 

Children  under  1  year 

"             1    TO  2   YEARS. 
"            2  TO  5   YEARS 

5  TO   15   YEARS. 

Over   15  years. 

Jan, 

Feb. 

Mar. 

APR. 

May 

June 

July 

Aug. 

Sept. 

Oct. 

Nov. 

Dec. 

Chart  showing  by  months  the  mortality  of  New  York  city  for  the  different  ages 
for  three  years.     (Scale,  1  in.  =  2,200  deaths.) 


THE  MOST  FREQUENT  CAUSES  OF  DEATH. 


41 


representing  a  total  mortality  of  128,136.    The  following  tabli'  gives;  for 
comparison  similar  figures  for  the  years  1898  to  1900  : 

Deaths — Neic  York  Citij- 


1890-189:2. 

1898-1900. 

Under  1  year. . . 

1  to    2  years. . . 

2  "     5      "... 
5  "  15      "... 
Over  15  years.  . 

. .  .     32,916  =  26  per  cent. 
...      10,547=    8       " 
..       9,794=    7       " 
...       5,470=    5       " 
.    .     69,409  =  54       " 

29,326  =  24  per  cent. 
9.012=    7      •• 
7,292=    6       •• 
6,922=    5       •• 

71,024  =  58      " 

Total 

...  128,136 

123,576 

Thus  about  one-fourth  of  all  the  deaths  occur  during  the  first  year 
of  life,  and  nearly  one-third  in  the  first  two  years.  The  only  age  in 
w'hich  the  mortality  is  much  increased  in  summer  is  the  first  year. 

The  Most  Frequent  Causes  of  Death  at  Different  Periods. — According 
to  the  statistics  of  Eross  from  sixteen  Continental  cities,  nearly  ten  per 
cent  of  all  infants  die  during  the  first  month  of  life.  At  this  time  the 
most  important  factor  is  congenital  debility ;  other  causes  are  asphyxia, 
infection,  congenital  malformations  of  the  heart,  intestine,  or  genito- 
urinary tract,  ha3morrhages,  convulsions,  acute  diarrhceal  diseases,  and 
pneumonia,  which  occurs  both  as  a  primary  and  a  secondary  lesion. 

Statistics  from  Xew  York  and  other  large  American  cities  show,  for 
the  past  ten  years,  a  gratifying  reduction  in  infant  mortality,  both  rela- 
tive and  actual.     The  following  figures  for  Xew  York  are  most  striking: 

Population,  Deaths,  and  Death  Rate  under  Five  Years,  Neiv  York  City. 


Year. 

Population 
under  5 
years. 

Deaths 
under  5 
years. 

Rate  per 

1,000. 

Year. 

Population 
under  5 
years. 

Deaths 
under  5 
3'ears. 

Rate  per 
1,000. 

1891.... 
1892  ... 
1893.... 
1894. . . . 
1895. . . . 

188,703 
194,214 
109,886 
205,723 
212,983 

18,224 
18,684 
17,865 
17,558 
18,221 

96-6 
96-2 
89-4 
85-3 
85-6 

1896 

1897 

1898 

1899.... 
1900 

216.728 
220,641 
224.736 
229,029 
233,537 

16,807 
15.395 
15.591 
14.391 
15,648 

77-5 
69-8 
69-3 
62-8 
67-0 

It  will  be  noted  that  the  actual  number  of  deaths  has  decreased  by 
1,500,  while  the  population  under  five  years  has  increased  by  55,000, 
and  the  death  rate  has  fallen  30  per  1,000. 

Several  causes  have  united  to  bring  about  this  result,  among  wbich 
may  be  mentioned  :  a  wider  diffusion  of  knowledge  in  tlie  matter  of  infant 
feeding  and  hygiene;  the  fact  that  a  larger  nuinhor  of  infants  tban  ever 
before  are  now  sent  into  the  country  in  summer;  that  all  infants  are 
looked  after  with  greater  care  during  the  summer,  many  agencies  being 
at  work  to  improve  their  condition.  Not  least  important  of  these  is  a  bet- 
tering of  the  milk  supply  nnd  tlie  furnishing  of  jiure  milk,  gratis,  from 


42  PECULIAEITIES  OF  DISEASE  IN  CHILDREX. 

different  centres,  together  with  a  general  adoption  during  hot  weather 
of  some  form  of  milk  sterilization — a  practice  well-nigh  nniversal  in  the 
tenement  districts.  Antitoxin  has  reduced  the  death  rate  among  older 
children.  We  find  among  rich  and  poor  alike  the  largest  number  of 
deaths  in  the  first  year  from  disease  of  the  gastro-enteric  tract  and  maras- 
mus. In  the  second  rank  are  acute  diseases  of  the  respiratory  tract. 
All  other  causes  of  mortality  fall  far  below  these  two.  Of  the  acute 
infectious  diseases  pertussis  takes  the  first  place,  with  measles  second; 
while  tuberculosis  ranks  first  of  the  chronic  infections.  Although  rarely 
the  cause  of  death,  rickets  is  a  very  important  factor  in  increasing  the 
mortality  of  other  diseases. 

During  the  second  year  the  diseases  of  the  gastro-enteric  tract  are 
still  a  large  factor  in  the  death  rate,  also  the  acute  diseases  of  the  lungs- 
and  the  acute  infectious  diseases,  especially  measles,  diphtheria,  and  per- 
tussis. Deaths  from  scarlet  fever  are  much  less  numerous.  General 
tuberculosis  and  tuberculous  meningitis  are  frequent. 

From  the  second  to  the  fifth  year  the  deaths  are  mainly  from  acute 
infectious  diseases — chiefly  diphtheria  and  scarlet  fever — much  less  fre- 
quently from  measles  or  pertussis.  In  the  next  group  come  the  acute  dis- 
eases of  the  lungs,  general  tuberculosis,  and  tuberculous  meningitis. 

From  the  fifth  to  the  fifteenth  year  the  mortality  in  childhood  is  re- 
markably small,  diphtheria  and  scarlet  fever  being  still  in  the  front  rank 
in  point  of  frequency.  Xext  come  the  acute  diseases  of  the  lungs,  simple 
as  well  as  tuberculous  meningitis,  diseases  of  the  bones,  appendicitis,, 
rheumatism,  and  cardiac  disease. 

Sudden  Death. — This  is  not  a  very  uncommon  occurrence  in  infants- 
who  are  apparently  healthy.  They  are  sometimes  found  dead  in  bed 
under  circumstances  in  which  grave  suspicion  may  unjustly  rest  upon 
the  attendants.  This  usually  happens  with  those  who  are  delicate  or 
suffering  from  malnutrition,  especialty  in  institutions  where  sudden  death 
is  by  no  means  rare.  The  most  frequent  causes  in  infants  are  the  fol- 
lowing : 

1.  Malformations. — While  in  most  cases,  to  be  sure,  malformations 
of  a  seriQus  nature  give  rise  to  symptoms,  they  may  be  absent,  or  may  be 
so  slight  as  to  be  overlooked.  Infants  may  succumb  during  the  first  few 
days  of  life  from  malformations  of  the  heart,  lungs,  kidneys,  stomach  or 
intestines,  and  sometimes  from  diaphragmatic  and  umbilical  hernia. 

2.  Internal  Ticemorrhage. — This  is  chiefly  limited  to  the  first  two 
weeks  of  life.  In  the  cases  that  have  come  to  my  notice  the  cause  has 
been  rupture  of  some  subperitoneal  haemorrhage  into  the  general  abdomi- 
nal cavity.  Such  cases  are  reported  in  the  chapter  upon  Visceral  Hsem- 
orrhages  in  the  ISTewly  Born.  Under  these  circumstances  no  S5'mptom3 
may  exist  until  the  occurrence  of  collapse,  with  death  in  a  few  hours. 

3.  Asphyxia  from  overlying. — This  is  not  very  common,  excepting 


SUDDEN   DEATH.  43 

among  the  lower  classes,  and  is  most  frequently  due  to  intoxication  on 
the  part  of  the  mother.  Such  infants  after  death  present  the  usual  le- 
sions of  death  from  asphyxia,  but  without  any  evidence  of  violence.  A 
recent  writer  in  the  British  Medical  Journal  states  that  one  thousand 
infants  die  every  year  from  this  cause  in  the  city  of  London  alone. 

4.  Asphyxia  from  aspiration  of  food  into  the  larynx  and  trachea. — 
This  may  be  due  to  vomiting  or  to  the  regurgitation  of  food  during  sleep ; 
in  a  very  weak  infant  it  may  occur  while  awake.  This  is  iisually  seen  in 
infants  who  are  less  than  a  year  old,  and  most  of  the  reported  cases  have 
been  under  six  months.  Such  children  are  usually  delicate.  There  seems 
to  be  vomiting  with  an  attempt  at  crying,  during  which  the  food  is  drawn 
into  the  air  passages.  In  some  cases,  as  that  reported  by  Demme,  a  single 
large  clot  of  milk  has  been  found  in  the  larynx.  In  others,  food  is  found 
in  the  larynx,  trachea,  and  large  bronchi.  'Cases  have  also  been  reported 
by  Partridge  and  Parrot,  and  I  have  myself  met  with  at  least  three.  The 
infants  have  generally  been  found  dead  in  bed  within  a  few  hours  after 
feeding.  This  accident  is  more  likely  to  happen  when  an  infant  lies 
upon  its  back. 

5.  Asphyxia  associated  with  enlargement  of  the  thymus. — These 
cases  are  as  yet  but  little  understood,  although  they  are  not  rare.  I 
have  notes  of  at  least  a  dozen,  and  in  recent  literature  many  have  been 
reported.  (See  Friedjung,  Arch,  fiir  Kinderheilk.,  vol.  xxix,  p.  344.) 
Most  of  the  cases  observed  have  been  between  four  and  eighteen  months 
old.  Pickets  is  associated  in  some;  in  some  there  is  a  general  enlarge- 
ment of  the  lymph  glands — status  lymphaticus.  Neither  of  these  condi- 
tions is  always  present.  Death  is  frequently  preceded  by  convulsions. 
Often  the  child  has  been  ill  with  some  minor  ailment  during  which  as- 
phyxia, convulsions,  and  death  have  unexpectedly  occurred.  The  fatal 
attack  is  believed  to  be  due  to  pressure  upon  the  trachea  or  the  heart  or 
the  pneumogastrics.  At  autopsy  the  thymus  is  found  greatly  enlarged, 
often  weighing  over  one  ounce  and  crowding  all  the  structures  in  the 
anterior  mediastinum. 

6.  Atelectasis. — In  very  young  infants  there  may  be  no  symptoms  ex- 
cepting malnutrition  until  sudden  death  occurs,  sometimes  with  convul- 
sions and  sometimes  without  any  such  symptoms.     (See  Atelectasis.) 

7.  Marasmus. — In  this  class  of  cases  sudden  death  is  of  very  common 
occurrence.  These  children  are  often  as  well  two  or  three  hours  before 
death  as  for  several  weeks.  Death  frequently  occurs  at  night,  the  chil- 
dren being  found  dead  in  bed  in  the  morning.  In  some  of  the  cases  the 
exciting  cause  seems  to  be  the  lowering  of  the  temperature,  while  in  many 
no  exciting  cause  can  be  found;  the  vital  spark  simply  goes  out  after 
burning  for  some  time  with  a  feeble  intensity.  In  some  of  these  cases  the 
autopsy  reveals  atelectasis,  but  in  many  cases  nothing  abnormal  is  found, 
death  apparently  resulting  from  heart  failure. 


44  PECULIARITIES   OP   DISEASE   IN   CHILDREN. 

8.  Convulsions  in  cliiJdren  previously  slwunng  no  signs  of  disease. — 
Most  of  these  eases  are  seen  in  children  who  were  previonsly  rachitic. 
In  them  the  autopsy  shows  no  lesion  except  those  commonly  associated 
with  death  from  conyulsious.  It  is  extremely  rare  for  a  cerebral  lesion 
such  as  hgemorrhage  to  produce  death  in  this  way.  In  some  of  these 
rachitic  cases  death  is  due  to  spasm  of  the  glottis. 

9.  Asphyxia  in  older  infants  and  young  cliildren. — This  may  result 
from  the  pressure  of  a  retropharyngeal  abscess  upon  the  larynx  or 
trachea,  or  from  the  rupture  of  such  an  abscess  during  sleep  and  the 
entrance  of  pus  into  the  air  passages.  While  in  most  such  cases  other 
symptoms  have  been  present,  they  may  be  latent.  A  rare  cause  of  sud- 
den asphyxia  in  children  from  eighteen  months  to  five  years  is  pressure 
upon  the  pneumogastric  by  tuberculous  bronchial  nodes,  or  by  ab- 
scesses in  the  posterior  mediastinum  connected  with  caries  of  the  spine. 
I  have  seen  examples  of  both  the  latter.  Gibney  has  reported  a  case  of 
sudden  death  from  dislocation  of  the  upper  cervical  vertebra?  consequent 
upon  caries. 

Sudden  asphyxia  may  follow  the  ulceration  of  tuberculous  lymph 
nodes  and  the  escape  of  cheesy  masses  into  the  trachea  or  primary 
bronchi.  This  usually  occurs  in  children  from  two  to  five  years  old.  and 
many  cases  have  been  reported. 

10.  Death  after  a  few  hours'  illness,  in  which  the  chief  symptom  is 
■high  temperature. — This  is  quite  a  common  occurrence.  Children  who 
are  apparently  well  may  be  taken  with  great  prostration  and  a  high  tem- 
perature, which  may  rise  rapidly  to  106°  or  even  107°  F.,  with  death  in  from 
six  to  twelve  hours,  sometimes  preceded  by  convulsions.  In  my  hospital 
experience  I  have  met  with  many  such  cases.  In  infants,  the  most  fre- 
quent explanation  of  these  symptoms,  as  shown  by  autopsy,  is  acute  con- 
gestive pneumonia ;  in  older  children  it  may  be  due  to  malignant  scarlet 
fever  or  epidemic  meningitis,  although  I  have  never  seen  an  instance  of 
either  of  these  diseases  in  which  death  occurred  in  the  first  twenty-four 
hours. 

It  does  not  fall  within  the  scojje  of  this  chapter  to  consider  cases  of 
sudden  death  from  heart  failure  after  diphtheria,  with  pleurisy  with  effu- 
sion, or  with  myocarditis.     These  will  be  discussed  elsewhere. 

PROPHYLAXIS. 

There  is  no  more  promising  field  in  medicine  than  the  prevention  of 
disease  in  childhood.  The  majority  of  the  ailments  from  which  children 
die,  it  is  within  the  power  of  man  in  great  measure  to  prevent.  Prophy- 
laxis should  aim  at  the  solution  of  two  distinct  problems  :  (1)  The  re- 
moval of  the  causes  which  interfere  with  the  proper  growth  and  develop- 
ment of  children  ;  (2)  the  prevention  of  infection.  The  former  can 
come  only  through  the  education  first  of  the  profession  and  then  the 


THERAPEUTICS.  45 

general  public,  in  the  fundamental  principles  of  infant  feeding  and  hy- 
giene. This  is  a  department  which  has  received  altogether  too  small  a 
place  in  medical  education.  The  latter  must  come  through  the  profession, 
and  through  legislation,  the  purpose  of  which  sliall  be  more  rigid  quaran- 
tine, more  thorough  disinfection,  and  improved  sanitation  in  all  its  depart- 
ments. 

THERAPEUTICS. 

Treatment  in  the  diseases  of  children,  and  particularly  those  of  infants, 
is  a  difficult  subject.  Therapeutics  in  infancy  consists  in  something  more 
than  a  graduated  dosage  of  drugs.  Many  therapeutic  means  which  are 
valuable  in  adults  are  useless  in  children,  and  many  others  which  are  of 
little  value  in  adults  are  extremely  useful  in  children.  There  is  no  doubt 
of  the  truth  of  the  statement  that  children  in  the  past  have  suffered  much 
from  overzealous  treatment,  particularly  from  drug-giving.  It  should  be 
a  fundamental  princij^le  never  to  give  a  dose  of  medicine  without  a  clear 
and  definite  indication.  If  this  rule  is  followed,  it  is  surprising  to  find 
how  often  medication  can  be  dispensed  with,  and  also,  in  many  cases,  how 
much  better  children  do  without  drugs  than  with  them.  A  second  rule 
is  equally  important :  never  to  give  a  nauseous  dose  when  one  that  is 
palatable  will  answer  the  purpose  equally  well.  This  is  no  small  matter, 
and  one  that  is  well  worth  the  physician's  careful  attention,  if  he  would 
succeed  in  the  management  of  sick  children.  The  simj^ler  prescriptions 
are  made,  the  better.  As  a  rule,  infants  revolt  against  most  of  the  highly 
seasoned  sirups  and  elixirs  which  are  used  to  disguise  the  taste  of  unpleas- 
ant doses.  Bitter  medicines  when  mixed  with  water,  are  frequently  ad- 
ministered without  the  slightest  difficulty. 

It  is  a  common  mistake  to  underestimate  the  importance  of  the  hy- 
gienic surroundings  of  the  patient,  the  value  of  good  nursing,  careful 
feeding,  and  judicious  stimulation,  just  as  it  is  to  overestimate  the  bene- 
ficial effects  of  drugs.  In  the  great  majority  of  acute  ailments  not  serious 
in  character,  for  which  a  physician  is  called,  the  patient  recovers  quite  as 
promptly  without  drugs  as  with  them.  This  does  not  mean  that  such 
children  require  no  treatment,  but  that  the  least  important  part  of  the 
treatment  is  drug-giving,  while  the  most  important  part  is  attention  to 
the  hygienic  matters  just  referred  to.  In  cases  of  severe  illness,  in  infants 
especially,  we  must  avoid  all  unnecessary  medication,  in  order  that  the 
stomach  may  not  be  disturbed  and  vomiting  excited.  Hence  the  impor- 
tance of  relying  as  far  as  possible  upon  local  measures  of  treatment.  The 
tendency  to  recovery  from  all  acute  processes,  Avhile  seen  in  adults,  is  even 
more  striking  in  children,  where,  if  we  can  but  remove  that  which  hampers 
the  bodily  functions.  Nature  will  conduct  the  case  to  a  satisfactory  termi- 
nation. Thus,  after  an  attack  of  ordinary  bronchitis  of  no  great  severity, 
it  is  often  seen  that  the  disturbance  of  the  stomach  and  intestines,  which 


46  PECULIARITIES   OF   DISEASE   IX   CHILDEEN. 

can  be  directly  traced  to  the  drugs  employed,  continues  long  after  the 
original  disease  has  subsided,  and  is  very  much  more  difficult  to  relieve. 
In  diseases  of  the  stomach  and  intestines  especially  there  is  a  great  amount 
of  overmedication,  very  much  to  the  detriment  of  the  patient.  In  all 
chronic  disturbances  of  nutrition — chronic  indigestion,  malnutrition,  and 
angemia — nothing  is  of  so  much  value  as  change  of  air  and  surroundings. 
This  is  most  strikiug  in  the  case  of  city  children.  With  them  it  is  a  fre- 
quent experience  that  tonics  of  every  description  are  of  little  or  no  avail, 
and  vet  immediate  and  most  marked  improvement  begins  when  the  chil- 
dren are  sent  to  the  country. 

The  tablet  triturates  have  furnished  us  with  a  convenient  method  of 
administering  many  drugs  to  children.  Those  which  are  especially  useful 
are  :  calomel,  from  one  tenth  to  one  half  grain;  gray  powder  in  the  same 
doses ;  antimony  and  ipecac,  one  one-hundredth  of  a  grain  each  ;  phena- 
cetine,  one  to  two  grains ;  arsenious  acid,  one  one-hundredth  of  a  grain ; 
paregoric,  lUv;  Dover's  powder,  one  tenth  of  a  grain;  atropine,  one  four- 
hundredth  to  one  two-hundredth  of  a  grain.  This  list  might  be  very 
greatly  extended. 

As  to  the  method  of  administration,  it  is  to  be  remembered  that 
several  small  doses  are  more  easily  given  and  less  likely  to  disturb  the 
stomach  than  a  few  larger  ones.  This  method  of  administering  very 
many  drugs  to  children  will  be  found  extremely  satisfactory — e.  g., 
sodium  bromide,  one  half  grain  every  fifteen  minutes,  is  often  better 
than  five  grains  every  two  hours ;  ]Dhenacetine,  one  half  grain  every  half 
hour,  is  better  than  two  grains  every  two  hours ;  calomel,  one  tenth  of  a 
grain  every  hour,  is  better  for  constipation  than  a  single  dose  of  two 
grains. 

Antipyretics. — The  indications  for  the  employment  of  antipyretics  in 
children  are  somewhat  different  from  those  in  adults.  It  is  to  be  borne 
in  mind  that,  where  the  cause  is  similar,  all  temperatures  in  children  are 
higher  than  in  adults.  Thus  a  simple  pharyngitis,  which  in  an  adult 
causes  a  rise  of  temperature  only  to  100°  or  101°  F.,  is  in  a  child  not  in- 
frequently accompanied  by  a  temperature  of  104°,  or  even  105°  F.  The 
height  of  the  temperature,  as  measured  by  the  thermometer,  is  not  to  be 
taken  as  the  only  guide  for  the  employment  of  antipyretics.  In  many 
cases  the  temperature  is  104°,  or  even  105°  F.,  and  yet  the  child  exhibits 
no  signs  of  unusual  discomfort.  Such  a  temperature  manifestly  does  not 
call  for  interference.  Again,  a  temperature  of  103°  F.  may  be  accom- 
panied by  very  marked  restlessness  and  other  signs  of  distress  which 
may  be  relieved  by  employing  some  antipyretic  measure.  The  number 
of  cases  seen  in  practice,  of  high  temperature  apparently  from  trivial 
causes,  is  very  great.  One  must  not  be  unduly  alarmed  even  by  a  very 
high  temperature  if  it  is  of  short  duration.  It  is  the  continuously  high 
temperature  which  indicates  serious  illness.     Whenever  the  temperature 


ANTIPYRETICS.  47 

is  found  to  be  much  above  tbe  normal  it  should  be  carefull}'  watched, 
but  not  interfered  with  until  a  diagnosis  has  been  made,  unless  the 
symptoms  urgently  demand  it ;  otherwise  the  physician  may  lose  one  of 
the  most  valuable  aids  to  diagnosis,  since  it  is  not  the  height  of  the 
temperature  but  its  course  which  is  significant.  In  many  cases  it  is  very 
important  to  know  whether  the  temperature  uninfluenced  by  drugs  is 
remittent,  intermittent,  or  steadily  high,  and  hence  the  advantage  of 
waiting  until  a  diagnosis  has  been  made  before  disturbing  the  tempera- 
ture curve.  This  is,  of  course,  not  admissible  when  the  temperature  is 
itself  a  source  of  real  danger,  which  after  all  is  seldom  the  case.  Since 
the  cause  of  a  great  many  obscure  temperatures  is  found  in  the  stom- 
ach and  intestines,  it  very  often  happens  that  a  purgative,  stomach- 
washing,  or  intestinal  irrigation  may  be  the  most  efficient  antipyretic.  In 
cases  of  moderate  elevation  of  temperature  we  need  go  no  further  than 
cold  sponging. 

The  most  reliable  antipyretic  measure  for  infants  is  the  use  of  cold. 
This  may  be  employed — 

(1)  As  an  ice  cap  to  the  head. — In  many  cases  of  quite  high  tempera- 
ture and  restlessness  in  infants  this  alone  will  reduce  the  temperature  one 
or  two  degrees  and  allay  the  nervous  symptoms. 

(2)  Cold  sponging. — For  this  purpose  water  about  80°  to  85°  F., 
equal  parts  of  alcohol  and  water,  or  equal  parts  of  vinegar  and  water  may 
be  employed.  In  the  case  of  infants,  all  the  clothing  except  the  diaper 
should  be  removed  and  the  child  laid  upon  a  blanket.  The  body  should 
be  sponged  for  from  ten  to  twenty  minutes,  and  then  wrapped  in  a 
blanket  without  further  dressing.  Cold  sponging  must  be  very  frequently 
employed  in  order  to  be  efficient  in  reducing  high  temperature.  Its  great 
value  in  allaying  nervous  symptoms,  even  when  the  temperature  is  not 
very  high,  is  not  sufficiently  appreciated.  Its  effect  is  often  more  satis- 
factory than  an  anodyne. 

(3)  Cold  pack. — This  is  one  of  the  simplest  and  most  efficient  means 
of  reducing  temperature  which  can  be  employed.  The  child  should  be 
stripped  and  laid  upon  a  blanket.  The  entire  trunk  should  then  be 
enveloped  in  a  small  sheet  wrung  from  water  at  a  temperature  of  100°  F. 
Upon  the  outside  of  this,  ice  may  now  be  rubbed  over  the  entire  trunk. 
first  in  front  and  then  behind.  By  this  method  there  is  no  shock  and 
no  fright,  and  any  ordinary  temperature  can  usually  be  readily  reduced. 

The  rubbing  with  ice  should  be  repeated  in  from  five  to  thirty  minutes, 
according  to  circumstances,  after  which  the  child  may  be  rolled  in  the 
blanket  upon  which  he  is  lying  without  the  removal  of  the  wet  pack. 
The  head  should  be  sponged  with  cold  water  while  this  is  being  carried 
on,  and  artificial  heat,  if  necessary,  should  be  applied  to  the  feet.  The 
pack  is  continued  from  one  to  twenty-four  hours,  according  to  circum- 
stances. 


48  PECULIARITIES  OF  DISEASE  IN  CHILDREN. 

(4)  The  cold  'bath. — The  child  is  put  into  a  bath  at  a  temperature  of 
100°  F.,  the  bath  being  gradually  lowered  by  the  addition  of  ice  to  85°  or 
80°  F.  The  body  should  be  well  rubbed  while  the  child  is  in  the  bath  and 
water  should  also  be  applied  to  the  head.  On  removal  from  the  bath,  the 
body  should  be  quickly  dried  and  rolled  in  a  warm  blanket.  The  bath  is 
usually  continued  from  five  to  ten  minutes. 

(5)  Evaporation  laths. — This  method  of  applying  cold  for  the 
reduction  of  temperature  has  been  elaborated  by  Williams  (Boston). 
The  trunk  is  closely  enveloped  in  two  layers  of  surgeon's  gauze,  or  some 
loosely  woven  equivalent,  which  is  moistened  from  time  to  time  with 
water  at  a  temperature  of  115°  F.,  continuous  evaporation  being  kept  up 
by  means  of  a  hand,  or  better  electric,  fan.  Williams  obtained  an  average 
reduction  of  2  :6°  F.  in  from  fifteen  to  thirty  minutes.  (Journal  of  the 
American  Med.  Ass'n,  May  18,  1901.)  The  evaporation  bath  would 
seem  to  possess  some  important  advantages  in  the  case  of  infants  and 
young  children,  in  that  it  is  more  efficient  than  sponging,  involves  practi- 
cally no  disturbance  of  the  patient,  and  causes  no  shock  or  fright.  Hot 
applications  should  be  kept  at  the  extremities. 

Antipyretic  Drugs. — Except  in  cases  of  malaria,  quinine  should  not  be 
employed  for  the  reduction  of  temperature  in  children.  The  dose  ug- 
quired  is  so  large,  the  difficulty  of  administration  is  so  great,  and  the 
tendency  to  upset  the  stomach  is  so  uniform,  that  its  use  should  be  dis- 
couraged altogether;  besides,  its  effect  is  extremely  uncertain. 

Of  the  three  antipyretics  more  recently  introduced — phenacetine, 
antip3'rine,  and  antif  ebrine — their  value  in  children  is  in  the  order  named. 
Phenacetine  has  the  advantage  of  being  tasteless,  but  the  slight  disadvan-. 
tage  of  being  insoluble.  Antipyrine  is  so  bitter  as  to  make  its  administra- 
tion often  difficult.  The  prostration  attending  the  use  of  antifebrine  is 
rather  greater  than  that  of  either  of  the  others.  Kone  of  these  drugs  is, 
however,  to  be  employed  in  large  doses  with  the  sole  jDurpose  of  reducing 
the  temperature.  Their  great  value  in  pediatrics  consists  rather  in  allay- 
ing the  nervous  symptoms  which  accompany  fever,  and  this  purpose  can 
be  accomplished  by  the  use  of  comparatively  small  doses.  To  an  infant 
of  one  year,  phenacetine  or  antipyrine  can  be  given  in  one-grain  doses 
every  hour  or  two  hours  until  the  desired  effect  is  produced.  For  a  child 
of  five  3'ears  a  dose  of  two  grains  may  be  given  in  the  same  manner.  When 
used  as  indicated,  these  drugs  are  of  very  great  value  in  making  the 
patient  more  comfortable,  in  promoting  sleep,  and  in  allaying  headache 
and  general  pains.  In  cases  of  hyperpyrexia  they  are,  however,  much  less 
certain  and  less  safe  than  the  use  of  cold.  In  many  cases  of  mild  pyrexia 
the  symptoms  are  relieved  by  the  administration,  either  separately  or  in 
combination,  of  citrate  of  potassium,  spiritus  a?theris  nitrosi,  and  liquor 
ammonii  acetatis,  in  small  frequent  doses. 

Stimulants. — In  spite  of  the  many  statements  to  the  contrary,  alco- 
holic stimulants  are  well  tolerated  even  by  very  young  infants.    Propor- 


STIMULANTS.  49 

tionatoly  larger  doses  of  alcohol  than  of  man}'  drugs  may  be  adminis- 
tered to  infants ;  still,  stimulants,  and  alcohol  in  particular,  are  very 
greatly  abused  in  the  hands  of  many  practitioners. 

The  indications  for  the  employment  of  stimulants  are  much  the  same 
in  young  children  as  in  adults.  They  are  to  be  used  whenever  the  pulse 
is  weak,  soft,  and  compressible,  and  whenever  the  general  powers  of  the 
patient  are  very  greatly  depressed.  In  most  of  the  acute  fevers  they  are 
not  to  be  given  early  in  the  disease,  and  in  many  cases  they  are  not  re- 
quired at  all.  They  must  often  be  used  very  sparingly  while  the  tem- 
perature is  high,  but  given  freely  as  soon  as  it  falls.  In  many  acute 
febrile  diseases  stimulants  are  not  called  for  at  any  period.  This  is 
especially  true  of  most  cases  of  lobar  pneumonia.  The  time,  however, 
when  they  are  most  likely  to  be  needed  is  at  or  just  after  the  crisis  of 
the  disease,  when  for  twenty-four  hours  they  should  be  very  freely  given. 
In  broncho-pneumonia  they  are  more  often  required,  and  their  use 
should  be  begun  earlier.  This  is  particularly  true  of  the  broncho-pneu- 
monia which  develops  secondarily  to  the  infectious  diseases.  In  all  toxic 
diseases,  such  as  diphtheria,  alcohol  should  be  begun  as  soon  as  depress- 
ing symptoms  show  themselves,  and  continued  in  doses  regulated  by  the 
degree  of  prostration.  In  the  acute  gastro-enteric  diseases  the  depletion 
is  often  great  and  there  is  little  absorption  of  food;  the  patients  may 
in  certain  cases  be  sustained  by  alcohol  for  several  days. 

Alcoholic  stimulants  are  contra-indicated  in  all  acute  febrile  processes 
where  there  is  high  temperature,  dry  skin,  flushed  face,  and  a  full,  strong 
pulse.     In  such  conditions  they  are  often  injurious. 

The  method  of  administering  stimulants  is  of  no  little  importance. 
Brandy  and  whisky  are  in  most  cases  to  be  preferred  to  the  wines,  but 
not  always.  Champagne  may  be  substituted  when  spirits  are  not  well 
borne  by  the  stomach.  For  infants  under  one  year  old,  brandy  should 
be  diluted  with  at  least  eight  parts  of  water.  It  is  commonly  given  in 
too  concentrated  a  form.  Altogether  the  best  method  of  administra- 
tion is  to  determine  the  amount  to  be  given  in  every  twenty-four  hours, 
have  it  diluted  sufficiently,  and  then  administer  it  in  small  doses  at  short 
intervals.  In  this  way  vomiting  is  rarely  produced.  Thv  addition  of 
brandy  to  the  water  required  by  the  thirst  makes  it  less  likely  to  disturb 
the  stomach. 

The  quantity  of  alcohol  will  (le])('n(l  \oit  iiuicli  upou  circunislaiices. 
An  infant  one  year  old,  for  whom  alcoholic  stim\ilniils  aiv  nccdcil  ,il  all, 
may  be  given,  to  begin  with,  half  an  ounce  of  whisky  or  hramly  duiiiig 
twenty-four  hours,  the  c|uantity  licing  incr(>as('d  for  a  sliorl  pci'iod  to  an 
ounce,  but  seldom  much  more  than  that  even  in  bad  cases. 

In  children  four  years  old  double  the  amount  may  be  employed  in  the 
corresponding  conditions.  Too  inucli  can  not  be  said  against  the  prac- 
tice, unfortunately  with  many  pi-nctitioncrs  a  common  one,  of  tlie  reck- 


50  PECULIARITIES   OF  DISEASE  IN   CHILDREN. 

less  use  of  alcohol  in  large  doses  in  young  children.  I  refer  to  such 
amounts  as  six  or  eight  ounces  daily  of  hrandy  or  whisky  for  children  of 
two  or  three  years  in  cases  of  pneumonia  or  diphtheria.  Little  good 
and  much  harm  is  likely  to  follow  such  therapeutics. 

Tonics. — Cod-liver  oil  stands  at  the  head  of  the  list  of  tonics  for  young 
children.  It  is  particularly  in  the  convalescence  after  acute  diseases  of 
the  respiratory  tract  that  we  see  its  most  striking  benefit.  It  is  also  of 
very  great  use  in  anaemia,  and  in  a  large  number  of  children  who  are 
extremely  delicate.  In  these  patients  it  may  be  advantageously  adminis- 
tered throughout  the  greater  part  of  nearly  every  winter  season.  In  con- 
valescence after  attacks  of  gastro-enteric  disease  it  is  not  nearly  so  useful, 
and  often  must  be  withheld  for  a  long  time.  It  is  a  mistake  to  give  cod- 
liver  oil  at  any  time  when  the  tongue  is  coated,  the  digestion  poor,  and  the 
stomach  easily  disturbed.  In  the  case  of  infants,  as  a  rule,  the  pure  oil 
is  to  be  preferred  to  the  emulsions,  but  this  is  not  always  the  case.  The 
administration  of  small  doses — i.  e.,  ten  or  twenty  drops  of  the  oil  three 
times  a  day  continued  for  a  long  period — is  much  better  than  the  use  of 
larger  doses  for  a  shorter  time. 

A  perfect  preparation  of  iron  for  use  in  infancy  has  not  yet  been  dis- 
covered. During  the  first  few  years  all  astringent  preparations  should  be 
avoided.  To  be  recommended  are  the  various  peptonates,  the  albumi- 
nate, bitter  wine,  sweet  wine,  saccharated  carbonate,  pomate,  and  malate. 
These  are  only  slightly  constipating,  and  most  of  them  can  be  given  with 
milk.  For  older  children  nothing  is  better  than  reduced  iron  or  Bland's 
jDills. 

Arsenic  is  second  only  to  iron  in  the  treatment  of  the  anaemia  of  chil- 
dren, and  in  very  many  cases  it  is  to  be  preferred  to  iron.  The  tablet 
triturates  of  arsenious  acid,  one  one-hundredth  of  a  grain,  may  be  given 
immediately  after  meals  three  times  a  day,  or  one  or  two  drops  of  Fowler's 
solution  largely  dilated  with  water. 

Alcohol  is  of  very  great  value  as  a  tonic  in  combination  with  some  of 
the  bitters,  either  small  doses  of  quinine,  nux  vomica,  or  the  bitter  wine 
of  iron.  Usually  wines,  especially  sherry,  are  to  be  preferred  to  spirits, 
although  some  children  take  spirits  better.  When  combined  with  a  bitter 
there  is  little  danger  of  the  formation  of  the  alcoholic  habit,  even  though 
its  use  may  be  long  continued. 

Of  the  bitter  tonics,  quinine  and  nux  vomica  are  easily  superior  to  all 
others. 

Opiates. — Strong  objections  have  been  urged  by  many  against  the 
employment  of  opium  in  the  diseases  of  infancj.  While  opiates  have 
no  doubt  been  abused,  the  fact  remains  that  opium  is  almost  as  valu- 
able a  remedy  in  the  treatment  of  disease  during  the  first  five  years 
as  at  any  other  period  of  life.  Infants  are,  however,  peculiarly  suscep- 
tible to  the  drug,  and  relatively  much  smaller  doses  are  required   than 


OPIATES— ANODYNES. 


51 


of  most  medicines.  If  the  physician  will  accustom  himself  to  the  use 
of  very  small  doses,  he  will  be  surprised  to  see  how  satisfactory  are  the 
effects  produced. 

The  most  useful  preparations  for  young  children  are  paregoric,  Dover's 
powder,  the  deodorized  tincture,  morphine,  and  codeine.  The  follow- 
ing table  gives  what  may  be  considered  safe  initial  doses  at  the  different 
affes  : 


1  month. 

3  months. 

1  year. 

5  years. 

Paregoric 

Deodorized  tincture 

Dover's  powder 

Morphine 

m  i 

Gr.^ff 
Gr.  tdW 
Gr.  shj 

TH,  ii 

Gr.iV 
Gr.^ 
Gr.  ^hj 

TTl  V  to  X 

m  i  toi 
Gr.  i  to  i 
Gr.  -ro-TT 
Gr.^ 

TTt  XXX  to  xl 

^.  ii  to  iii 
Gr.  ii  to  iii 
Gr.  ^  to  ^V 
Gr.  -^0  to  i 

Codeine 

Ordinarily  doses  like  the  above  should  not  be  repeated  oftener  than 
every  two  hours.  In  exceptional  circumstances,  as  when  very  great  pain 
is  present,  the  dose  may  be  given  more  frequently.  In  the  hyj)odermic 
use  of  morphine  it  should  be  remembered  that  its  effects  are  always  more 
uniform  and  striking  than  when  the  drug  is  administered  by  the  mouth, 
and  the  dose  should  therefore  be  smaller.  In  every  instance  where  a  full 
dose  of  opium  has  been  given  the  physician  should  wait  until  the  effects 
have  subsided  before  the  dose  is  repeated. 

Anodynes. — Chloral  is  usually  well  borne  even  by  quite  young  infants. 
In  them  it  should  never  be  administered  by  the  mouth,  but,  on  account 
of  its  irritant  properties,  always  by  the  rectum.  After  rectal  administra- 
tion its  effects  are  usually  manifest  in  half  an  hour,  and  sometimes  sooner. 
The  rectal  dose  for  an  infant  of  one  month  is  one  grain ;  three  months, 
two  grains ;  one  year,  three  to  five  grains.  It  may  be  repeated  every  two 
to  four  hours,  according  to  indications.  Other  drugs  may  replace  this 
in  most  diseases,  but  in  the  case  of  infantile  convulsions  nothing  is  so 
reliable  as  chloral. 

Belladonna  is  well  borne  by  children,  and  in  larger  doses  than  most 
•drugs.  A  tolerance  is  quite  readily  established.  The  eruption  is  more 
readily  produced  than  the  other  physiological  effects,  and  even  quite  small 
doses  may  be  sufficient  to  bring  out  a  very  abundant  blush.  The  parents 
should  be  advised  of  this  fact,  lest  undue  alarm  be  felt. 

The  drugs  classed  as  antip3Tetics — phenacetine,  antipyrine,  and  anti- 
febrine — are  exceedingly  valuable  in  the  treatment  of  many  diseases  of 
infancy  where  irritative  nervous  s)'mptoms  are  prominent.  In  many  cases 
they  may  advantageously  take  the  pUice  of  opium,  excci)t  where  pain  is 
the  principal  symptom,  as  in  otitis  or  pleurisy.  In  all  conditions  where 
spasm  is  a  prominent  symptom,  whether  of  the  larynx  or  bronchi,  or  local 
or  general  convulsions,  antipyrine  is  especially  valuable. 


52  PECULIARITIES   OP   DISEASE   IN   CHILDREN. 

Drags  well  borne  by  Children. — In  this  list  might  be  mentioned 
belladonna,  the  bromides,  the  iodides,  chloral,  quinine,  calomel — in  fact, 
all  mercurials— and  alcohol. 

The  drugs  not  well  borne  include  particularly  cocaine  and  all  prepa- 
rations of  opium.  In  the  case  of  many  others,  while  the  constitutional 
effects  are  well  tolerated,  they  must  be  given  carefully  to  young  infants, 
since  they  are  irritants  to  the  stomach.  In  this  class  may  be  mentioned 
the  salicylates,  salol,  the  astringent  preparations  of  iron,  and  the  acids. 

Counter-irritants. — These  are  of  great  value  in  a  large  variety  of  dis- 
eases. Blisters  should  never  be  employed  in  the  case  of  infants,  and  very 
rarely,  and  never  needlessly,  in  the  case  of  older  children.  In  the  latter 
they  may  be  required  in  inflammations  of  the  ear,  of  the  joints,  or  of  the 
spine ;  they  should  never  be  apj)lied  to  the  chest. 

The  mustard  paste  is  probably  the  most  satisfactory  means  of  pro- 
ducing quick  counter-irritation  over  a  large  surface.  To  make  a  mustard 
paste :  Take  one  part  powdered  mustard  and  six  parts  of  wheat  flour,  mix 
with  lukewarm  water,  and  spread  between  two  layers  of  muslin.  This 
should  be  removed  as  soon  as  a  thorough  redness  of  the  skin  has  been 
produced — in  most  cases  from  five  to  eight  minutes,  according  to  the 
strength  of  the  mustard  employed.  This  may  be  repeated  as  often  as 
every  three  hours,  and  continued  for  a  week  if  necessary,  without  pro- 
ducing excoriations  of  the  skin.  For  older  children  the  paste  may 
be  made  one  part  mustard  to  four  parts  flour.  In  pulmonary  diseases 
it  should  be  large  enough  to  surround  the  chest.  When  it  is  used 
to  produce  general  reaction  in  heart  failure  it  should  cover  the  entire 
trunk. 

The  mustard  pach. — The  child  is  stripped  and  laid  upon  a  blanket, 
and  the  trunk  is  surrounded  by  a  large  towel  or  sheet  saturated  with 
mustard  water.  This  is  made  as  follows  :  One  tablespoonful  of  mustard 
to  one  quart  of  tepid  water.  In  this  a  towel  is  dipped,  and  while  drip- 
ping wound  around  the  entire  body.  The  patient  should  then  be  rolled 
in  the  blanket.  This  pack  may  be  continued  for  ten  or  fifteen  minutes, 
at  the  end  of  which  time  there  will  usually  be  a  very  decided  redness  of 
the  whole  body.  It  may  be  repeated  according  to  indications.  Where  it 
is  desired  to  produce  a  general  counter-irritation,  the  mustard  pack  is  not 
quite  as  efficient  as  the  mustard  bath,  but  it  has  the  advantage  in  causing 
much  less  disturbance  to  the  patient.  The  mustard  pack  is  useful  in  the 
condition  of  collapse  or  of  great  prostration  from  any  cause  whatever,  in 
convulsions,  and  in  cerebral  or  pulmonary  congestion. 

The  turpentine  stupe  is  made  by  wringing  a  piece  of  flannel  out  of 
water  as  hot  as  can  be  borne  by  the  hand.  Upon  this  is  sprinkled  ten  or 
fifteen  drops  of  the  spirits  of  turpentine.  The  stupe  is  then  applied  to 
the  body  and  covered  with  oiled  silk  or  dry  flannel.  It  is  useful  chiefly 
in  abdominal  pains  or  inflammations,  but  in  infancy  must  be  carefully 


POULTICES.  53 

watched  or  vesication  will  be  produced.  For  continuous  use  it  is  not  so 
valuable  as  the  mustard  paste. 

Stimulating  linivieyits  containing  turpentine  and  other  irritants  are 
useful  in  inflammation  of  the  chest,  although  less  reliable  than  the  mus- 
tard paste.  One  of  the  mildest  and  most  useful  j^i'eparations  is  camphor- 
ated oil.  Another  is  olive  oil  four  parts  and  turpentine  one  part.  These 
may  either  be  rubbed  upon  the  surface,  or  a  piece  of  flannel  may  be  satu- 
rated with  them  and  then  ajDplied  to  the  skin.  The  old-fashioned  spice 
bag  is  useful  in  many  cases  where  a  very  mild  counter-irritant  is  desired 
over  the  abdomen. 

D7'y  cups  may  be  used  even  in  young  infants,  to  relieve  acute  pul- 
monary congestion.  They  are  sometimes  of  very  great  value,  and  may 
succeed  in  cases  in  which  there  is  no  reaction  from  the  mustard.  From 
four  to  six  cups  may  be  applied,  and  the  effect  may  be  continued  by  the 
application  of  the  mustard  paste.  Wet  cups  should  never  be  used  in 
young  children. 

Poultices  are  useful  in  local  inflammations  about  the  glands  of  the 
neck,  the  joints,  and  in  cellulitis  in  various  parts  of  the  body.  The  pro- 
longed use  of  poultices  can  not  be  too  strongly  condemned  in  cases  of 
otitis.  In  diseases  of  the  chest,  poultices  may  do  harm  because  their 
weight  embarrasses  respiration,  and  sometimes  because  of  the  exposure 
when  they  are  changed.  They  are  most  useful  in  pulmonary  diseases  in 
which  there  is  great  pain,  as  in  pleurisy  or  in  pleuro-pneumonia.  In 
bronchitis  and  in  broncho-pneumonia  they  are  objectionable,  certainly  for 
prolonged  use,  on  account  of  their  weight.  Better  effects  can  generally  be 
produced  by  hot  fomentations  and  counter-irritation.  Ground  flaxseed  is 
the  best  material  for  poultices.  This  should  be  mixed  with  boiling  water 
until  the  proper  consistency  is  reached,  when  the  poultice  should  be  put 
into  a  bag  of  muslin.  The  poultice  should  be  covered  with  oiled  silk  or 
cotton  batting,  so  that  it  will  retain  its  heat  as  long  as  possible.  To  be  of 
value,  poultices  must  be  applied  hot  and  changed  frequently. 

Hot  fomentations  are  more  cleanly  than  poultices  and  much  more 
easily  changed.  One  of  the  best  means  of  applying  them  is  by  a  piece  of 
spongio-jDiline  wrung  from  water  as  hot  as  the  hand  can  bear.  Where 
this  can  not  be  obtained,  a  large  piece  of  flannel  may  be  used  in  the  same 
way,  covered  with  cotton  batting,  and  then  with  oiled  silk.  This  method 
of  using  hot  fomentations  is  exceedingly  satisfactory  for  applications  to  the 
extremities. 

Cold. — Cold  is  useful  in  all  forms  of  inflammation  of  the  eyes  and 
brain.  In  inflammation  of  the  cervical  lymph  glands  and  of  the  joints  it 
is  of  undoubted  value,  but  its  advantage  over  heat  is  questionable.  The 
efficiency  of  both  cold  and  heat  in  these  cases  depends  largely  upon  the 
method  of  application.  Sometimes  in  pleurisy  much  greater  relief  is  ob- 
tained from  the  use  of  an  ice  bag  to  the  chest  than  from  hot  applications, 


54  PECULIARITIES   OP   DISEASE   IN    CHILDREN. 

but  this  is  not  the  general  experience.  The  treatment  of  pneumonia  by 
the  application  of  the  ice  bag  to  the  chest  has  some  excellent  advocates, 
although  my  own  experience  has  not  led  me  to  look  upon  it  with  much 
favor.  It  is  admissible  only  in  lobar  pneumonia.  The  use  of  cold  in  in- 
flammations of  the  larynx,  trachea,  or  bronchi  is,  in  my  opinion,  positively 
contra-indicated,  certainly  so  in  infants  and  young  children. 

Cold  is  best  applied  to  the  head  by  an  ice  cap  made  like  a  helmet ;  an 
ordinary  rubber  or  flannel  bag  filled  with  ice  may  answer  the  purpose. 
The  rubber  coil  filled  with  ice  water  is  also  an  excellent  method.  For 
inflamed  glands  or  joints  the  ice  bag  should  be  used ;  for  the  eyes  cold 
compresses  changed  every  minute. 

The  Hot  Pack. — All  clothing  is  to  be  removed  and  the  child's  body 
covered  with  towels  wrung  from  water  at  a  temperature  of  from  100°  to 
110°  F.,  after  which  the  body  should  be  rolled  in  a  thick  blanket.  These 
hot  applications  may  be  changed  every  twenty  or  thirty  minutes  until  free 
perspiration  is  produced,  which  may  be  continued  as  long  as  necessary. 
This  is  mainly  useful  in  ursemia. 

The  Hot  Bath,  like  the  mustard  pack  or  the  mustard  bath,  may  be 
used  to  promote  reaction  in  cases  of  shock  or  collapse.  The  patient  should 
be  put  into  the  bath  at  a  temperature  of  100°  F.,  the  water  being  gradu- 
ally raised  to  105°,  or  even  to  110°,  but  rarely  above  this  point.  The  body 
should  be  well  rubbed  while  the  patient  is  in  the  bath.  A  thermometer 
should  be  kept  in  the  water  to  see  that  the  temperature  does  not  go  too 
high.    During  the  bath,  in  most  cases,  cold  should  be  applied  to  the  head. 

The  Hot-Air  or  Vapour  Bath. — All  the  clothing  should  be  removed 
and  the  patient  laid  upon  the  bed  with  the  bedclothing  raised  above  the 
body  ten  or  twelve  inches,  and  sustained  by  means  of  a  wicker  support. 
The  bedclothing  should  be  pinned  tightly  about  the  neck,  so  that  only 
the  head  is  outside.  Beneath  the  bed  clothing  hot  vapour  is  introduced 
from  a  croup  kettle  or  a  vapourizer.  This  will  usually  induce  free  per- 
spiration in  fifteen  or  twenty  minutes.  It  may  be  continued  from  twenj;y 
to  thirty  minutes  at  a  time.  Instead  of  vapour,  hot  air  may  be  intro- 
duced in  the  same  way.  The  air  space  about  the  body  is  indispensable. 
The  vapour  bath  is  applicable  chiefly  to  cases  of  uremia. 

The  Mustard  Bath. — Four  or  five  tablespoonfuls  of  powdered  mustard 
should  be  mixed  for  a  few  minutes  Avith  one  gallon  of  tepid  water.  To 
this  should  be  added  four  or  five  gallons  of  plain  water  at  a  temperature 
of  100°  F.  The  temperature  of  the  bath  may  be  raised  by  the  addition  of 
hot  water  to  105°  or  110°  F.  if  desired.  Nothing  is  more  efficient  than 
the  hot  mustard  bath  for  a  general  derivative  effect  in  bringing  the  blood 
to  the  surface  in  cases  of  shock,  collapse,  heart  failure  from  any  cause,  or 
in  sudden  congestion  of  the  lungs  or  brain.  The  bath  should  not  usually 
be  continued  for  more  than  ten  minutes.  If  necessary,  it  may  be  repeated 
in  an  hour. 


NASAL  SPRAY. 


55 


The  Bran  Bath. — Put  one  quart  of  ordinary  wheat  bran  in  a  bag  made 
of  coarse  muslin  or  cheese  cloth  and  place  this  in  four  or  five  gallons  of 
water.  The  bran  bag  should  be  frequently  squeezed  and  moved  about 
until  the  bath  water  resembles  a  thin  porridge.  It  may  be  of  any  tem- 
perature desired,  but  usually  about  90°  to  95°  F.  is  best.  A  bran  bath  is 
of  great  value  in  cases  of  eczema,  excoriations  about  the  buttocks,  or  in 
other  cases  where  the  skin  is  very  delicate,  and  plain  water  seems  to  irri- 
tate it. 

The  Tepid  Bath  may  be  given  at  a  temperature  of  95°  to  100°  F.  It  is 
very  useful  in  many  conditions  of  excitement  or  extreme  nervous  irrita- 
bility.    To  induce  sleep  it  is  often  more  efficient  than  drugs. 

The  Cold  Sponge  or  Shower  Bath  should  be  given  in  the  morning 
before  breakfast,  and  in  a  warm  room.  The  child  should  stand  in  a 
foot  tub  containing  warm  water  enough  to  cover  the  feet,  then  a  large 
sponge  holding  about  a  pint  of  water  at  a  temperature  of  from  40°  to  60° 
F.  should  be  squeezed  three  or  four  times  over  the  chest,  shoulders,  and 
spine  of  the  child,  the  skin  being  rubbed  meanwhile.  The  bath  should 
not  last  more  than  half  a  minute.  It  should  be  followed  by  a  brisk  rub- 
bing until  a  thorough  reaction  is  established.  This  is  very  useful  at  all 
ages,  but  a  particularly  valuable  tonic  in  delicate  children.  It  may  be 
used  in  those  only  eighteen  months  old.  Not  the  least  of  the  beneficial 
results  is  the  full  expansion  of  the  lungs  from  the  strong  cry  which  the 
bath  usually  excites.  In  younger  infants  a  cold  plunge  may  be  sub- 
stituted. This  should  be  merely  a  single  dip  of  the  entire  body  in 
water  at  a  temperature  of  50°  to  60°  F.  In  order  that  beneficial  effects 
shall  follow  the  cold  plunge  or  cold  sponging,  a  good  reaction  must  be 
established.  If  children  lack  suffi- 
cient vitality  to  secure  this,  and  if 
they  remain  pale,  pinched,  and  blue 
for  some  time  after  the  bath,  it 
must  be  discontinued  altogether, 
or  water  of  a  higher  temperature 
used. 

Nasal  Spray. — This  may  be  either 
of  an  aqueous  or  oily  solution.     For 
the  oil  spray  an  atomizer  similar  to 
that   shown    in    the    accompanying 
cut  should  be  employed.     It  is  valu- 
able in  cases  of  dry  catarrh,  where  there  is  a  formation  of  crusts  in  the 
nose.     A  variety  of  oils  may  be  used  in  the  spray,  albolene  being  per- 
haps  as   satisfactory   as   any.     Fig.    8   shows   an   efficient   atomizer   for 
albolene. 

There  are  a  good  many  forms  of  hand  atomizers  to  be  found  in  the 
market  for  the  production  of  an  aqueous  spray.     For  a  cleansing  nasal 


iVlbok'iU'  utoniizLT. 


56  PECULIARITIES   OP   DISEASE   IN   CHILDREN. 

spray,  D obeli's  *  solution,  Seller's  f  solution,  Listerine  ten-per-cent  solu- 
tion, or  a  two-per-cent  solution  of  boric  acid  may  be  used. 

Nasal  Syringing. — In  cases  of  considerable  nasal  obstruction  and  in 
the  more  serious  affections  of  the  rhino-pharynx  only  the  syringe  can  be 
considered  an  efficient  means  of  cleansing  the  cavity.  The  nasal  syringe 
should  be  small  enough  to  be  easily  worked  with  one  hand.  It  should 
have  a  soft-rubber  tip  to  prevent  injuring  the  nose,  and  the  tip  should  be 
large  enough  to  fill  the  nostril.  The  best  syringe  for  nasal  use  is  shown 
in  Fig.  9.     This  is  made  either  of  glass  or  hard  rubber  and  fulfils  all  the 


Fig.  9. — Nasal  syringe. 

conditions  mentioned.  J  It  is  easy  of  action,  can  be  readily  cleansed,  and 
holds  about  half  an  ounce.  The  same  syringe  should  not  be  used  for  more 
than  one  patient,  unless  it  has  been  very  thoroughly  disinfected.  In  hos- 
pitals, and  even  in  private  practice,  nasal  syringes  are  frequent  carriers  of 
infection.  Two  positions  may  be  used  in  nasal  syringing.  In  diphtheria, 
scarlet  fever,  or  any  constitutional  disease  attended  by  great  depression,  the 
child  should  not  be  removed  from  the  bed.  The  syringing  may  be  done 
by  a  single  nurse  who  stands  at  the  head  of  the  bed,  alternately  syringing 
the  right  and  left  nostril,  turning  the  head  from  side  to  side  (Fig.  10), 
The  other  method  is  to  hold  the  child  erect  on  the  lap  with  the  head  in- 

*  Dobell's  solution : 

Sodium  biborate 3  j 

Sodium  bicarbonate 3  ] 

Glycerin  of  carbolic  acid 3  i] 

Water  to  make  half  a  pint. 

f  Seller's  solution : 

Sodium  bicarbonate §  j 

Sodium  biborate §  j 

Sodium  benzoate gr.  xx 

Sodium  salicylate gr.  xx 

Eucalyptol gr.  x 

Thymol gr.  x 

Menthol gr.  v 

Oil  gaultheria gtt.  vj 

Glycerine 1  viij  ss. 

Alcohol I  i j 

Water  to  make  sixteen  pints. 

This  is  also  sold  in  tablets,  one  of  which  is  dissolved  in  four  ounces  of  water  to 
make  the  solution  of  the  above  strength. 

X  This  is  made  by  the  Goodyear  Company. 


NASAL  SYRINGING. 


57 


clined  a  little  forward,  the  syringing  being  done  from  behind.  In  either 
position  the  child's  arms  and  hands  should  be  securely  pinioned  to  the 
sides  by  a  sheet.    To  make  sure  that  the  rhino-pharynx  has  been  reached 


n 


i?'iG.  lU.^Method  of  syringing  the  nose. 

the  water  should  return  through  the  opposite  nostril  or  the  mouth. 
When  properly  done,  no  prostration  and  very  little  irritation  are  c-aused. 
Syringing  the  mouth  and  pharynx  is  useful  in  many  pathological  con- 
ditions of  tliese  parts,  particuhirly  in  children  t(io  youug  to  gargle. 
Either  an  ordinary  hard-rubber  piston  syringe  or  a  bulb  (Davison)  syr- 
inge may  be  used.  If  the  pharynx  is  to  be  reached,  the  nozzle  is  used  as  a 
tongue  de])ressor.  This  should  be  placed  at  I  lie  angle  of  the  mouth  be- 
tween the  back  teeth.  The  child  should  he  held  in  tlic  sitting  posture, 
with  the  head  inclined  I'oi'ward.     Only  mild  solutions  should  be  emplo3'ed. 


58 


PECULIARITIES  OP  DISEASE  IN   CHILDREN. 


Inhalations. — These  are  of  very  great  utility  in  all  affections  of  the 
respiratory  tract.  To  be  efficient,  the  patient  should  be  put  under  a  tent. 
A  satisfactory  tent  may  be  made  by  erecting  a  T-shaped  piece  of  wood  at 
the  head  and  foot  of  the  crib  and  throwing  over  this  a  large  sheet  folded 
and  pinned  at  the  corners.  Another  method  is,  to  stretch  a  cord  around 
the  top  of  each  of  the  four  posts  of  the  crib,  or  simply  from  the  centre  of 
the  head  piece  to  the  centre  of  the  foot  piece ;  the  sheet  should  be  used  as 
in  the  first  instance.  A  very  good  tent  may  be  improvised  by  throwing  a 
large  sheet  over  an  open  umbrella.  Instead  of  an  ordinary  cotton  sheet 
one  of  rubber  cloth  may  be  used.  For  hospital  use  I  have  found  it  con- 
venient to  have  a  rubber  cover  made  to  fit  closely  over  the  top  of  the  crib 
to  be  used  for  inhalations.  The  better  the  tent  the  more  satisfactory  are 
the  results  from  inhalations. 

Inhalations  may  be  in  the  form  of  vapour  or  spray.  The  apparatus 
employed  may  be  the  croup  kettle,  the  vapourizer,  or  the  steam  atomizer. 
As  all  of  these  are  used  with  alcohol  lamps,  innumerable  accidents  from 
fire  have  occurred  with  them.  Patients  and  nurses  should  always  be  cau- 
tioned regarding  this.  The  ordinary  croup  kettle  is  a  clumsy  affair  and 
especially  likely  to  be  the  cause  of  accidents.  In  Fig.  11  is  shown  one 
of  an  improved  pattern,*  which  possesses  the  advantages  both  of  the  ordi- 
nary croup  kettle  and  of  the 
vapourizer.  The  base  has  been 
weighted,  to  prevent  the  appa- 
ratus being  easily  upset.  The 
pail  is  low,  which  fact  also  contributes 
to  its  stability.  It  is  provided  with  a 
safety  alcohol  lamp,  the  flame  of  which 
can  be  regulated  by  a  screw.  The 
lamp  holds  enough  alcohol  to  burn 
from  five  to  six  hours.  This  kettle 
may  be  used  to  produce  simple  vapour, 
or  vapour  from  lime  water,  or  a  medi- 
cated vapour  may  be  employed.  If  the 
latter  is  desired,  the  substance  to  be  va- 
pourized  is  placed  on  a  sponge  held  in 
the  expansion  of  the  spout.  The  kettle 
should  be  filled  with  hot  water  before 
using.  It  should  be  placed  upon  the 
floor  or  a  low  box  beside  the  crib,  so  that  the  end  of  the  spout  is  just  in- 
side the  tent  at  a  level  with  the  surface  of  the  bed. 

The  vapourizer  f   (Fig.  12)  is  one  of  the  most  satisfactory  means  of 


Fig.  11. — The  author's  croup  kettle. 


*  Made  by  Lewis  &  Conger,  130  W.  42d  St.,  New  York, 
f  Made  by  Whitall  &  Tatum,  New  York  and  Philadelphia. 


OILED-SILK  JACKET. 


59 


obtaining  medicated  inhalations.     The  boiler  is  half  filled  with  water,  and 
the  substance  to  be  Yapourized  is  placed  upon  a  sponge  which  lies  on  a  per- 


Fig.  12. — Vapourizer. 


Fig.  13. — Steam  atomizer. 


forated  diaphragm  placed  at  the  top  of  the  boiler,  so  that  all  the  steam 
generated  in  the  boiler  passes  through  it. 

The  steam  atomizer  is  shown  in  Fig.  13.  For  this  no  tent  is  required. 
It  should  be  placed  about  one  and  a  half  or  two  feet  from  the  patient's 
face,  and  the  clothing  protected  by  a  rubber  sheet.  This  is  very  efficient 
-where  steam  or  vapour  of  lime  water  are  used,  but  is  not  to  be  advised  for 
carbolic  acid,  creosote,  etc. 

Oiled-silk  Jacket. — In  all  forms  of  acute  pulmonary  inflammation  this 
form  of  local  application  has  largely  supplanted  the  time-honoured  poul- 
tice, both  in  hospital  and  in  private  practice.  It  keeps  the  skin  at  a  uni- 
form temperature,  maintains  a  moderate  degree  of  counter-irritation,  and 
gives  the  patient  a  great  deal  of  comfort.  The  jacket  consists  of  three 
layers^an  outer  one  of  oiled 
silk,  an  inner  one  of  cheese 
cloth  or  light  flannel,  and  a 
middle  one  of  cotton  batting 
or  wool.  The  middle  layer 
should  be  half  an  inch  in 
thickness.  The  purpose  of 
the  lining  is  to  keep  the  cot- 
ton in  position.  Fig.  14 
shows  the  pattern  of  the 
jacket.  It  is  generally  made 
in  two  pieces,  each  of  which  should  be  about  twelve  inches  wide  and  twelve 
inches  long  for  a  child  of  one  year.  These  are  sewed  together  along  one 
border  and  lapped  at  the  other,  where  it  is  secured  by  safety  pins.  A 
properly  made  jacket  will  last  two  weeks. 


Fig.  14.— Pattern  for  ollcd-.silk  jacket. 


€0 


PECULIARITIES  OP  DISEASE   IN  CHILDREN. 


Stomach-Washing  consists  in  the  introduction  of  water  into  the  stom- 
ach through  a  flexible  catheter  or  stomach  tube  and  then  siphoning  it 
out.  It  was  introduced  into  general  practice  among  infants  by  Epstein, 
of  Prague.     To  Seibert  (New  York)   is  due  the  credit  of  bringing  the 

subject  prominently  before  the  minds  of 
the  medical  profession  in  America.  It  is 
one  of  the  most  valuable  therapeutic 
measures  we  possess.  Stomach- washing 
has  been  employed  almost  daily  for  the 
past  twelve  years  in  the  hospitals  with 
which  I  am  connected,  during  which 
period  the  stomach  has  been  washed 
many  thousand  times.  No  accident 
whatever  has  occurred,  and  the  operation 
may  be  considered  entirely  free  from 
danger ;  in  fact,  it  is  difficult  to  pass 
the  tube  anywhere  else  than  into  the 
cesophagus.  The  amount  of  prostration 
may  be  compared  to  that  of  an  ordinary 
attack  of  vomiting. 

The  apparatus  for  stomach-washing 
is  very  simple  (Fig.  15).  There  is  re- 
quired a  soft-rubber  catheter,  size  16, 
American  scale  (24  French) — one  with  a 
large  eye  is  preferred ;  a  glass  funnel, 
holding  four  to  six  ounces ;  two  feet  of 
rubber  tubing,  and  a  few  inches  of  glass  tubing  to  join  this  to  the  cathe- 
ter. The  child  should  be  held  in  a  sitting  posture  (Fig.  16),  the  body 
well  protected  by  a  rubber  sheet,  with  a  large  basin  conveniently  near. 
The  catheter  should  be  moistened.  While  the  tongue  is  depressed  with 
the  forefinger  of  the  left  hand,  the  catheter  is  passed  rapidly  back  into  the 
pharynx  and  down  the  oesophagus.  It  is  important  that  the  first  part 
of  the  introduction  should  be  as  rapid  as  possible,  for  if  the  child  begins 
to  gag  from  the  pharyngeal  irritation  the  introduction  of  the  tube  may 
be  quite  difficult.  No  resistance  is  ordinarily  encountered  after  the  tube 
reaches  the  oesophagus.  About  ten  inches  of  the  catheter  should  be  passed 
beyond  the  lips.  When  it  has  reached  the  stomach  the  funnel  should  be 
raised  as  high  as  possible,  to  allow  the  escape  of  gases  almost  invariably 
present.  It  should  then  be  lowered,  in  order  to  siphon  out  the  fluid  con- 
tents. If  nothing  escapes,  the  funnel  is  then  to  be  raised  and  from  two 
to  six  ounces  of  water  poured  into  it  from  a  pitcher;  the  funnel  is  then 
lowered  and  the  water  siphoned  out.  This  procedure  is  repeated  from 
four  to  ten  times,  or  until  the  fluid  comes  back  perfectly  clear.  About  a 
quart  of  water  is  ordinarily  used.     Various  solutions  have  been  advised 


Fig.  15. — Apparatus  for  Ktomach- 
washinff. 


STOMACH- WASHING. 


61 


for  stomach- washing,  but  nothing  is  better  than  boiled  water,  used  at  the 
temperature  of  from  100°  to  110°  F. — the  higher  temperature  being  em- 
ployed when  the  gastric  irritation  is  very  great.  Through  the  tube  are 
easily  discharged  mucus  and  small  curds ;  larger  ones  are  gradually  broken 
down  by  repeated  washing.  Vomiting  may  be  induced  by  overdistending 
the  stomach  with  water.  If  there  is  great  thirst  there  is  often  an  advan- 
tage in  leaving  one  or  two  ounces  of  water  in  the  stomach.  To  this  water 
■it  is  at  times  beneficial  to  add  lime  water. 

Stomach-washing  in  its  application  is  practically  limited  to  children 
under  two  and  a  half  years.     It  is  easiest  in  those  under  eighteen  months. 


Fig.  16. — Position  for  stomach-washing. 

Children  of  three  years  and  over  are  usually  so  much  alarmed  and  struggle 
60  violently  as  to  make  it  difficult  and  undesirable. 

The  indications  for  stomach-washing  are  :   (1)   Acute  gastric  indiges- 
tion, either  with  or  without  persistent  vomiting.     Here  the  purpose  is 
6 


62  PECULIARITIES  OF   DISEASE  IN  CHILDREN. 

simply  to  clear  the  stomach  of  its  irritating  contents,  and  a  single  wash- 
ing may  be  sufficient.  (2)  Chronic  indigestion  attended  with  great 
production  of  gastric  mucus,  and  sometimes,  though  rarely,  by  dilatation 
of  the  stomach.  In  these  cases  daily  washing  is  required  for  a  consider- 
able period.      (3)   Poisoning. 

Gavage. — Gavage  consists  in  the  forcible  introduction  of  food  into  the 
stomach  by  a  tube  passed  through  the  mouth.  The  same  apparatus  is 
employed  as  in  stomach-washing,  and  the  method  is  similar,  with  the 
exception  that  for  gavage  the  child  should  be  placed  flat  upon  the  back, 
the  head  being  steadied  by  an  assistant.  In  older  children  a  mouth-gag- 
is  often  necessary.  After  the  tube  has  entered  the  stomach  the  funnel 
should  be  raised  to  allow  the  gas  to  escape.  The  food  is  then  poured 
into  the  funnel ;  as  soon  as  it  has  disappeared  the  tube  is  tightly  pinched 
and  quickly  withdrawn,  to  prevent  food  from  trickling  into  the  pharynx,, 
since  this  is  often  a  cause  of  vomiting.  In  young  infants,  after  remov- 
ing the  tube,  it  is  well  to  keep  the  jaws  separated  by  the  fingers  for  a  few 
moments  to  prevent  gagging.  If  the  food  is  regurgitated  this  usually 
happens  at  once.  It  may  then  be  introduced  a  second  time.  After  feed- 
ing, the  child  should  be  kept  absolutely  quiet  upon  the  back. 

In  cases  where  all  the  food  is  given  by  gavage  the  interval  between 
feedings  must  be  considerably  longer  than  under  other  circumstances. 
The  food  given  should  be  either  wholly  or  partly  predigested,  since  diges- 
tion in  these  cases  is  usually  feeble.  The  stomach  should  be  washed 
before  each  feeding,  in  order  to  remove  mucus  and  to  be  sure  that  it  is 
empty  before  the  meal  is  given. 

Gavage  is  valuable,  as  already  indicated  in  connection  with  the  incu- 
bator, in  the  management  of  premature  infants  and  after  certain  opera- 
tions upon  the  mouth  and  neck.  It  is  also  useful,  first,  in  the  case  of  very 
young  infants,  who,  suffering  from  severe  malnutrition,  can  not  be  in- 
duced to  take  food  enough  to  sustain  life ;  secondly,  in  many  acute  dis- 
eases, particularly  in  septic  cases  where  the  child  will  not  readily  take  the 
necessary  food,  as  in  diphtheria,  scarlet  fever,  typhoid,  pneumonia,  etc. ; 
thirdly,  in  many  cases  of  cerebral  disease  where  food  is  refused  on  account 
of  delirium  or  coma ;  and,  fourthly,  in  uncontrollable  vomiting.  Kerley 
found,  after  a  large  number  of  experiments,  that  food  given  by  gavage  was 
often  retained  when  very  much  smaller  quantities  administered  by  the 
spoon,  bottle,  or  even  from  the  breast,  were  immediately  vomited.  Ker- 
ley's  experiments  were  conducted  in  the  New  York  Infant  Asylum  during 
my  service  there,  and  his  results  have  been  verified  by  subsequent  experi- 
ence in  that  and  in  other  institutions.  The  explanation  seems  to  be  that 
the  passage  of  the  tube  causes  less  irritation  of  the  pharynx  than  does 
the  food  after  it  has  been  swallowed,  vomiting  being  due  apparently  to 
such  pharyngeal  irritation.* 

*  For  fuller  report  of  Dr.  Kerley's  cases  see  Archives  of  P;T?diatrics,  February,  1892;. 
also  article  by  the  writer,  New  York  Medical  Record,  April  28,  1894. 


IRRIGATION  OF   THE  COLON.  63 

Gavage  is  a  very  simple  procedure  and  one  which  a  nurse  can  easily  he 
taught.  It  is  free  from  danger,  and  in  a  great  majority  of  cases  food  is 
not  regurgitated.  In  acute  septic  cases  not  only  may  food  he  given, 
but  also  such  medicines  and  stimulants  as  may  he  required,  with  little  or 
no  trouhle.  The  advantage  of  gavage  over  the  continued  coaxing  or  hold- 
ing the  nose  and  forcing  the  patient  to  swallow  will  be  at  once  apparent 
to  one  using  it. 

Nasal  Feeding. — The  method  is  similar  to  gavage,  the  only  difference 
being  that  the  tube  is  passed  through  the  nose,  and  consequently  a  much 
smaller  one  is  used.  No.  10  American  or  No.  16  French  scale  is  a  proper 
size.  Nasal  feeding  is  applicable  to  children  over  two  years  old,  in  whom 
the  tube  can  seldom  be  passed  through  the  mouth  without  the  use  of  a 
gag,  and  then  only  after  much  struggling.  It  is  of  value  after  intu- 
bation, tracheotomy,  and  other  operations  about  the  throat,  also  in  some 
cases  of  throat  paralysis,  especially  after  diphtheria.  It  can  not  be  con- 
tinued as  long  as  can  gavage  on  account  of  the  irritation  to  the  nose 
which  the  tube  causes.  Care  should  be  taken  to  have  the  tube  well  oiled ; 
the  arms  should  be  pinioned  to  the  sides  by  a  sheet. 

Irrigation  of  the  Colon, — By  irrigation  of  the  colon  is  meant  the  flush- 
ing of  the  entire  large  intestine  by  fluids  injected  high  up  through  a 
catheter  or  rectal  tube.  Under  no  circumstances  is  it  possible  to  inject 
fluids  beyond  the  ileo-csecal  valve,  but  we  can  be  quite  sure  that  if  proper 
precautious  be  taken  they  will  reach  as  high  as  this  point. 

The  apparatus  required  for  irrigating  the  colon  is  a  fountain  syringe, 
five  or  six  feet  of  rubber  tubing,  and  a  flexible  rectal  tube  or  soft-rubber 
catheter — No.  18  or  20,  American  scale,  being  preferred.  The  child  is 
placed  upon  the  back,  with  the  thighs  flexed  and  the  buttocks  brought  to 
the  edge  of  the  bed  or  table.  It  should  lie  upon  a  rubber  sheet  so  arranged 
as  to  form  a  trough  emptying  into  a  large  basin  or  tub.  The  clothing  is 
rolled  up  to  the  hips.  The  bag  containing  the  water  is  hung  four  or  five 
feet  above  the  bed.  The  catheter  is  oiled  and  inserted  just  within  the 
anus  before  the  water  is  turned  on.  As  it  flows  the  catheter  is  gradually 
pushed  upward  to  a  distance  of  twelve  or  fourteen  inches.  The  water 
distending  the  intestine  in  advance  of  the  catheter  usually  makes  its  iutro- 
duction  quite  easy.  If,  however,  the  attempt  be  made  to  introduce  the 
catheter  before  turning  on  the  water,  it  almost  invariably  doubles  upon 
itself.  In  Fig.  17  is  shown  the  colon  of  an  infant  of  six  months  in  posi- 
tion. It  is  the  peculiar  curve  and  the  great  length  of  the  sigmoid  flexure 
that  make  the  introduction  of  water  difficult,  unless  the  tube  is  passed 
quite  to  the  descending  colon.  When  this  is  done  the  renuiinder  of  the 
colon  fills  with  ease;  but  if  the  tube  is  introduced  only  three  or  four 
inches  the  irrigation  is  not  likely  to  extend  beyond  tlie  sigmoid  flexure. 

Usually  a  pint,  and  often  a  quart,  will  be  introduced  before  any  water 
returns.     'J'his  is  an  advantage,  since  one  can  then  be  reasonably  sure  that 


64 


PECULIARITIES   OF  DISEASE   IN   CHILDREN. 


the  upper  part  of  the  colon  has  been  reached.  The  water  is  passed  from 
time  to  time  alongside  the  catheter,  often  with  considerable  force.  At 
least  a  gallon  of  water  should  be  used  for  a  single  irrigation.  The  wash- 
ing should  be  continued  until  the  water  returns  quite  clean.  Gentle 
kneading  of  the  abdomen  should  be  continued  during  the  irrigation,  par- 
ticularly the  early  part  of  it,  to  facilitate  the  passage  of  the  water  into  the 


Fig.  17. — Colon  of  a  child  six  months  old,  in  position.     (From  a  photograph.) 


upper  part  of  the  colon.  At  the  end  of  the  irrigation  the  rubber  tube  is  de- 
tached and  the  water  allowed  to  escape  through  the  catheter,  which  remains 
in  situ.  Sometimes  as  much  as  a  pint  of  water  remains  in  the  intestine. 
This  is  usually  passed  within  half  an  hour.  As  the  irrigation  of  the  colon 
almost  invariably  excites  active  peristalsis  of  the  lower  ileum,  this  part  of 
the  intestine  is  emptied  as  well.  It  is  to  be  remembered  that  the  colon 
of  an  infant  six  months  old  will  hold  one  pint  without  distention,  and  at 
the  age  of  two  years  from  two  to  three  pints. 

Irrigation  of  the  colon  is  useful  to  clear  this  part  of  the  intestine  of 
mucus,  fsecal  matter,  undigested  food,  and  the  products  of  decomposition. 


ENEMATA.  (55 

It  may  also  be  employed  as  a  means  of  local  medication  in  ileo-colitis. 
Where  the  object  is  simply  to  cleanse  the  intestine,  a  saline  solution — a 
teaspoonful  of  common  salt  to  a  pint  of  water — is  preferred.  In  cases  of 
inflammation  of  the  colon  various  astringent  injections  may  be  used;  but 
the  employment  of  antiseptic  injections  is  of  doubtful  advantage. 

The  temperature  of  the  water  used  for  irrigation  may  be  varied  ac- 
cording to  the  special  indications.  For  ordinary  purposes,  where  cleans- 
ing only  is  aimed  at,  the  temperature  of  from  95°  to  100°  F.  seems  to  be 
best.  When  the  body  temperature  is  high,  or  when  there  is  much  pain, 
tenesmus  and  straining,  cold  water  has  important  advantages.  The  pa- 
tient's temperature  may  sometimes  be  reduced  as  effectively  by  a  cold- 
water  injection  as  by  a  bath.  In  cases  of  collapse  or  great  prostration 
hot  injections  may  be  employed;  these  should  not  be  higher  than  110° 
F.,  but  at  this  temperature  they  may  be  used  with  safety. 

Irrigation  under  most  circumstances  is  required  only  once  in  twenty- 
four  hours.  When  it  is  employed  it  is  important  to  use  a  large  quantity 
of  water.  In  acute  intestinal  diseases  with  severe  symptoms  two  or  three 
irrigations  a  day  may  be  advantageous.  This  means  of  treatment  cer- 
tainly forms  a  most  valuable  addition  to  our  therapeutics  in  the  manage- 
ment of  intestinal  diseases.  With  ordinary  care  irrigations  are  free 
from  danger.  They  must  be  done  thoroughly  to  be  of  value,  and  either 
by  the  physician  himself  or  an  experienced  nurse.  The  chief  points  of 
importance  are,  that  the  catheter  should  be  introduced  high  into  the 
bowel,  and  that  a  large  quantity  of  fluid  should  be  employed. 

Enemata. — Simple  enemata  are  useful  in  infants  and  older  children, 
to  empty  the  bowels  in  cases  of  constipation.  Where  an  immediate  effect 
is  desired  the  most, efficient  is  one  containing  glycerine — e.g.,  for  an 
infant,  one  teaspoonful  to  one  ounce  of  water.  Oil  enemata  are  useful 
where  the  fseeal  mass  is  hard  and  dry  and  expelled  with  difficulty.  For 
this  purpose  from  two  drachms  to  half  an  ounce  of  sweet  oil  may  be  given. 
Enemata  should  always  be  given  with  care,  and  preferably  a  rubber  tube 
should  be  attached  to  the  nozzle  of  the  S3Tinge,  since  injury  may  be  done 
by  a  hard-rubber  or  metal  tip. 

Xutrient  enemata  have  a  limited  application  in  infancy.  The  rectum 
soon  becomes  intolerant,  and  rarely  can  more  than  three  or  four  injec- 
tions be  given  before  they  cease  to  be  retained.  The  quantity  injected 
should  be  small,  rarely  more  than  one  ounce,  and  the  interval  between 
injections  should  be  at  least  four  hours.  In  older  children  they  may  be 
used  as  in  adults.  For  this  purpose  either  completely  peptonized  milk 
or  some  of  the  forms  of  beef  peptones,  like  Mosquera's  beef  jelly,  may  be 
employed.  In  giving  stimulants  in  enemata  care  should  always  be  taken 
that  tiiey  be  well  diluted — one  part  of  brandy  to  at  least  eight  parts  of 
water. 

The  administration  of  drugs  per  rectum  is  useful  in  certain  cases 


66  PECULIARITIES  OF  DISEASE  IN  CHILDREN. 

where^  on  account  of  the  unpleasant  taste  or  vomiting,  the  administration 
by  mouth  is  clitTicult.  In  tliis  connection  Tve  may  mention  particularly 
quinine  and  chloral.  As  a  diluent  gruel  is  preferable  to  water.  If  quinine 
is  used,  the  bisulphate  is  the  best  preparation,  but  this  must  be  well  diluted. 
The  use  of  solutions  stronger  than  four  grains  to  the  ounce  often  results 
in  the  production  of  rectal  catarrh.  The  temperature  of  all  enemata 
which  are  to  be  retained  should  be  about  100°  F.  It  is  necessary  in  in- 
fancy to  press  the  buttocks  together  for  at  least  half  an  hour  afterwards 
to  prevent  the  expulsion  of  the  injection. 

Hypodermic  Medication. — This  is  not  often  used  in  childhood,  but  it 
must  not  be  forgotten  that  it  is  at  times  of  the  greatest  service  even  in 
infancy.  The  use  of  morphine  hypodermically  in  convulsions,  of  mor- 
phine and  atropine  in  cholera  infantum,  of  atropine  in  opium  poisoning, 
of  strychnine  in  heart  failure,  as  in  pneumonia  and  syncope,  may  be  cited 
as  examples.  These  are  all  conditions  in  which  the  hypodermic  needle 
may  save  life. 

Massage. — In  older  children  massage  is  useful  for  the  same  conditions 
as  those  for  which  it  is  employed  in  adults ;  the  most  important  are 
anaemia  and  general  malnutrition — in  conjunction  with  the  "  rest  treat- 
ment " — in  chorea,  and  in  chronic  constipation.  For  the  last  mentioned 
only  abdominal  massage  is  employed.  The  special  method  of  doing  this 
will  be  referred  to  in  the  chapter  on  Constipation.  In  children,  even  more 
than  in  adults,  it  is  necessary  that  in  the  beginning  only  the  mildest  move- 
ments of  massage  should  be  employed,  and  these  but  for  a  short  time. 

In  infancy  massage  has  a  limited  application,  and  it  is  doabtful 
whether  it  really  does  more  than  can  be  accomplished  by  the  general 
friction  of  the  body.  This  rubbing,  either  with  the  bare  hand,  or  with 
cocoa  butter,  or  some  other  fat,  is  very  useful  in  all  forms  of  malnutrition, 
in  rickets,  and  in  wasting  diseases  where  the  circulation  is  feeble  and  the 
muscular  tone  low.  Any  form  of  fat  may  be  employed  for  inunction. 
Cocoa  butter  is  cleanly  and  has  a  pleasant  odor,  and  is,  I  think,  quite  as 
valuable  as  the  more  commonly  employed  cod-liver  oil,  which  is  exceed- 
ingly disagreeable.  The  inunctions  should  be  given  daily  after  the  morn- 
ing bath,  the  child  lying  upon  the  nurse's  lap  before  an  open  fire,  covered 
only  by  a  blanket.  The  rubbing  should  be  continued  for  fifteen  to  twenty 
minutes  each  time. 


PART  TL 

SECTION   I. 
DISEASES  OF  THE  NEWLY  BORN. 

CHAPTER   I. 
ASPHYXIA. 

The  lungs  in  the  full-term  fcetus  are  of  a  uniform  dark  red  colour,  and 
show  very  distinctly  upon  their  surface  the  lobular  divisions.  They  are 
firm  and  solid  and  readily  sink  in  water.  The  connective  tissue  is  very 
abundant,  and  forms  distinct  fibrous  septa,  which  stretch  through  the 
lungs  in  every  direction. 

Inflation  of  the  lungs  begins  with  the  first  cry  uttered  by  the  infant 
as  it  is  born  into  the  world.  The  parts  first  expanded  are  the  anterior 
borders  of  the  lungs,  then  the  upper  lobes,  and  finally  the  lower  lobes 
posteriorly.  The  superficial  lobules  are  nearly  always  expanded  before 
those  in  the  interior  of  the  lung.  The  inflation  is  sometimes  irregular, 
because  of  the  accumulation  of  mucus  in  some  of  the  bronchial  tubes. 
The  right  lung  is  frequently  stated  to  be  expanded  earlier  than  the  left. 
Although  this  is  often  the  case,  there  is  no  uniformity  in  this  respect. 
The  important  point  to  be  remembered  is,  that  the  parts  last  inflated  are 
the  posterior  portions  of  the  lower  lobes.  The  expansion  of  the  lungs  is  a 
gradual  process,  and  in  healthy  infants  it  is  probably  not  complete  much 
before  the  end  of  the  second  day.  In  delicate  children  it  may  be  post- 
poned for  several  days,  or  even  weeks.  The  above  statements  are  based 
upon  post-mortem  observations  upon  infants  dying  from  various  causes 
during  the  first  weeks.  It  has  often  been  a  matter  of  great  surprise  to 
find  at  autopsy  on  an  infant  two  or  three  days  old,  that  less  than  one  half 
of  the  lung  tissue  was  expanded,  although  the  child  had  breathed  well 
and  shown  no  signs  of  atelectasis.  Under  normal  conditions  at  full  term 
inflation  of  the  lung  takes  place  very  readily,  but  not  so  readily  in  pre- 
mature or  delicate  infants,  on  account  of  the  feebleness  of  the  respiratory 
muscles.  The  longer  it  is  postponed  after  birth  the  more  difficult  does  it 
become,  on  account  of  the  changes  which  occur  in  the  collapsed  air  vesi- 

67 


68  DISEASES   OF   THE   NEWLY  BORN. 

cles.  The  condition  of  the  child  171  liter 0  may  be  described  as  one  of 
foetal  apncea,  its  oxygen  being  received  and  its  carbon  dioxide  discharged 
through  the  placenta,  which  is  essentially  the  organ  of  respiration  at  this 
period.  This  condition  is  interrupted  by  cutting  off  the  supply  of  oxygen 
and  the  accumulation  of  carbon  dioxide  in  the  blood.  Which  of  these  is 
the  important  factor  in  inducing  pulmonary  respiration  has  been  much 
debated ;  but  the  best  experimental  evidence  seems  to  show  that  it  is  the 
want  of  oxygen  which  stimulates  the  respiratory  centres. 

Under  the  term  "  asphyxia  "  may  be  included  all  cases  in  which  pri- 
mary respiration  is  not  spontaneously  established  with  sufficient  force  to 
maintain  life.  Usually  there  is  no  attempt  at  pulmonary  respiration  until 
after  the  birth  of  the  child,  but  it  may  occur  m  utero  or  at  any  stage  of 
parturition.     Asphyxia  may  be  of  intra-uterine  or  extra-uterine  origin. 

Etiology. — 1.  Intra-uterine  asphyxia.  The  maternal  causes  include 
any  disturbance  of  the  placental  circulation  during  labour — anything 
which  prolongs  the  second  stage  of  labour,  convulsions,  hfemorrhage,  the 
use  of  ergot  in  the  second  stage,  or,  finally,  the  death  of  the  mother.  The 
causes  relating  to  the  child  are  pressure  upon  the  cord,  multiple  winding 
of  the  cord  about  the  neck,  early  separation  of  the  placenta,  and  pressure 
upon  the  brain.  If  the  respiratory  stimulus  comes  before  the  birth  of 
the  child,  the  effort  at  respiration  may  cause  the  entrance  into  the  mouth 
and  air  passages  of  amniotic  fluid,  mucus,  blood,  meconium,  etc. 

2.  Extra-uterine  asphyxia.  This  condition  is  a  much  less  common 
one.  It  arises  from  causes  quite  apart  from  those  above  mentioned,  and 
depends  upon  malformations  or  intra-uterine  disease  of  the  organs  of 
respiration,  circulation,  or  of  the  brain.  It  may  be  secondary  to  an  injury 
of  any  of  these  organs  received  during  parturition.  It  is  also  seen  in  pre- 
mature infants,  where  it  depends  upon  the  feeble  development  of  the  nerve 
centres  and  respiratory  muscles  and  upon  the  soft,  yielding  chest  walls. 

Lesions. — In  infants  dying  of  intra-uterine  asphyxia  there  are  seen 
the  usual  changes  found  in  death  from  suffocation,  together  with  the  effects 
of  attempts  at  breathing  in  utero.  There  is  general  congestion  of  all  the 
viscera,  particularly  of  the  brain  and  its  meninges,  the  liver,  and  the  lungs. 
They  may  show  small,  punctate  hasmorrhages,  and  occasionally  large  ex- 
travasations. Blood  or  bloody  serum  may  be  found  in  any  of  the  serous 
cavities.  The  right  heart  is  overdistended  with  dark,  soft  clots,  and  the 
blood  generally  is  more  fluid  than  normal.  The  lungs  may  contain  no 
air,  but  more  frequently  there  are  small,  scattered  areas  in  which  lobular 
inflation  has  taken  place.  If  the  child  has  lived  several  hours  there  are 
larger  areas  of  expanded  lung,  especially  in  the  upper  lobes,  and  these 
may  even  be  emphysematous,  if  artificial  inflation  has  been  employed. 
In  the  mouth,  nose,  larnyx,  and  even  as  far  as  the  finest  bronchi,  there 
may  be  found  aspirated  materials — amniotic  fluid,  blood,  mucus,  or  me- 
conium.    In  extra-uterine  asphyxia  there  are  organic  changes  in  the  vis- 


ASPHYXIA.  69 

cera — malformations  of  the  lungs  or  the  heart,  intra-uterine  pneumonia 
or  pleuritic  effusion,  malformation  of  the  diaphragm  and  sometimes  of 
the  brain. 

Symptoms. — Under  normal  conditions  the  newly-born  infant  begins  at 
once  to  scream  and  to  use  its  limbs,  the  purplish  colour  of  the  skin  giving 
place  in  a  few  moments  to  a  rosy  pink.  In  the  first  degree  of  asphyxia — 
asphyxia  livicla — the  child  is  deeply  cyanosed.  Either  no  attempt  what- 
ever is  made  at  respiration,  or  it  is  superficial  and  repeated  only  at  long 
intervals.  The  pulse  is  slow,  full,  and  strong.  The  vessels  of  the  cord 
are  distended.  Muscular  tone  is  preserved,  and  also  cutaneous  irritability, 
so  that  with  the  application  of  almost  any  kind  of  external  stimulus,  respi- 
ration is  excited  and  the  symptoms  disappear. 

In  the  second  degree — asphyxia  pallida — the  picture  is  quite  a  different 
one.  The  face  is  pale  and  death-like,  though  the  lips  may  still  be  blue. 
The  heart's  action  is  weak,  and  by  palpation  can  rarely  be  felt  at  all.  By 
auscultation  the  sounds  are  feeble,  irregular,  and  usually  slow.  The  cord 
is  soft,  pale,  and  flaccid,  and  its  vessels  nearly  empty.  The  sphincters  are 
relaxed,  and  meconium  oozes  from  the  anus.  There  is  entire  loss  of  tone 
in  the  voluntary  muscles,  so  that  the  extremities  and  entire  body  seem 
perfectly  limp.  Cutaneous  sensibility  is  abolished.  The  extremities  are 
often  cold.  There  may  occur  a  few  short,  convulsive  contractions  of  the 
respiratory  muscles,  but  these  are  without  effect  and  soon  cease.  Unless 
such  cases  receive  the  most  prompt  and  efficient  treatment,  the  heart's 
action  becomes  more  and  more  feeble  until  it  ceases  and  death  occurs. 
Other  cases  are  partly  resuscitated  and  may  survive  for  a  few  hours  or 
days,  when  they  gradually  sink,  respiration  becoming  more  and  more 
feeble  in  spite  of  all  efforts  to  maintain  it.  Between  these  two  extremes 
all  degrees  of  severity  are  seen. 

In  extra-uterine  asphyxia  there  may  be  some  attempts  at  voluntary 
respiration  continuing  for  several  hours,  sometimes  for  a  day  or  two,  but 
this  may  be  inadequate  to  sustain  life. 

Diagnosis. — Almost  the  only  condition  with  which  asphyxia  is  likely 
to  be  confounded  is  cerebral  compression  from  a  meningeal  htvmorrhage. 
The  difficulties  in  the  case  are  much  increased  by  the  fact  that  the  two 
conditions  are  not  infrequently  associated.  It  may  then  be  impossible  to 
tell  that  in  addition  to  asphyxia,  intracranial  haemorrhage  is  present.  If  the 
haemorrhage  is  extensive  and  the  asphyxia  only  moderate,  a  diagnosis  is 
possible  in  most  of  the  cases.  In  hemorrhage  there  is  often  a  history  of 
undue  compression  during  delivery — sometimes  the  use  of  forceps.  The 
fontanel  is  bulging ;  there  is  coma,  and  there  may  be  paralysis.  The  re- 
spiratory murmur  may  be  quite  strong  for  several  hours,  but  it  gradually 
fails  as  the  child  becomes  completely  comatose.  Anaemia  resulting  from 
a  large  haemorrhage,  like  that  due  to  rupture  of  the  cord,  may  simulate  the 
severe  form  of  asphyxia. 


YO  DISEASES   OF  THE   NEWLY  BORN. 

Prognosis. — This  depends  upon  the  grade  of  asphyxia  and  the  treat- 
ment employed.  There  is  but  little  tendency  to  spontaneous  recovery  in 
any  form.  In  the  milder  cases  recovery  is  almost  invariable  with  any 
intelligent  treatment.  In  the  severest  cases  the  outcome  is  always  doubt- 
ful, although  by  persistent  effort  many  that  are  apparently  hopeless  may  be 
saved.  In  a  prognosis  as  to  the  ultimate  result,  the  frequent  complica- 
tion of  asphyxia  with  meningeal  hsemorrhage  should  always  be  kept  in 
mind.  Apart  from  this  complication  it  is  doubtful  whether  asphyxia  has 
anything  to  do  with  the  production  of  idiocy. 

Treatment. — In  every  case  the  first  step  is  to  clear  the  mouth  and 
pharynx  of  mucus  by  means  of  the  finger  covered  with  absorbent  cotton. 
In  the  milder  forms  respiration  is  usually  excited  either  by  spanking  the 
child  or  the  alternate  use  of  hot  and  cold  baths.  If  the  hot  bath  is  em- 
ployed, the  water  should  be  from  105°  to  110°  F.  and  always  tested  by  a 
thermometer.  After  a  few  moments  the  child  may  be  dipped  into  ice- 
water,  or  the  body  may  be  douched  with  it.  In  the  livid  cases  relief  is 
often  afforded  by  allowing  the  cord  to  bleed  for  a  few  moments  before  liga- 
tion. The  loss  of  half  an  ounce  of  blood  is  ordinarily  sufficient.  Simply 
swinging  the  child  in  the  air  is  a  powerful  stimulus  to  respiration.  The 
above  means  will  suffice  in  the  great  majority  of  cases.  In  the  more  severe 
forms,  however,  these  are  inadequate.  There  is  no  response  whatever  to 
external  stimulation,  either  by  heat  or  mechanical  irritation.  In  these 
cases  two  methods  of  resuscitation  may  be  employed  :  artificial  respiration 
and  direct  inflation  of  the  lungs. 

One  of  the  most  widely  employed  methods  of  inducing  artificial  resjai- 
ration  is  that  of  Schultze.  The  infant  is  grasped  by  both  axillse  in  such 
a  way  that  the  thumbs  of  the  physician  rest  upon  the  anterior  surface  of 
the  chest,  the  index  fingers  in  the  axillse,  and  the  remaining  fingers  extend- 
ing across  the  back.  The  child  is  thus  suspended  at  arm's  length  between 
the  knees  of  the  physician,  the  feet  downward  and  the  face  anterior.  The 
body  is  now  swung  forward  and  upward,  until  the  physician's  arms  are 
nearly  horizontal.  This  produces  the  inspiratory  effort.  When  this  point 
is  reached,  an  arrest  in  the  swinging  causes  flexion  of  the  trunk,  the  head 
now  being  directed  downward,  the  lower  extremities  fall  toward  the  phy- 
sician until  the  whole  weight  of  the  body  rests  upon  the  thumbs.  In  this 
way  expiration  is  produced.  Lusk  cautions  against  the  employment  of 
this  method  if  the  heart's  action  is  very  feeble,  as  it  may  cause  the  heart 
to  stop  altogether. 

A  method  introduced  by  Dew  has  been  extensively  employed  in  New 
York.  The  infant  is  grasped  in  such  a  way  that  the  neck  rests  between 
the  thumb  and  forefinger  of  the  left  hand,  the  head  being  allowed  to  fall 
far  backward,  the  upper  portion  of  the  back  resting  upon  the  palm  of  the 
hand;  with  the  right  hand  the  knees  are  grasped  between  the  thumb 
and  fingers,  the  thighs  resting  against  the  palm  of  the  hand.     Inspiration 


ASPHYXIA.  ^i 

is  produced  by  depressing  the  pelvis  and  lower  extremities  thus  causin<y 
the  abdominal  organs  to  drag  upon  the  diaphragm,  and  at  the  same  time 
gently  bending  the  dorsal  region  of  the  spine  backward.  In  expiration 
the  movement  is  reversed,  the  head  being  brought  forward  and  flexed 
upon  the  thorax,  while  at  the  same  time  the  thighs  are  flexed  so  as  to 
bring  them  against  the  abdomen.  The  body  is  thus  alternately  folded 
upon  itself  and  unfolded  as  the  movements  are  carried  on.  If  there  is 
much  mucus  in  the  mouth,  the  movement  of  expiration  should  first  be 
made  with  the  body  completely  inverted.  This  method  is  simple,  efficient, 
and  much  less  fatiguing  than  that  of  Schultze  when  it  is  to  be  main- 
tained for  a  long  time.  It  is  also  of  great  advantage  in  that  it  can  be 
carried  on  while  the  child  is  in  the  hot  bath,  one  of  the  greatest  objec- 
tions to  the  method  of  Schultze  being  the  loss  of  animal  heat  incident  to 
its  use. 

In  all  cases  where  artificial  respiration  is  used  the  first  movement 
should  be  that  of  expiration,  to  expel,  so  far  as  possible,  foreign  substances 
from  the  air  passages.  The  movements  should  be  made  from  eight  to 
twelve  times  a  minute,  and  not  too  forcibly,  the  child  being  kept  in  the 
hot  bath  between  the  movements,  and  as  much  as  possible  during  them. 
As  long  as  the  heart  beats  resuscitation  is  possible,  and  the  case  should 
not  be  abandoned. 

Inflation  of  the  lungs  is  not  usually  of  so  much  general  value,  although 
it  is  sometimes  successful  when  all  other  means  have  failed.  It  may  be 
done  by  the  mouth-to-mouth  method,  or  by  the  introduction  of  a  catheter 


Fig.  18. — Eibemont's  laryngeal  tube  for  intiating  the  lungs. 

into  the  larnyx.  The  former  is  much  easier,  but  is  much  less  certain, 
since  the  air  is  liable  to  pass  into  the  stomach.  If,  however,  the  head  be 
carried  pretty  well  backward,  compression  made  over  the  epigastrium,  and 
the  nose  closed,  this  is  less  likely  to  occur.  The  introduction  of  a  flexible 
catheter  into  the  larynx  is  by  no  means  an  easy  matter  even  with  consid- 
erable practice.  The  use  of  a  stiif  catheter  is  not  so  difficult,  but  it  is  capa- 
ble of  doing  harm.  A  much  better  instrument  is  the  laryngeal  tube  of 
Ribemont  (Fig.  18).  This  is  inserted  like  an  intubation  tube.  By  means 
of  the  rubber  bag  attached,  air  may  be  forced  into  the  lung,  or  mucus 
aspirated  from  the  trachea  and  bronchi  as  may  be  desired.  In  all  these 
methods,  but  especially  when  the  catheter  is  used,  care  is  necessary  not  to 
employ  too  much  force.     It  should  always  be  remembered  that  the  ca- 


72  DISEASES  OP  THE  NEWLY  BORN. 

pacity  of  the  kmgs  of  the  child  is  much  less  than  that  of  those  of  the 
physician.  Like  artificial  respiration,  inflation  is  to  be  nsed  in  connec- 
tion with  the  external  application  of  heat,  preferably  the  continuous  hot 
bath. 

The  method  introduced  by  Laborde,  of  making  rhythmical  traction 
upon  the  tongue  ten  or  twelve  times  a  minute  as  a  means  of  exciting  res- 
piration, is  one  of  the  most  efficient  within  our  reach.  It  may  be  resorted 
to  in  conjunction  with  other  methods,  or  used  alternately  with  them. 

In  cases  of  asphyxia  it  is  not  enough  to  make  the  child  cry.  The 
deep  respirations  must  be  made  to  continue,  for  very  often  it  happens 
that  resuscitation  is  only  partial,  and  that  the  child  after  six  or  eight 
hours  lapses  into  its  previous  condition.  All  severe  cases  require  careful 
watching  for  the  first  twenty-four  or  thirty-six  hours,  as  a  repetition  of 
the  treatment  is  often  required. 


CHAPTER   II. 

CONGENITAL  ATELECTASIS. 

This  condition  is  one  in  which  there  is  a  persistence  of  the  foetal  state 
in  the  whole  or  in  any  part  of  the  lung. 

Atelectasis  is  the  pathological  condition  with  which  asphyxia  of  the 
newly  born  is  usually  associated.  In  most  of  the  cases  the  condition  of 
atelectasis  is  completely  overcome  by  the  means  employed  in  resuscitation ; 
in  some,  however,  these  means  are  only  partially  successful,  so  that  a  por- 
tion of  lung  of  variable  extent  remains  in  the  foetal  condition.  These  are 
the  circumstances  in  which  most  of  the  cases  of  atelectasis  arise.  But 
there  are  others  in  which  there  is  no  history  of  early  asphyxia,  where  the 
primary  respirations,  although  taking  place  spontaneously,  have  not  been 
of  sufficient  force  and  depth  to  produce  full  pulmonary  expansion.  This 
usually  occurs  in  feeble  infants,  or  in  those  who  are  premature.  The 
causes  of  congenital  atelectasis  are  therefore,  in  the  main,  those  mentioned 
as  producing  asphyxia. 

Lesions. — In  cases  where  the  child  dies  during  the  first  few  days  the 
amount  of  expanded  lung  is  often  very  small,  frequently  not  more  than 
one  fourth  of  the  pulmonary  area.  The  expanded  portion  is  usually  the 
anterior  borders  of  the  upper  lobes.  This  is  often  the  seat  of  acute  em- 
physema. The  rest  of  the  lung  is  still  in  the  foetal  state;  it  is  of  a 
brownish-red  colour,  very  vascular,  does  not  crepitate,  and  shows  the  lobu- 
lar outlines  both  on  the  surface  and  on  section.  With  a  little  force  the 
atelectatic  lung  may  be  completely  inflated. 

If  children  have  lived  several  months,  nearly  the  whole  of  the  upper 


CONGENITAL   ATELECTASIS.  Y3 

lobes  and  the  anterior  portion  of  the  lower  lobes  are  usually  well  inflated. 
These  portions  are  either  normal  or  slightly  emphysematous.  The  pos- 
terior portion  of  the  upper  lobes  and  the  lower  lobes  are  almost  invariably 
the  seat  of  the  atelectasis.  On  the  surface  even  these  portions  may  pre- 
sent quite  a  large  area  of  expanded  vesicles,  but  the  lobe  is  solid  to  the 
touch,  and  crepitates  but  slightly.  On  section  it  is  seen  that  only  the 
most  superficial  part  of  the  lung  is  inflated,  often  only  to  the  depth  of 
a  line,  while  the  interior  of  the  lobe  is  unexpanded.  Small  haemorrhages 
are  frequently  seen  beneath  the  pleura. 

It  is  usual  for  both  lungs  to  be  affected,  and  often,  but  by  no  means 
uniformly,  to  about  the  same  degree.  It  is  frequently  a  great  surprise  to 
discover  that  a  child  has  lived  two  or  three  months  without  presenting 
any  signs  of  cyanosis,  using  not  more  than  one  third  of  its  pulmonary  area. 
This  variety  of  atelectasis  closely  resembles  the  hypostatic  pneumonia  of 
delicate  infants,  and  very  often  the  two  conditions  are  associated.  It  may 
require  the  microscope  to  decide  between  them.  If  congenital  atelectasis 
has  existed  for  some  months,  there  are  usually  found  evidences  of  pneu- 
monia. Inflation  is  not  so  easy  as  in  recent  cases,  but  with  force  the 
greater  part  of  the  lung  can  usually  be  expanded.  The  heart  commonly 
shows  the  right  auricle  and  ventricle  to  be  distended  with  dark  clots,  and 
there  is  occasionally  found  a  patent  foramen  ovale  or  some  other  form  of 
congenital  lesion.  The  liver  and  spleen  are  in  most  cases  congested,  and 
the  spleen  may  be  considerably  enlarged.  The  mucous  membrane  of  the 
stomach  and  intestines  is  sometimes  dee23ly  congested. 

Symptoms.— In  one  group  of  cases  the  children  are  asphyxiated  at 
birth,  but  the  attempts  at  resuscitation  have  been  only  partially  successful. 
Although  the  patients  may  live  for  a  few  days,  there  is  cyanosis,  which 
gradually  deepens,  and  death  takes  j)lace  from  asphyxia,  exhaustion,  or 
convulsions. 

In  a  second  group  of  cases  the  infants  have  been  asphyxiated  at  birth, 
and  resuscitated  perhaps  with  difficulty,  but  to  all  appearance  completely. 
They  do  not  thrive,  however,  remaining  small  and  delicate,  gaining  very 
little  or  not  at  all  in  weight,  and  showing  poor  circulation,  cold  extremi- 
ties, and  occasionally  subnormal  temperature.  It  is  characteristic  of  these 
cases  that  the  cry  is  never  loud,  strong,  and  lusty.  Some  of  them  will  not 
cry  at  all.  Such  children  may  live  several  weeks,  or  even  months.  There 
may  develop  at  any  time,  often  quite  suddenly  and  without  assignable  cause, 
attacks  of  cyanosis  with  prostration.  Children  may  have  several  such  at- 
tacks, which  do  not  excite  suspicion  since  they  pass  away  spontaneously. 
In  other  cases  the  symptoms  are  so  severe  that  they  may  result  fatally  in  a 
few  hours,  death  being  frequently  preceded  by  convulsions.  If  energetically 
treated  the  symptoms  may  pass  away  but,  reappearing  in  a  few  hours,  or 
again  after  a  week  or  more,  they  gradually  deepen  in  intensity  until  death 
occurs. 


74  DISEASES  OP   THE  NEWLY  BORN. 

Two  cases  coming  under  my  observation  in  the  New  York  Infant 
Asylum  in  1890,  illustrate  this  point.  The  infants  were  twins,  ten  weeks 
old  and  delicate.  Suddenly  at  night  one  child  was  taken  with  convul- 
sions, became  deeply  cyanosed,  and  died  in  two  and  a  half  hours.  It  had 
been  suffering  from  a  slight  attack  of  indigestion  and  diarrhoea  for  a  week 
previous,  but  apparently  was  not  seriously  ill.  The  other  twin  had  been 
on  the  previous  day  as  well  as  for  several  weeks.  Two  hours  after  the 
death  of  the  first  child  the  second  was  taken  with  similar  symptoms,  dying 
in  a  few  hours.  At  autopsy  I  found  very  extensive  atelectasis  involving 
the  posterior  part  of  the  upper  and  the  greater  part  of  both  lower  lobes. 
The  lesions  were  almost  identical  in  the  two  cases.  In  both,  the  stomach 
was  greatly  distended  with  food  and  gas.  I  have  repeatedly  seen  the 
effect  of  overdistention  of  the  stomach  in  producing  cyanosis  in  young 
children,  and  in  this  instance  I  believe  it  to  have  been  the  exciting  cause 
of  the  final  symptoms.  It  was  subsequently  learned  that  during  the  six 
weeks  of  observation  the  nurse  had  witnessed  several  slight  attacks  of  cy- 
anosis in  one  of  the  infants. 

I  have  seen  a  number  of  such  cases,  in  which  there  was  nothing  what- 
ever to  attract  attention  to  the  lungs  until  the  final  attack  of  cyanosis 
occurred,  the  children  showing  only  the  signs  of  malnutrition.  In  not  all 
of  these  cases  is  there  a  history  of  asphyxia  at  birth.  Some  are  only  puny, 
delicate  or  premature,  exhibiting  during  the  early  weeks  of  life  all  the 
signs  of  feeble  vitality.  The  subsequent  course  is  the  same  as  in  those  in 
which  there  is  early  asphyxia.  The  duration  of  life  in  these  cases  depends 
chiefly  upon  the  extent  of  the  atelectasis. 

It  is  not  to  be  supposed  that  all  cases  of  congenital  atelectasis  ter- 
minate fatally.  Infants  in  whom  there  is  every  reason  to  believe  that 
atelectasis  exists,  from  the  occasional  attacks  during  the  first  few  weeks  of 
cyanosis,  feeble  cry,  poor  circulation,  etc.,  may  under  favourable  conditions 
recover  completely,  even  though  no  special  treatment  is  directed  to  the 
lungs. 

Diagnosis. — For  this  the  physical  signs  are  of  much  less  value  than  the 
symptoms.  It  should  be  remembered  that  the  principal  seat  of  the  disease 
is  the  lower  lobes  posteriorly.  Percussion  usually  gives  resonance  over  the 
entire  chest,  although  this  may  be  somewhat  diminished  posteriorly.  There 
is  not,  however,  so  much  change  as  one  would  expect  to  find,  for  the  col- 
lapsed areas  are  surrounded  by  others  which  are  overdistended,  and  there 
are  in  the  midst  of  the  collapsed  parts,  especially  upon  the  surface,  lobules 
which  are  inflated.  If  the  two  sides  are  involved  to  about  the  same  degree, 
as  is  often  the  case,  we  can  get  no  difference  in  the  percussion  note  over 
the  two  lungs,  and  the  change  from  the  normal  may  be  so  slight  as  not  to 
be  appreciable.  Where  only  one  lung  is  affected  a  difference  can  usually 
be  made  out.  The  respiratory  murmur  is  rarely  bronchial,  but  generally 
only  feeble  in  its  intensity,  and  rather  ruder  in  quality  than  normal.     As 


ICTERUS.  75 

in  the  case  of  percussion,  if  only  one  lung  is  affected  this  is  of  some  value 
in  diagnosis,  but  it  is  not  sufficiently  marked  to  be  readily  recognized 
when  both  sides  are  involved.     Occasionally  rales  are  present. 

Treatment. — In  the  newly-born  child,  whether  asphyxiated  or  not,  the 
physician  should  see  to  it  that  the  infant  not  only  cries,  but  does  so 
loudly  and  strongly,  and  that  this  cry  is  repeated  every  day.  If  children 
do  not  cry  naturally  they  must  be  made  to  do  so  by  the  alternate  use  of 
the  hot  and  cold  bath,  as  in  cases  of  asphyxia,  or  by  mechanical  means, 
like  spanking.  This  should  be  repeated  at  least  twice  a  day,  and  con- 
tinued for  from  fifteen  to  thirty  minutes.  It  may  seem  cruel,  but  it  is 
often  the  only  means  of  saving  life.  Expansion  of  the  lungs  is  much 
more  easily  induced  during  the  first  few  days  of  life,  becoming  more  and 
more  difficult  the  longer  it  is  delayed.  Provided  the  condition  is  recog- 
nized, treatment  is  fairly  successful.  In  institutions  where  delicate  infants 
spend  most  of  the  time  in  their  cribs,  atelectasis  is  likely  to  be  found. 
An  infant  needs  exercise,  and  this  is  often  only  to  be  obtained  by  taking 
the  child  from  its  crib  several  times  a  day,  by  general  friction,  massage, 
the  stimulus  of  fresh  air,  etc.  Nothing  is  more  certain  to  perpetuate 
atelectasis  than  to  allow  the  infant  a  life  of  feeble  vegetative  existence. 
Food  and  feeding  must  be  carefully  attended  to,  but  even  these  are  of  less 
importance  than  the  maintenance  of  the  animal  heat.  The  temperature 
is  often  subnormal,  and  should  be  closely  watched.  If  there  is  difficulty 
in  keeping  the  child  warm  it  should  be  rolled  in  cotton  and  surrounded 
by  hot  bottles,  or  kept  in  an  incubator  during  the  first  few  weeks.  (See 
page  10.)  During  attacks  of  cyanosis  the  same  means  are  to  be  employed 
as  in  cases  of  asphyxia  of  the  newly  born — cutaneous  stimulation  and  arti- 
ficial respiration — the  administration  of  drugs  being  of  little  or  no  value. 


CHAPTER   III. 

ICTERUS. 

Several  varieties  of  icterus  are  met  with  in  the  newly  born. 

1.  It  is  often  seen  in  the  various  forms  of  pyogenic  infection.  In 
such  cases  the  icterus  is  usually  mild. 

2.  It  may  depend  upon  syphilitic  hepatitis — a  rare  cause. 

3.  It  may  be  due  to  congenital  malformations  of  the  bile-ducts. 

4.  The  most  frequent  of  all  varieties  is  the  so-called  idiopathic  icterus, 
sometimes  spoken  of  as  "  physiological "  icterus. 

In  the  cases  included  under  the  first  and  second  heads  icterus  is  a 
minor  symptom.  The  other  varieties  are  sufficiently  important  to  require 
separate  consideration. 


Yg  DISEASES  OP  THE  NEWLY  BORN. 

MALFORMATIONS  OP  THE  BILE-DUCTS. 

The  common  bile-duct  is  the  most  frequently  affected.  There  may- 
be atresia  at  the  point  where  it  opens  into  the  intestine,  the  duct  may 
be  represented  by  a  fibrous  cord,  or  it  may  be  absent  altogether.  In 
many  cases  this  is  the  only  lesion;  in  others  it  is  associated  with  an  im- 
pervious hepatic  or  cystic  duct;  in  still  others  the  common  duct  is  nor- 
mal, but  the  cystic  or  hepatic  ducts  are  impervious. 

At  autopsy  all  the  organs  are  usually  found  intensely  jaundiced,  par- 
ticularly the  liver.  In  recent  cases  this  is  very  much  swollen,  but  pre- 
sents no  marked  organic  changes.  In  cases  which  have  lasted  several 
months  there  is  commonly  found  chronic  intestinal  hepatitis,  sometimes 
to  a  very  marked  degree.  This  was  present  in  nine  of  the  fifty  cases  col- 
lected by  Thomson.*  The  gall-bladder  is  usually  small,  and  often  rudi- 
mentary. In  cases  of  atresia  of  the  common  duct  it  may  be  greatly  dis- 
tended. 

The  condition  of  the  bile-ducts  is  ascribed  to  an  error  in  development 
-and  subsequent  catarrhal  inflammation.  There  does  not  seem  to  be  suf- 
ficient evidence  to  prove  that  hereditary  syphilis  is  an  etiological  factor 
of  much  importance.  This  was  present  in  but  five  of  Thomson's 
cases. 

Symptoms. — The  m.ost  striking  symptom  is  jaundice,  which  is  usually 
noticed  a  day  or  two  after  birth,  and  steadily  increases  until  it  becomes 
intense.  The  urine  is  colored  a  dark  brown  or  bronze  by  bile  pigment, 
and  even  the  meconium  stools  may  be  white,  except  in  cases  where  mal- 
formation is  limited  to  the  cystic  duct.  The  liver  as  a  rule  is  much  en- 
larged. The  spleen  is  often  swollen.  Heemorrhages  beneath  the  skin  or 
from  any  of  the  mucous  membranes  are  quite  common.  Vomiting  is 
usually  absent.  In  most  cases  there  is  progressive  wasting,  and  death 
within  the  first  few  weeks.  Of  Thomson's  fifty  cases,  nine  lived  less 
than  a  month,  and  only  eighteen  over  four  months.  Lotze  has  reported 
a  case  of  a  child  living  eight  months  with  an  impervious  hepatic  duct. 
A  frequent  cause  of  death  in  the  rapid  cases  is  convulsions. 

These  malformations  cannot  be  influenced  by  any  treatment. 

PHYSIOLOGICAL  OR  IDIOPATHIC  ICTERUS. 

In  900  consecutive  births  at  the  Sloane  Maternity  Hospital  icterus 
was  noted  in  300  cases.  In  88  it  was  intense,  in  212  it  was  mild.  Ac- 
cording to  the  statistics  of  various  lying-in  hospitals  of  Germany,  it  was 
found  in  from  40  to  80  per  cent,  of  all  infants.  In  the  300  cases  just 
referred  to,  icterus  was  noticed  on  the  first  day  in  4,  on  the  second  day  in 
19,  on  the  third  day  in  72,  on  the  fourth  day  in  86,  on  the  fifth  day  in  67, 


*  Edinburgh  Medical  Journal,  1892. 


ICTERUS.  77 

and  on  or  after  the  sixth  day  in  44.  From  the  second  to  the  fiftli  day  ia 
therefore  the  usual  period  for  its  appearance. 

It  usually  increases  in  severity  for  one  or  two  days  and  then  slowly 
disappears.  The  average  duration  in  the  mild  cases  is  three  or  four  days ; 
in  those  of  moderate  severity  about  a  week ;  in  the  most  severe  cases  it 
may  last  for  two  weeks.  The  icterus  is  first  noticed  in  the  skin  of  the 
face  and  chest,  then  in  the  conjunctivas,  then  in  the  extremities.  The 
skin  varies  in  colour  from  a  pale  to  an  intense  yellow.  The  urine  in  most 
cases  is  normal.  It  sometimes  is  of  a  light  brown  colour,  and  only  in  the 
most  severe  cases  does  it  contain  bile  pigment.  According  to  Runge,  both 
urea  and  uric  acid  are  produced  in  larger  amounts  than  in  children  not 
icteric.  The  stools  are  unchanged,  the  normal  yellow  evacuations  occur- 
ring in  the  icteric  as  early  as  in  those  not  affected. 

According  to  some  observers,  in  infants  who  are  icteric  the  initial  loss 
in  weight  is  greater  and  the  subsequent  gain  slower  than  in  other  children. 
This  is  not  borne  out  by  the  Sloane  statistics.  Of  the  300  icteric  children, 
155  made  satisfactory  progress  in  every  respect  and  gained  rapidly.  The 
progress  in  106  cases  was  said  to  be  "  fair " — i.  e.,  at  the  time  of  dis- 
charge, usually  on  the  tenth  day,  a  slight  gain  in  weight  was  noted. 
The  remaining  39  did  badly,  not  gaining  in  weight  and  showing  other 
symptoms  of  malnutrition.  The  proportion  of  icteric  infants  who  did 
well,  moderately,  and  badly,  was  practically  the  same  as  of  the  other 
-children  in  the  institution  not  suffering  from  icterus.  Icterus  occurs  wdth 
equal  frequency  in  both  sexes.  According  to  Kehrer,  it  is  more  frequent 
in  first  children  than  in  later  ones,  and  considerably  more  frequent  in 
premature  children  than  in  those  born  at  term.  The  presentation,  the 
duration  of  labour  and  its  character — whether  natural  or  artificial — have 
no  influence  upon  the  production  of  icterus.  As  a  rule  icteric  children 
appear  in  other  respects  healthy,  but  in  those  below  the  average  size  the 
icterus  is  apt  to  be  more  intense. 

Few  subjects  have  given  rise  to  wider  speculation  than  this  form  of 
icterus.  Its  exact  pathology  is  at  present  unknown.  Of  tlie  many  theo- 
ries advanced,  that  of  Silbermann  is  perhaps  the  most  satisfactory — viz., 
that  the  icterus  is  due  to  resorption,  and  is  hepatogenous  in  its  origin. 
With  this  view  Frerichs  and  Schultze  agree.  Silbermann  explains  the 
resorption  by  the  existence  of  stasis  in  the  capillary  bile-ducts  which  are 
compressed  by  the  dilated  branches  of  the  portal  vein  and  the  blood  capil- 
laries. The  change  in  the  circulation  of  the  liver  is  one  of  the  results  of 
the  change  in  the  blood  which  occurs  soon  after  birth.  This  results  from 
an  extensive  destruction  of  the  red  blood  cells — a  kind  of  blood  fermenta- 
tion. The  more  feeble  the  child  the  more  intense  the  icterus,  because 
the  blood  changes  are  more  intense.  In  consequence  of  this  destruction 
of  red  blood  cells  abundant  material  for  the  formation  of  bile  pigment 
exists  and  accumulates  in  the  hepatic  vessels. 


Y8  DISEASES  OF   THE   NEWLY  BORN. 

In  jaundiced  infants  wlio  have  died  from  accident  or  other  causes  the 
skin  and  almost  all  the  internal  organs  are  found  icteric.  There  is  also 
staining  of  the  internal  coat  of  the  arteries,  the  endocardium,  the  peri- 
cardium, and  the  pericardial  fluid.  Sometimes  the  subcutaneous  connect- 
ive tissue  is  yellow,  also  the  brain  and  cord  ;  the  spleen  and  kidneys  only 
in  the  most  severe  cases.  In  the  kidneys  uric-acid  infarctions  are  often 
found,  and  sometimes  bile  pigment.  The  liver  is  rarely  discoloured.  The 
bile-ducts  are  normal.  In  certain  cases  Birch-Hirschfeld  has  discovered 
bile  pigment  in  the  liver  cells. 

This  jaundice  is  never  fatal,  and  is  not  serious.  Other  conditions, 
such  as  atelectasis,  may  coexist,  which  may  make  the  case  grave.  The  chief 
point  in  diagnosis  is  not  to  confound  physiological  icterus  with  that  de- 
pending upon  other  more  serious  conditions,  such  as  sepsis  or  congenital 
malformation  of  the  bile-ducts.  In  sepsis  other  symptoms  are  present, 
usually  an  abnormal  condition  of  the  umbilicus,  and  the  sym]3toms  ap- 
pear at  a  later  date.  In  malformation  of  the  bile-ducts  the  jaundice 
is  very  intense,  and  is  frequently  accompanied  by  marked  hepatic  en- 
ia.rgement. 

Physiological  icterus  requires  no  treatment. 


CHAPTER  IV. 

THE  ACUTE  INFECTIOUS  DISEASES   OF   THE  NEWLY  BORN. 

It  is  possible  for  the  newly-born  infant  to  suffer  from  almost  all  of  the 
common  infectious  diseases.  Smallpox  probably  has  been  most  frequently 
observed.  In  rare  instances  measles,  influenza,  typhoid  fever,  malaria, 
and  pneumonia  have  occurred  in  the  flrst  days  of  life.  As  the  mothers 
in  many  instances  were  suffering  from  the  diseases  during  or  just  prior  to 
delivery,  the  infants  appear  to  have  been  infected  before  birth  through  the 
circulation  of  the  mother.  In  other  cases,  especially  in  pneumonia  and 
influenza,  infection  may  take  place  soon  after  birth.  The  symptoms  of 
these  diseases  in  the  newly  born  differ  little  from  those  occurring  in  any 
young  infant.  The  prognosis,  however,  is  very  much  worse  on  account  of 
the  tender  age  and  feeble  resistance  of  the  patient. 

In  addition  to  the  diseases  mentioned,  there  are  other  forms  of  infec- 
tion which  belong  especially — some  of  them  exclusively — to  the  newly 
born.  We  shall  consider  :  (1)  The  Pyogenic  Diseases,  which  are  due  to 
the  entrance  of  pyogenic  germs ;  in  this  class  are  to  be  included  Ophthal- 
mia and  Erysipelas ;  (2)  Tetanus  ;  and  (3)  diseases  probably  infections,  but 
as  yet  not  proved  to  be  so— Acute  Fatty  Degeneration,  Epidemic  Hemi- 
globinuria,  and  Pemphigus. 


THE  ACUTE   PYOGENIC   DISEASES. 


THE  ACUTE  PYOGENIC  DISEASES. 


Under  this  head  are  grouped  various  infections  of  the  newly  born,  due 
to  the  entrance  of  the  common  pyogenic  bacteria.  They  have  been  desig- 
nated as  puerperal  fever  of  the  child,  also  as  pycemia  or  septiccemia,  or 
simply  as  sepsis  of  the  neivly  horn.  A  variety  of  pathological  and  clinical 
conditions  are  met  with.  In  some  cases  there  is  only  a  localized  external 
inflammation,  often  terminating  in  abscess  formation ;  sometimes  one  or 
more  of  the  internal  organs  is  affected;  occasionally  a  general  blood  in- 
fection— a  true  septicemia — is  seen  without  any  noteworthy  local  lesion ; 
finally,  there  are  the  cases  attended  by  the  production  of  multiple  ab- 
scesses in  the  viscera,  joints,  or  cellular  tissue — a  true  pysemia. 

The  micro-organisms  most  frequently  causing  the  suppurative  pro- 
cesses are  the  staphylococcus  pyogenes  aureus  and  the  streptococcus. 
These  are  probably  the  exciting  cause  of  four  fifths  of  the  cases.  The 
remainder  are  due  to  one  or  more  of  the  other  bacteria  which  cause  sup- 
puration. The  germs  may  be  found  alone,  or  they  may  be  associated  with 
others.  In  the  investigations  made  thus  far  the  streptococcus  has  been 
most  frec[uently  found.  This  was  discovered  by  Prudden  in  the  dust  of 
a  ward  in  the  Xew  York  Infant  Asylum,  where  several  cases  had  occurred, 
also  in  an  umbilical  abscess,  and  in  the  pseudo-membranous  sore  throat  of 
one  of  the  cases.  Of  a  group  of  three  cases,  all  occupying  the  same  bed  at 
the  Sloane  Maternity  Hospital,  one  was  studied  bacteriologically  by  Prud- 
den, and  showed  only  streptococci.  A  case  of  meningitis  occurring  in  the 
same  hospital  was  studied  by  A^an  Gieson,  who  found  in  cultures  from  the 
exudate  only  streptococci,  which  were  also  present  in  the  umbilical  vessels. 
The  streptococcus  was  discovered  by  Allard  in  cases  of  osteomyelitis.  In 
three  recent  cases  of  my  own,  all  with  multiple  joint  suppuration,  the 
staphylococcus  was  found  in  two  and  the  streptococcus  in  one — in  every 
case  in  pure  culture.  The  severity  of  the  symptoms  depends  somewhat 
uponthe  nature  of  the  bacteria  which  excite  the  disease,  the  form  being 
usually  milder  when  due  to  the  staphylococcus  than  when  due  to  the 
streptococcus.  Still  more  important,  however,  is  the  degree  of  virulence 
of  the  bacteria  at  the  time  of  infection.  Thus  the  streptococcus  some- 
times excites  only  a  very  mild,  and  at  others  a  most  violent  inflammation. 

Most  frequently  the  avenue  of  entrance  is  the  umbilical  wound.  This 
obtains  probably  in  four-fifths  of  the  cases.  It  may  be  through  an  abra- 
sion of  the  skin,  such  as  often  exists  about  the  anus  or  genitals,  through  a 
wound  about  the  scalp  or  body  inflicted  during  instrumental  delivery, 
through  erosions  of  the  mucous  membrane  of  the  mouth,  or  through  the 
eyes.  Infection  through  the  milk  is  denied  by  some  writers.  Although  it 
has  been  shown  that  in  a  great  proportion  of  the  cases  the  milk  of  a 
woman  suffering  from  mastitis  or  from  septicaemia  contains  pyogenic 
germs,  still  the  taking  of  these  into  the  stomach  is  very  unlikely  to  in- 


80  DISEASES   OF   THE   NEWLY  BORN. 

feet  the  infant.  Karlinski  has  reported  a  fatal  case,  in  which  the 
milk  appeared  to  be  the  means  of  infection,  and  by  experiments  on  ani- 
mals he  proved  the  possibility  of  infection  in  this  manner.  Bacteria  may 
be  aspirated  during  or  after  labour,  giving  rise  to  sejDtic  pneumonia.  The 
source  of  the  poison  may  be  other  sejDtic  cases  in  an  institution,  either 
among  infants  or  mothers.  It  may  be  carried  by  the  physician,  the  nurse, 
the  instruments,  or  the  dressings. 

Infection  through  the  umbilicus  may  occur  either  before  or  after  the 
separation  of  the  cord.  The  poison  may  enter  through  the  umbilicus, 
although  this  may  give  no  external  evidence  of  disease.  This  was  true 
in  a  case  recently  studied  by  Van  Gieson,  in  vrhich  the  infant  died  of 
meningitis  when  eight  days  old.  The  cord  had  healed  properly,  and  at 
the  autopsy  the  navel  appeared  normal.  It  was  accidentally  discovered 
that  the  umbilical  vessels  inside  the  body  contained  j)us.  From  this  the 
meningitis  evidently  arose,  as  the  same  bacteria  were  found  by  culture 
both  there  and  in  the  brain.  Entering  through  the  mouth,  bacteria  may 
lead  to  infectious  processes  in  the  throat,  or  spreading  downward  may 
involve  the  stomach  and  intestines,  rapidly  producing  death  ;  or  the  ali- 
mentary tract  may  be  the  focus  from  which  infection  of  distant  parts  may 
arise. 

Clinical  Varieties. — OmplioMtis. — In  this  variety  there  is  inflammation 
of  the  umbilicus,  and  cellulitis  of  the  abdominal  wall  in  the  immediate 
neighbourhood.  This  results  in  the  formation  of  an  umbilical  phlegmon. 
It  may  terminate  in  resolution,  in  abscess,  or  in  gangrene.  The  usual 
termination  is  in  abscess.  These  abscesses  may  be  small  and  superficial, 
or  they  may  be  more  deeply  seated  between  the  abdominal  muscles  and 
the  peritonaeum.  Omphalitis  usually  begins  in  the  second  or  third  week 
of  life,  before  the  umbilicus  has  cicatrized.  Locally  there  are  redness, 
swelling,  and  induration.  The  process  may  result  in  abscess,  there  may 
be  diffuse  inflammation  of  the  abdominal  walls  of  an  erysipelatous  char- 
acter with  extensive  sloughing,  or  the  infection  may  spread  to  the  peri- 
tonasum. 

Inflammation  of  the  iimiilical  vessels. — This  is  one  of  the  most  fre- 
quent primary  processes  in  pygemic  infection.  The  umbilical  arteries  are 
more  frequently  involved  than  the  vein.  According  to  Eunge,  inflamma- 
tion of  the  vessels  is  always  preceded  by  inflammation  of  the  connective 
tissue  which  surrounds  them,  as  the  poison  is  taken  up  by  the  lymphat- 
ics and  not  by  the  blood-vessels.  Omphalitis  is  frequently  present,  but  in 
some  cases  the  umbilicus  shows  nothing  abnormal. 

In  arteritis  the  vessels  may  be  involved  to  any  degree :  sometimes 
only  a  short  distance  from  the  abdominal  wall,  sometimes  quite  to  the 
bladder.  They  contain  pus,  and  often  septic  thrombi.  Saccular  dilata- 
tion is  frequently  present  at  several  points.  Pus  sometimes  exudes  from 
the  umbilical  stump  on  pressure.    The  other  lesions  accompanying  arteritis 


THE   ACUTE   PYOGENIC    DISEASES.  81 

are  those  of  pyaemic  infection,  more  or  less  widely  distributed.  There  are 
frequently  peritonitis,  suppuration  of  the  joints,  erysipelas,  multiple  ab- 
scesses of  the  cellular  tissue,  sometimes  suppurative  parotitis.  Atelectasis 
is  common.  Pneumonia  was  found  in  twenty-two  of  Runge's  fifty-five 
cases. 

In  cases  of  phlebitis,  the  umbilical  vein  is  usually  involved  for  its  entire 
length  from  the  abdominal  wall  to  the  liver.  This  may  lead  to  an  acute 
interstitial  hepatitis  going  on  to  suppuration,  or  to  phlebitis  of  the  portal 
vein  and  some  of  its  branches.  In  either  case  there  is  more  or  less  paren- 
chymatous hepatitis,  and  often  multiple  abscesses  of  the  liver,  most  of  the 
patients  being  jaundiced.     Peritonitis  also  is  a  frequent  complication. 

Peritonitis. — This  is  one  of  the  most  frequent  pathological  processes 
in  pyemic  infection,  and  is  very  often  the  cause  of  death.  It  is  generally 
associated  with  umbilical  arteritis,  and  often  with  erysipelas.  In  a  con- 
siderable number  of  cases  it  is  the  most  important  lesion  found.  It  may 
be  localized  or  general.  Localized  peritonitis  is  generally  in  the  neigh- 
bourhood of  the  umbilicus  or  of  the  liver.  It  may  result  in  adhesions,  or 
in  the  formation  of  peritoneal  abscesses.  More  frequently  the  peritonitis 
is  general,  and  resembles  the  septic  peritonitis  of  adults.  There  is  a  great 
outjDouring  of  lymph  coating  the  intestines  and  other  viscera  and  the 
inner  surface  of  the  abdominal  wall,  causing  adhesions  between  the  ab- 
dominal contents.  Collections  of  sero-pus  are  found  in  the  jDelvis  and  in 
.  various  pockets  formed  by  the  adhesions.  Sometimes  blood  is  present  in 
the  exudation. 

The  special  symptoms  which  indicate  peritonitis  are  vomiting,  abdomi- 
nal tenderness  and  distention,  and  protrusion  of  the  umbilicus.  The  ab- 
dominal enlargement  is  chiefly  from  gas,  but  may  be  partly  from  fluid. 
There  are  present  thoracic  respiration,  dorsal  decubitus,  and  flexion  of 
the  thighs  as  in  all  varieties  of  acute  peritonitis.  The  temperature  is 
usually  but  not  necessarily  high. 

Pneumonia. — The  most  common  form  seen  is  pleuro-pneumonia. 
There  is  an  abundant  exudate  of  grayish-yellow  lymph  covering  the 
lung.  Occasionally  collections  of  pus  are  found  in  the  sacs  formed  by 
the  adhesions.  Serous  elfusions  are  rare.  The  pulmonary  lesion  con- 
sists usually  in  a  broncho-pneumonia,  with  consolidation  of  larger  or 
smaller  areas  in  the  lungs — more  often  in  the  upper  than  in  the  lower 
lobes.  It  is  not  uncommon  for  minute  abscesses  to  be  found  in  the  lung 
at  various  points.  There  is  a  purulent  bronchitis  of  the  larger  and 
smaller  tubes. 

The  symptoms  are  obscure  and  often  indefinite.  The  only  character- 
istic ones  are  cyanosis  and  rapid  respiration,  with  recession  of  the  chest 
walls  on  inspiration.  The  physical  signs  are  inconstant  and  uncertain. 
Pneumonia  cannot  usually  be  diagnosticated  during  life.  In  most  of  the 
fatal  cases  of  pyogenic  infection,  whatever  its  type,  there  is  found  some 


82  DISEASES  OF  THE   XEWLY  BORN. 

involvement  of  the  lungs.     The  changes  are  most  extensive  in  cases  in 
which  the  serous  membranes  are  involved. 

Pericarditis  is  rare  and  usually  associated  with  pleurisy.  Endocar- 
ditis is  very  rare.     Hirst  has,  however,  reported  a  case. 

Meningitis. — The  pia  mater  is  the  least  liable  to  be  affected  of  all  the 
serous  membranes,  with  the  possible  exception  of  the  pericardium.  When 
meningitis  is  present  it  is  usually  associated  with  peritonitis  or  with 
pleurisy.  The  lesions  are  those  of  acute  purulent  meningitis  with  a 
copious  exudation,  sometimes  associated  with  meningeal  hemorrhages, 
or  with  acute  encejahalitis  and  the  production  of  multiple  minute  ab- 
scesses in  the  cortex.  The  local  symptoms  are  usually  not  marked,  and 
are  sometimes  very  obscure.  The  most  characteristic  are  stupor,  strabis- 
mus, dilated  pupils,  opisthotonus,  bulging  fontanel,  convulsions,  and  occa- 
sionally localized  paralyses.     The  temperature  is  generally  high. 

Gastro-enteritis. — Diarrhoea  is  a  frequent  symptom  in  all  sej^tic  cases, 
constipation  being  I'arely  present.  In  many  instances  vomiting  is  a  promi- 
nent symptom.  In  a  small  proportion  of  cases  the  most  important  local 
lesions  are  in  the  intestines,  generally  in  the  nature  of  a  superficial 
catarrhal  inflammation. 

Pseudo-meivibranous  inflammations  of  the  throat. — These  are  rarely 
seen  in  the  newly  born.  In  1888  J.  Lewis  Smith  made  a  report  on  a 
group  of  five  cases  occurring  as  a  small  epidemic  in  the  ISTew  York 
Infant  Asylum.  They  were  associated  with  other  lesions,  and  all  were 
fatal.  In  several  cases  there  was  omj)lialitis;  One  of  these  was  studied 
biologically  by  Prudden,  who  found  no  Loefiler's  bacilli,  but  streptococci 
both  in  the  exudation  in  the  throat  and  in  the  umbilical  abscess.  The 
streptococcus  was  cultivated  from  the  dust  of  the  ward,  and  it  is  probable 
that  this  was  the  nature  of  the  infection  in  all  the  cases.  These  throat 
inflammations  are  to  be  regarded  as  one  manifestation  of  a  general  strep- 
tococcus infection. 

Osteomyelitis. — Allard  *  has  reported  a  series  of  cases  in  which,  after 
the  general  and  local  symptoms  of  pyogenic  infection  had  existed  for  some 
time,  suppuration  occurred  over  various  bones,  especially  the  humerus, 
tibia,  metatarsal  bones,  sacrum,  etc.  Trephining  revealed  the  lesions  of 
osteomyelitis.  The  abscesses  usually  made  their  appearance  between  the 
fourth  and  the  sixth  week.  The  most  rapid  case  died  on  the  fourteenth 
day,  and  none  lasted  more  than  two-and-a-half  months. 

Joint  suppuration. — In  certain  jDyasmic  cases,  and  in  some  in  which 
there  are  no  other  symptoms,  acute  sujDpuration  in  the  Joints  occurs  with- 
out any  change  in  the  bones  themselves.  This  may  come  on  very  acutely 
in  the  first  or  second  week,  or  more  slowly  as  late  as  the  second  or  third 
month.    One  or  several  joints  may  be  involved,  and  almost  any  articula- 

*  These,  Paris.  1890. 


THE   ACUTE   PYOGENIC   DISEASES.  83 

tion  in  the  body.  I  have  recently  seen  four  cases  of  this  kind.  In  one, 
a  shoulder  and  one  temporo-maxillary  articulation  were  involved ;  in  an- 
other, a  shoulder  and  hip ;  in  the  remainder  there  were  multiple  lesions 
affecting  nine  or  ten  joints,  including  the  elbows,  ankles,  and  sterno-clavic- 
ular  joints,  together  with  the  wrists,  fingers,  and  toes. 

Abscesses  in  the  cellular  tissue. — These  are  quite  frequent,  and  may 
occur  with  suppuration  in  the  joints  or  internal  organs,  or  they  may  exist 
as  the  only  lesion.  They  may  be  found  where  the  adipose  tissue  is  scanty, 
as  over  the  heels,  the  elbows,  and  the  malleoli ;  also  in  the  thighs,  the 
ischio-rectal  region,  and  sometimes  in  the  abdominal  walls.  They  are 
nearly  always  multiple.  They  vary  in  size  from  that  of  a  small  pea  to  one 
containing  half  an  ounce  of  pus.  They  are  due  to  the  introduction  of 
pyogenic  germs,  usually  staphylococci.  Their  course  is  benign,  and  they 
require  no  treatment  except  incision  and  cleanliness.  Where  there  is  a 
disposition  to  their  continued  formation,  the  skin  should  be  washed  with 
an  antise]3tic  solution. 

Erysipelas. — This  is  seen  especially  during  the  first  two  weeks  of  life, 
-and  most  frequently  starts  from  the  umbilicus,  although  it  may  follow  any 
wound  or  abrasion  of  the  skin.  When  originating  at  the  umbilicus  it  is 
generally  complicated  by  other  lesions,  such  as  peritonitis  and  umbilical 
phlebitis.  If  it  starts  from  any  other  part  of  the  body  it  may  be  uncom- 
plicated. Erysipelas  beginning  at  the  umbilicus  gives  rise  to  an  area  of 
induration  and  a  circumscribed  blush.  At  first  it  may  resemble  a  sim- 
ple cellulitis;  but  the  steadily  increasing  area  of  elevated  induration 
and  redness  soon  indicates  the  nature  of  the  inflammation.  From  what- 
ever point  starting,  the  erysipelatous  inflammation  spreads  widely  in 
most  cases.  The  entire  abdomen,  chest,  and  back  may  be  involved,  and 
it  may  even  spread  to  the  extremities.  It  may  extend  so  rapidly  that 
nearly  the  whole  trunk  is  affected  in  one  or  two  days.  It  usually  involves 
only  the  skin  and  superficial  cellular  tissue ;  but  it  may  extend  into  the 
deeper  areolar  planes  and  terminate  in  diffuse  suppuration  or  even  in 
gangrene. 

The  constitutional  symptoms  are  severe :  great  prostration,  continu- 
ously high  temperature — 102°  to  105°  F. — rapid  wasting,  and  often  vom- 
iting, diarrhoea,  or  convulsions  are  present.  The  disease  is  always  seri- 
ous, and  when  starting  from  the  umbilicus  usually  fatal.  The  prognosis 
is  better  in  cases  originating  elsewhere,  but  under  all  conditions  the  dis- 
ease is  a  very  serious  one. 

Distribution  of  the  Lesions. — The  frequency  of  the  different  visceral 
lesions  in  eighty-seven  autopsies  published  by  Bcdnar  was  as  follows : 
Peritonitis  in  twenty-nine,  pneumonia  in  fifteen,  pleurisy  in  ten,  menin- 
gitis in  nine,  meningeal  haemorrhage  in  eight,  encephalitis  in  eight,  cere- 
bral hemorrhage  in  four,  entero-colitis  in  five,  pericarditis  in  four.  In 
thirty-one  cases  there  was  umbilical  arteritis,  and  in  nine  cases  umbilical 


g4  DISEASES   OF   THE   NEWLY  BORN. 

phlebitis.  There  was  one  case  each  of  pulmonary  hgemorrhage,  pleural 
haemorrhage,  acute  hydrocephalus,  acute  bronchitis,  and  suppuration  in 
the  cellular  tissue.  Runge's  later  observations  of  thirty-six  cases  showed 
umbilical  arteritis  in  thirty,  umbilical  phlebitis  in  three,  and  normal  um- 
bilicus in  three.  He  found  pneumonia  in  twenty-two  of  fifty-five  cases. 
Other  lesions  frequently  associated  are  atelectasis,  swelling  and  softening 
of  the  spleen,  cloudy  swelling  of  the  liver  and  kidneys,  occasionally  with 
foci  of  supj)uration  in  these  organs.  The  blood  is  dark,  and  coagulates, 
imperfecth'. 

General  Symptoms. — These  may  begin  at  any  time  during  the  first  ten 
(Jays — very  rarely  after  the  twelfth  day.  Fever  is  an  exceedingly  variable 
symptom — it  may  be  very  high  ;  it  may  be  almost  absent ;  occasionally 
there  is  subnormal  temperature.  The  course  of  the  temperature  is  very 
irregular.  Wasting  is  constant  and  quite  rapid.  It  depends  upon  the 
inability  to  take  and  digest  food,  upon  the  intestinal  complications,  and 
upon  infection.  In  quite  a  number  of  cases  wasting  is  almost  the  only 
symptom.  Icterus  is  exceedingly  common ;  in  many  of  the  worst  cases 
it  is  intense.  It  is  met  with  where  the  liver  is  the  seat  of  an  acute  paren- 
chymatous or  acute  suppurative  inflammation,  and  in  many  other  cases 
where  it  depends  apparently  upon  the  blood  changes.  Hsemorrhages  are 
common,  and  may  be  the  direct  cause  of  death.  They  are  most  frequent 
from  the  umbilicus,  from  the  intestine,  and  into  the  subcutaneous  cellu- 
lar tissue.  They  may  occur  in  almost  any  organ  or  from  any  mucous 
membrane.  Xervous  symptoms  are  generally  present,  and  are  sometimes 
marked.  They  are  restlessness,  rolling  of  the  head,  a  constant  whining 
cry,  twitchings  of  the  muscles  of  the  extremities  or  face,  stiffening  of  the 
body,  more  rarely  general  convulsions.  Late  in  the  disease,  dulness  and 
stupor  are  present.  The  pulse  is  rapid  and  Aveak  and  the  respirations  are 
often  irregular  even  when  there  is  no  cerebral  complication.  Diarrhoea  is 
frequent ;  the  stools  are  green,  brown,  sometimes  black  from  the  presence 
of  blood,  and  are  often  very  foul.     Vomiting  is  less  common. 

In  addition  to  these  there  are  symptoms  due  to  the  various  forms  of 
local  inflammation — peritonitis,  meningitis,  pneumonia,  subcutaneous  sup- 
puration and  gangrene,  these  all  being  found  in  varying  degrees  and  in 
various  combinations. 

Prophylaxis. — Pyogenic  infection  of  the  child,  like  puerperal  fever  in 
the  mother,  may  be  considered  a  preventable  disease.  Its  occurrence  is 
usually  due  to  a  failure  to  carry  out  proper  rules  regarding  cleanliness  and 
asepsis  in  connection  with  delivery.  The  statistics  of  the  Moscow  Lying- 
in  Asylum,  published  by  Miller  in  1888,  show  that  previous  to  the  general 
introduction  of  antiseptic  methods,  from  six  to  eight  per  cent  of  all  in- 
fants born  in  the  institution  died  from  some  variety  of  infection.  In 
twenty-three  hundred  successive  labours  at  the  Sloane  Maternity  Hospital,, 
in  New  York,  up  to  January,  1893,  not  a  single  marked  case  occurred^ 


OPHTHALMIA.  S5 

From  these  figures  it  will  be  evident  that  in  the  vast  majority  of  case& 
the  occurrence  of  a  case  of  infection  of  a  serious  nature,  is  the  fault  of  the 
physician  or  nurse  in  attendance. 

The  umbilicus  should  be  cleansed  and  treated  like  any  other  fresh 
wound.  Dry  dressing  should  invariably  be  employed,  and  antiseptic 
gauze  or  salicylated  cotton  in  preference  to  household  linen.  If  suppu- 
ration occurs  at  the  time  the  cord  separates,  the  parts  should  be  cleansed 
daily  with  1-3,000  bichloride  solution,  and  powdered  with  iodoform.  All 
wounds  of  the  face,  scalp,  and  other  parts  should  be  treated  in  the  same 
way.  The  ligatures  and  everything  which  comes  in  contact  with  the  um- 
bilical wound  should  be  sterilized.  Careful  attention  should  be  given  to 
the  mouth,  genitals,  and  all  the  muco-cutaneous  surfaces,  to  prevent  ex- 
coriations and  intertrigo.  Finally,  every  septic  case  occurring  in  an  insti- 
tution should  be  immediately  isolated.  A  nurse  in  charge  of  a  septic 
mother  should  not  have  the  care  of  the  infant. 

Prognosis. — Pyogenic  infection  in  the  newly  born,  even  in  its  mildest 
forms,  is  a  serious  disease,  and  in  its  severer  forms  is  almost  invariably 
fatal.  Few  cases  recover  in  which  there  is  present  any  form  of  visceral 
inflammation. 

Treatment. — The  treatment  of  cases  of  pyogenic  infection  practically 
resolves  itself  into  the  treatment  of  individual  symptoms  as  they  arise. 
Wherever  suppuration  occurs,  external  abscesses  should  be  evacuated  and 
treated  antiseptically.  For  the  local  inflammations  of  the  lungs,  peri- 
tonaeum, and  brain,  little  or  nothing  can  be  done  in  the  way  of  direct 
treatment.  The  condition  is  one  to  be  prevented,  but  not  cured.  The 
general  indications  are  to  sustain  the  patient  by  proper  feeding  and  the 
use  of  stimulants  whenever  required  by  the  pulse.  For  local  use  in  ery- 
sipelas, nothing,  in  my  experience,  is  better  than  a  ten-per-cent  ointment 
of  ichthyol  made  up  with  lanoline,  kept  constantly  applied.  When 
affecting  only  one  of  the  extremities,  the  treatment  by  the  Kraske  method,. 
of  making  scarifications  beyond  the  line  of  redness  and  covering  with  wet 
bichloride  dressings,  is  sometimes  successful,  but  this  is  not  applicable  to 
cases  involving  the  trunk. 

OPHTHALMIA. 

Ophthalmia  of  the  newly  born  is  to  be  classed  among  the  pyogenic  dis- 
eases. It  usually  consists  in  a  purulent  conjunctivitis.  In  the  more  severe 
cases  there  may  be  ulceration  of  the  cornea,  and  even  perforation  into  the 
anterior  chamber  of  the  eye. 

The  infectious  nature  of  this  ophthalmia  is  now  fully  established.  In 
the  most  severe  cases  the  micro-organism  generally  found  has  been  the 
gonococcus;  but  in  the  milder  forms  the  gonococcus  is  absent,  and  any 
of  the  common  pyogenic  germs  may  be  found.  In  the  gonorrheal  cases 
the  infection   occurs  during  labour  from  the  secretions  of  the  mother, 


gg  DISEASES   OP   THE   NEWLY  BORN. 

from  the  examining  fingers  of  the  physician,  or  from  instruments ;  or 
after  birth  from  infected  cloths  and  other  materials  which  come  in  con- 
tact with  the  eye.  Healthy  lochia  produce  only  a  catarrhal  inflammation. 
The  infection  occurring  after  birth  may  take  place  at  any  time.  That 
■due  to  gonorrhoeal  infection  from  the  mother  is  generally  manifested  on 
the  third  day,  and  is  often  violent  from  the  outset. 

The  symptoms  are  swelling  of  the  lids,  chemosis,  copious  purulent  dis- 
charge, sometimes  haemorrhages  from  the  lids,  ulceration  and  there  may 
even  be  sloughing  of  the  cornea.  The  course  of  the  disease  depends  upon 
the  cause  and  upon  the  treatment  employed.  In  the  cases  not  due  to 
the  gonococcus  the  course  is  generally  benign,  and  with  ordinary  cleanli- 
ness usually  results  in  recovery  without  any  permanent  damage  to  the 
sight.  The  gonorrhoeal  cases,  unless  energetically  treated  from  the  outset, 
^re  very  frequently  followed  by  permanent  loss  of  vision.  The  best  sta- 
tistics upon  the  causes  of  blindness  in  adults  show  that  from  twenty-six 
to  thirty  per  cent  of  such  cases  are  due  to  ophthalmia  in  the  newly  born. 
This  disease  is  occasionally  complicated  by  other  symptoms  of  gonorrhoeal 
infection  of  a  pysemic  nature.  Widmark,  Lucas,  and  Davies-Colley  have 
reported  cases  followed  by  acute  articular  symptoms. 

Prophylaxis  is  of  the  utmost  importance.  Crede's  statistics  show  that 
in  1874  the  frequency  of  ophthalmia  in  his  lying-in  hospital  was  13-6  per 
■cent.  In  the  three  years  ending  1883,  among  1,160  newly-born  children 
only  one  or  two  cases  occurred.  The  method  of  prophylaxis  which  he 
adopted  consists  in  dropping  into  the  eyes  of  every  child,  immediately  after 
birth,  one  or  two  drops  of  a  two-per-cent  solution  of  nitrate  of  silver. 
The  general  adoption  of  Crede's  method,  or  of  some  similar  means  of  dis- 
infection, has  resulted  in  a  very  great  diminution  in  the  frequency  of  oph- 
thalmia throughout  the  world.  These  prophylactic  means  should  be 
obligatory  in  all  institutions,  and  should  be  used  in  all  cases  in  private 
practice  wherever  there  is  any  possible  suspicion  of  the  existence  of  gon- 
orrhoea. In  all  other  cases  the  eyes  should  be  carefully  cleansed  with  a 
saturated  solution  of  boric  acid.  The  use  before  delivery  of  an  antiseptic 
vaginal  douche  is  theoretically  indicated,  but  practically  it  has  been  found 
to  be  inadequate  to  the  prevention  of  the  disease. 

Treatment. — Everything  which  comes  in  contact  with  the  eyes  should 
be  carefully  disinfected.  All  cloths,  cotton,  etc.,  used  for  cleansing  should 
be  immediately  burned.  The  strictest  antiseptic  precautions  should  be  in- 
sisted on  to  prevent  the  spread  of  the  infection  by  nurses.  In  institutions 
containing  infants,  severe  cases  of  ophthalmia  should  always  be  isolated. 
The  most  important  thing  is  to  keej)  the  eyes  clean.  In  severe  cases  they 
must  be  cleansed  every  twenty  minutes,  night  and  day.  It  may  be  done 
by  irrigation,  or  by  using  an  eye-dropper  with  a  bulbous  tip,  inserted 
alternately  at  the  inner  and  the  outer  angle  of  the  eye,  and  the  fluid  in- 
jected with  force  sufficient  to  empty  thoroughly  the  conjunctival  sac. 


TETANUS.  87 

Either  a  saturated  solution  of  boric  acid,  or  a  l-to-5,000  solution  of 
bichloride,  may  be  used  in  this  way.  Once  or  twice  in  twentj^-four  hours 
two  or  three  drops  of  a  one-per-cent  solution  of  protargol  should  be  used 
in  each  eye  after  cleansing  with  sterile  water;  this  preparation  is  alto- 
gether more  efficient  than  the  commonly  employed  silver  nitrate.  Next 
to  these  measures  is  the  use  of  cold.  It  may  be  applied  as  ice  compresses 
which  are  changed  every  minute  or  two  from  a  block  of  ice  to  the  eye. 
These  may  be  continued  one-fourth  of  the  time  in  the  milder  cases ;  in 
the  severe  ones  almost  constantly.  When  the  cornea  is  involved  the 
pupil  should  be  dilated  by  atropine.  If  only  one  eye  is  affected  the 
sound  one  should  be  protected  b}^  covering  it  with  a  compress  kept  wet 
with  an  antiseptic  solution. 

TETANUS. 

Tetanus  is  an  acute  infectious  disease  characterized  by  tonic  muscular 
spasm,  which  increases  in  severity  by  paroxysms  occurring  at  longer  or 
shorter  intervals.  It  may  be  limited  to  the  muscles  of  the  jaw  (trismus), 
or  may  affect  all  the  muscles  of  the  trunk,  extremities,  and  neck. 

Though  many  writers  have  sought  to  maintain  a  difference  between 
tetanus  of  the  newly  born  and  tetanus  of  later  life,  whether  traumatic  or 
not,  their  identity  has  been  admitted  for  at  least  a  dozen  years.  The  dis- 
covery of  the  exact  cause  of  tetanus  is  due  to  the  work  of  Nicolaier,  who 
in  1884  found  a  bacillus  in  the  soil,  with  which  he  produced  the  disease  in 
animals.  He  demonstrated  the  presence  of  this  bacillus  in  the  wounds  of 
tetanus  patients.  Nicolaier  did  not,  however,  obtain  the  germ  in  pure 
culture ;  but  this  was  done  by  Kitasato  in  1889.  The  bacillus  is  generally 
known  as  Nicolaier's  bacillus.  Since  that  time  the  germ  has  been  found 
in  the  wounds  of  numerous  patients  with  tetanus,  including  newly-born 
Infants. 

The  rapidity  with  which  the  infection  spreads  from  the  point  of  inoc- 
ulation is  very  remarkable,  as  shown  by  Kitasato's  experiments.  Thus,  if 
one  hour  elapsed  after  infection  before  cauterizing  the  inoculated  wound, 
the  animal  succumbed  to  the  disease.  The  bacilli  are  not  found  in  the 
blood  or  internal  organs.  The  symptoms  of  the  disease  have  been  shown 
to  depend  upon  the  absorption  of  a  toxic  product  of  the  tetanus  bacillus 
called  tetano-toxine. 

The  germ  of  tetanus  usually  gains  access  to  the  body  of  the  infant 
through  the  umbilical  wound.  It  exists  in  the  soil,  and  the  disease  pre- 
vails endemically  in  certain  localities.  It  is  common  in  certain  parts 
of  Long  Island  and  New  Jersey.  Among  the  negroes  in  some  parts  of 
the  South  it  has  for  many  years  occurred  with  great  frequency.  It  is 
stated  that  on  one  of  the  islands  of  the  Hebrides  every  fourth  or  fifth 
child  dies  of  tetanus.     In  a  single  house  in  Copenhagen  eighteen  cases 


gg  DISEASES   OF  THE   NEWLY  BORN. 

were  observed.  Tetanus  is  rare  except  where  dirt  and  filth  prevail ;  but 
these  alone  are  not  sufficient  to  produce  the  disease.  It  is  a  very  rare  dis- 
ease in  the  tenements  of  New  York. 

Lesions. — There  are  no  essential  lesions  of  tetanus.  Those  which  have 
been  found  have  been  partly  accidental  and  partly  a  result  of  the  disease 
rather  than  its  cause.  In  most  of  the  cases  intense  h3^per8emia  of  the 
spinal  cord  and  its  membranes  is  found,  and  not  infrequently  small  ex- 
travasations of  blood.  Such  small  haemorrhages  are  occasionally  found  in 
the  meninges  of  the  brain — more  frequently  at  the  base  than  at  the  con- 
vexity. In  rare  instances  hsemorrhages  of  considerable  size  have  occurred 
into  the  brain  itself.  The  lungs  are  generally  congested,  and  the  right 
side  of  the  heart  overdistended.  In  most  of  the  cases  the  umbilicus  has 
not  healed,  and  it  may  present  evidences  of  septic  infection  in  varying 
degrees. 

Symptoms. — These,  as  a  rule,  begin  on  the  fifth  or  sixth  day,  or  at 
the  time  of  the  separation  of  the  cord.  The  first  symptoms  may  not 
appear  until  the  tenth  or  twelfth  day,  but  rarely  later  than  this.  G-en- 
erally  the  first  thing  noticed  is  difficulty  in  nursing,  which,  on  examina- 
tion, is  found  to  be  due  to  rigidity  of  the  jaws  (trismus).  Nursing  may 
be  impossible  on  this  account.  The  muscles  of  the  jaw  feel  hard,  the  lips 
pout  and  all  the  muscles  of  the  face  seem  firm.  Soon  a  slight  stiffening 
of  the  body  occurs,  the  child  straightening  the  back  as  it  lies  upon  the 
lap  and  continuing  rigid  for  a  moment  or  two.  In  the  interval  it  is  at 
first  completely  relaxed.  These  paroxysms  soon  increase  in  frequency 
until  they  may  come  on  every  few  minutes,  being  excited  by  any  move- 
ment of  the  body.  The  relaxation  is  then  only  partial,  and  the  neck  and 
extremities,  sometimes  nearly  the  whole  body,  become  rigid  and  stiff  as  a 
piece'  of  wood.  The  arms  are  extended,  the  thumbs  adducted,  and  the 
hands  clenched.  The  thighs  and  legs  are  extended,  and  no  motion  is  pos- 
sible at  the  hip  or  knee.  The  jaws  can  be  separated  slightly  or  not  at  all. 
The  firm  contractions  of  the  facial  muscles  give  a  peculiar  expression  to 
the  features.  There  is  a  low,  whining  cry.  Swallowing  is  difficult,  some- 
times impossible.  The  pulse  is  rapid  and  soon  becomes  weak.  The  tem- 
perature at  first  is  normal,  but  in  the  most  acute  cases  rises  rapidly  to  104° 
or  even  106° ;  in  the  milder  cases  it  does  not  go  above  101°  F. 

Death  is  due  to  exhaustion,  to  fixation  of  the  respiratory  muscles,  or 
to  spasm  of  the  larynx.  In  the  less  severe  cases  all  the  symptoms  are 
milder,  and  there  may  be  intervals  in  which  the  rigidity  is  scarcely  notice- 
able, so  that  respiration  and  deglutition  may  be  carried  on  for  some  time. 
In  cases  which  terminate  in  recovery  the  temperature  is  but  slightly  ele- 
vated. The  tonic  contractions  gradually  become  less  severe,  and  the 
paroxysms  less  frequent.  The  children  usually  suffer  for  several  weeks 
from  the  general  symptoms  of  malnutrition,  which  are  proportionate  to 
the  severity  of  the  attack.     Of  eighty-eight  fatal  cases  which  are  reported 


TETANUS.  89 

by  Stadtfeldt  all  but  five  died  between  the  ages  of  six  and  ten  days.  The 
duration  of  the  disease  in  the  fatal  cases  is  seldom  more  than  forty-eight 
hours,  often  less  than  twenty-four  hours ;  in  those  terminating  in  recov- 
ery, between  one  and  three  weeks. 

Prognosis. — No  disease  of  infancy  is  more  fatal  than  tetanus.  Where 
it  prevails  endemically  it  is  regarded  by  the  laity  as  so  uniformly  fatal  that 
usually  no  physician  is  called.  Scattered  through  medical  literature  are 
quite  a  large  number  of  isolated  cases  in  which  recovery  has  occurred.  At 
the  present  time  the  proportion  of  fatal  cases  is  probably  between  ninety 
iind  ninety-five  per  cent.  Sporadic  cases  more  frequently  recover  than 
those  occurring  in  districts  where  the  disease  is  endemic.  The  later  the 
■development  of  the  symptoms,  the  slower  their  course,  and  the  lower  the 
temperature  the  more  likely  is  the  case  to  recover. 

Prophylaxis. — A  proper  understanding  of  the  nature  of  the  disease  has 
brought  with  it  the  means  of  rational  prevention.  The  first  essential  is 
■obstetrical  cleanliness,  which  must  include  scissors,  hands,  dressings,  liga- 
tures— in  short,  everything  which  comes  in  contact  with  the  umbilical 
wound.  In  districts  where  tetanus  is  endemic,  thorough  antiseptic  treat- 
ment of  the  umbilicus  should  be  insisted  upon,  both  at  the  first  dressing 
and  later,  particularly  at  the  time  of  the  separation  of  the  cord. 

Treatment. — All  drugs  whose  physiological  action  is  that  of  motor 
depressants  of  the  spinal  cord  have  a  certain  amount  of  value  in  tetanus. 
,The  most  important  ones  are  chloral,  the  bromides,  and  calabar  bean. 
Nearly  all  the  reported  cures  have  been  by  one  of  these  drugs  or  a  com- 
bination of  them.  The  mistake  usually  made  is  in  using  too  small  doses 
to  be  of  any  efficacy.  Enough  to  produce  the  physiological  effects  of  the 
drug  must  be  given.  The  initial  dose  should  not  be  large,  but  it  should 
be  repeated  until  the  full  effects  are  obtained.  Of  those  mentioned,  chloral 
has  been  the  one  most  generally  relied  upon.  An  hourly  dose  of  one  or 
two  grains  is  usually  required.  If  no  effect  is  visible  in  ten  or  twelve 
hours  the  dose  may  be  further  increased,  as  the  patient  is  in  much  greater 
•danger  from  the  disease  than  he  can  possibly  be  from  the  drug.  Chloral 
may  be  given  by  the  mouth  or  by  the  rectum,  but  must  always  be  well 
diluted.  The  single  case  of  recovery  which  I  have  witnessed  was  one 
treated  by  the  bromide  of  potassium.  This  infant  took  eight  grains  every 
two  hours  for  three  days,  afterwards  smaller  doses.  Calabar  bean  has  the 
advantage  in  that  its  extract  may  be  given  hypodermically ;  one  tenth  of 
a  grain  may  be  administered  from  three  to  ten  times  daily,  according  to 
the  severity  of  the  symptoms.  Monti  has  re2)ortod  two  cases  cured  by 
its  use.  The  child  must  at  all  times  be  kept  as  quiet  as  possible,  without 
unnecessary  handling  or  bathing.  If  nursing  or  feeding  by  the  moutli  is 
impossible,  because  the  jaws  cannot  be  separated,  the  child  may  be  fed 
by  a  tube  passed  through  the  nose.  This  is  greatly  to  be  preferred  to 
rectal  alimentation.     Drugs  may  be  administered  in  the  same  way. 


90  DISEASES  OP  THE  XEWLY   BORX. 

The  antitoxine  treatment. — Behring  and  Kitasato^  after  a  series  of 
experiments  upon  animals,  were  the  first  to  produce  an  antitoxine  which, 
has  the  power  of  neutralizing  the  tetanus  poison.  In  animals  immunity- 
is  produced  by  its  injection.  It  is  also  curative  in  those  cases  where 
tetanus  has  been  produced  experimentally.  Its  value  has  now  been  dem- 
onstrated in  quite  a  large  number  of  cases  of  traumatic  tetanus  in  adults. 
The  practical  obstacle  to  the  success  of  the  antitoxine  treatment  is  the 
rapid  absorption  of  the  tetanus  poison  from  the  wound.  To  be  efficient 
it  must  be  used  early. 

Cases  of  tetanus  neonatorum  successfully  treated  by  antitoxine  have 
been  reported  by  Papiewski,  Escherich,  McCaw,  and  others;  but  the 
number  of  cases  in  which  it  has  been  used  is  as  yet  too  small  to  admit  of 
positive  deductions.  It  should  by  all  means  be  tried  wherever  practica- 
ble. The  best  method  of  administration  is  still  binder  discussion.  Eoux's 
experiments  appear  to  show  that  the  antitoxine  is  more  efficient  when  in- 
jected directly  into  the  brain  than  when  used  subcutaneously.  Fortu- 
nately in  the  newly-born  child  this  adds  no  difficulty,  since  the  needle  can 
readily  be  introduced  through  the  open  sutures.  It  is  hardly  necessary 
to  add  that  the  strictest  antiseptic  precautions  must  be  observed.  Eeli- 
able  tetanus  antitoxine  is  now  prepared  by  Behring,  the  jSTew  York  Health 
Department,  and  Parke,  Davis  &  Co.  The  question  of  dosage  is  still 
unsettled. 

EPIDEMIC   H^MOGLOBIXURIA   (WINCKEL'S   DISEASE). 

The  essential  features  of  this  disease  are  haemoglobinuria  Avith  icterus 
and  cyanosis,  this  combination  giving  the  skin  a  deeply  bronzed  hue  {mala- 
die  ironzee).  It  is  a  rare  disease,  but  has  generally  occurred  epidemically 
in  institutions.  It  is  usually  fatal.  All  the  symptoms  point  to  an  acute, 
rapid  disintegration  of  the  red  blood-cells — a  sort  of  blood  fermentation. 
The  changes  have  been  compared  with  those  produced  in  the  blood  in 
poisoning  by  chlorate  of  potash  or  phosphorus.  The  cause  is,  without 
doubt,  some  sort  of  infection,  but  its  exact  nature  has  not  been  discovered. 
Although  generally  called  by  the  name  of  Winckel,*  who  in  1879  made  a 
full  report  upon  an  epidemic  of  twenty-three  cases  in  a  hospital  in  Dres- 
den, the  disease  was  quite  well  described  by  Charrinf  in  1873,  with  a 
report  of  fourteen  cases,  and  observed  by  Bigelow,J  in  Boston,  in  1875. 
All  the  cases  included  in  Winckel's  report  occurred  in  one  institution, 
affecting  one  fourth  of  the  children  born  during  the  period. 

There  are  cyanosis,  and  a  more  or  less  intense  icterus  of  the  skin  and 

*  Winckel,  VerofEentlich.  der  padiatrischen  Section  der  Gesellsch.  f.  Heilk.,  Berlin^ 
April,  1879. 

f  Charrin,  These  de  Paris,  1873. 

X  Bigelow,  Boston  Medical  and  Surgical  Journal,  March,  1875. 


FATTY   DEGENERATIOX.  9I 

internal  organs.  The  umbilical  vessels  are  usually  normal.  The  kidnevs 
are  swollen,  show  small  ha?morrhages  into  their  substance,  and  under  the 
microscope  the  straight  tubes  are  seen  to  be  filled  with  crystals  of  hemo- 
globin, but  contain  no  blood-cells.  The  bladder  frequently  contains 
brownish,  smoky  urine.  The  spleen  is  swollen  and  filled  with  blood  pig- 
ment, which  is  diffused  throughout  the  cells  of  the  pulp,  and  free  in  the 
blood-vessels.  Punctate  haemorrhages  are  seen  in  most  of  the  other  vis- 
cera. Fatty  degeneration  is  at  times  observed  in  the  heart  and  liver. 
Peyer's  patches  and  the  mesenteric  glands  are  frequently  swollen. 

This  disease  most  frequently  attacks  those  who  have  been  previously 
healthy.  The  symptoms  usually  begin  from  the  fourth  to  the  eighth  day 
after  birth.  They  are  intense  and  fulminating  in  character,  seldom  lasting 
more  than  two  days,  and  often  only  one.  The  early  symptoms  are  general 
restlessness,  rapid  pulse  and  respiration,  prostration,  cyanosis  of  the  face, 
and  general  icterus,  Avhich  is  at  first  slight,  but  steadily  increases  until  it 
becomes  intense,  the  skin  resembling  that  of  a  mulatto.  The  temperature 
is  normal  or  slightly  elevated.  Gastro-enteric  symptoms  are  occasionally 
present,  but  they  are  not  a  feature  of  this  disease.  There  is  rapid  asthenia, 
often  terminating  in  coma  or  convulsions.  The  most  characteristic  symp- 
toms are  those  connected  Avith  the  urine.  It  is  passed  frequently,  in  small 
quantities,  with  pain  and  straining.  It  is  of  a  brown,  smoky  colour,  and 
under  the  microscope  shows  hsemoglobin  in  considerable  quantity,  renal 
-epithelium,  and  sometimes  granular  casts  and  blood-cells,  but  does  not 
contain  bile  pigment.  Albumin  is  sometimes  present,  but  not  in  large 
quantity.  Examination  of  the  blood  shows  an  increase  of  the  white  cells, 
and  many  free  granules. 

Treatment  is  of  little  avail,  since  all  severe  cases  die.  It  is  to  be 
directed  against  individual  symptoms. 

FATTY   DEGENERATIOX   OF   THE   NEWLY  BORN   (BUHL'S   DISEASE). 

A  disease  has  been  described  by  the  author  whose  name  it  bears,  the 
essential  nature  and  causation  of  which  are  unknown.  It  is  character- 
ized by  inflammatory  changes  leading  to  fatty  degeneration  in  the  viscera, 
especially  the  heart,  liver,  and  kidneys ;  it  seldom  lasts  more  than  two 
weeks,  and  is  almost  invariably  fatal.  There  may  be  haemorrhages  in  any 
of  the  viscera,  into  the  serous  cavities,  or  from  any  mucous  membrane. 
In  the  lungs  are  found  large  or  small  haemorrliagic  infarctions,  and  the 
bronchi  contain  blood  and  bloody  mucus.  There  is  granular  or  fatty  de- 
generation of  the  ej^ithelial  cells  of  the  alveoli.  In  cases  that  have  lasted 
some  time,  the  heart-muscle  is  pale,  soft,  and  fatty.  The  liver  in  re- 
cent cases  is  large  and  soft ;  in  those  of  longer  standing  it  is  pale  and 
jaundiced,  and  shows  marked  fatty  degeneration.  The  spleen  is  large 
and  soft.  The  stomach  and  intestines  contain  blood,  and  the  mucous 
membrane  shows  ecchymoses.      The    epithelium    of   the  tubules  of  the 


^2  DISEASES   OF   THE   NEWLY  BORN. 

Mdney  is  fatty,  and  the  tubes  are  choked  with  granular  and  fatty  detri- 
tus. The  umbilicus  is  normal,  but  often  there  are  haemorrhages  into  the 
neighbouring  tissues.  Many  of  the  lesions  are  similar  to  the  ordinary 
post-mortem  changes,  and  when  found  they  should  not  be  interpreted  as 
pathological  unless  the  autopsy  is  made  within  at  least  twelve  hours 
after  death. 

The  disease  occurs  most  frequently  in  patients  who  have  previously 
presented  the  symptoms  of  as23hyxia,  which  to  a  greater  or  less  degree 
have  persisted.  In  other  respects  the  infants  may  be  strong  and  well- 
nourished.  The  symptoms  develop  gradually.  Those  most  constantly 
present  are  vomiting  of  blood,  bloody  stools,  icterus,  and  oedema  which 
may  affect  only  the  dependent  parts,  or  may  be  general.  When  the  cord 
separates  there  is  often  bleeding  at  the  umbilicus.  The  constitutional 
symptoms  are  prostration,  rapid  loss  in  weight,  and  all  the  evidences  of 
malnutrition.  There  is  no  appreciable  rise  in  temj^erature.  External 
hasmorrhages  may  be  wanting  altogether.  Death  occurs  from  progressive 
asthenia  or  hasmorrhage.  The  clinical  features  resemble  those  of  pyogenic 
infection,  but  in  Buhl's  disease  the  umbilicus  is  healthy,  aside  from  occa- 
sional haemorrhages,  and  there  is  no  rise  of  temperature.  The  disease 
occurs  in  isolated  cases,  not  in  groujDS.  The  treatment  is  entirely  symp- 
tomatic. 

PEMPHIGUS. 

Pemphigus  is  a  term  used  to  designate  a  lesion  rather  than  a  disease. 
By  it  is  meant  an  eruption  of  bull^  occurring  usually  upon  a  red  base, 
the  contents  being  in  most  cases  clear  serum.  The  term  has  been  made 
in  the  past  to  include  several  different  diseases  even  in  the  newly  born. 

1.  Traumatic  pemphigus  is  a  condition  which  has  been  induced  by 
putting  infants  into  very  hot  baths. 

2.  Pemphigus  is  seen  as  one  of  the  lesions  of  congenital  sj-philis.  In 
these  cases  the  eruption  is  often  present  at  birth.  It  rarely  appears  after 
the  fourteenth  day.  The  bullse  are  often  seen  upon  the  palms  and  the 
soles,  but  may  be  present  on  any  part  of  the  body.  These  infants  are 
usually  in  a  wretched  condition,  and  die  in  a  few  weeks,  often  in  a  few 
•days. 

3.  There  is  a  variety  of  pemphigus  which  seems  clearly  due  to  infec- 
tion. This  has  been  observed  in  small  epidemics  in  institutions.  Quite  a 
number  of  such  epidemics  have  been  seen  in  Europe,  but  none  that  I  am 
aware  of  have  been  reported  in  America.  Koch  reports  twenty-three  cases 
occurring  in  two  years  in  the  practice  of  one  midwife,  she  herself  being 
probably  the  source  of  infection.  The  same  writer  states  that  in  two  cases 
the  disease  developed  upon  the  breasts  of  mothers  who  were  nursing  af- 
fected children.  While  the  infectious  character  of  the  disease  is  pretty 
generally  admitted,  the  exact  nature  of  the  exciting  cause  has  not  yet  been 


HEMORRHAGES.  93 

determined.     The  greater  number  of  the  cases  studied  thus  far  have 
shown  the  presence  of  the  staphylococcus  pyogenes  aureus. 

The  clinical  picture  presented  by  this  form  of  pemphigus  is  so  striking 
that  the  disease  can  scarcely  be  mistaken.  The  symptoms  begin  in  most 
cases  between  the  third  and  sixth  day  of  life.  There  is  a  bullous  erup- 
tion, which  appears  upon  the  abdomen,  neck,  face,  or  thighs.  It  is  com- 
monly seen  first  upon  the  trunk.  Usually  there  are  but  ten  or  twenty 
bullae  present ;  but  nearly  the  whole  body  may  be  covered  except  the 
palms  and  soles,  where  they  are  rarely  seen.  They  may  even  appear  upon 
the  conjunctiva  or  the  mucous  membrane  of  the  mouth.  The  single  vesi- 
cles vary  in  size  from  one  fourth  to  one  or  two  inches  in  diameter.  They 
are  usually  rounded,  with  a  reddened  base.  The  contents  may  be  clear  or 
cloudy.  The  small  vesicles  may  coalesce  and  form  very  large  bullae.  Eup- 
ture  usually  occurs  in  one  or  two  days,  and  there  is  left  a  moist  red  sur- 
face, which  quickly  dries.  After  the  falling  off  of  the  crust  there  remains 
a  red  or  violet  patch  upon  the  skin.  The  eruption  may  come  out  quite 
rapidly,  almost  at  once,  or  the  disease  may  be  prolonged,  the  bullse  appear- 
ing in  crops  for  from  one  to  three  weeks.  If  ulceration  occurs  the  dura- 
tion of  the  disease  may  be  considerably  lengthened.  In  many  particulars 
the  pemphigus  resembles  impetigo  contagiosa,  with  which  it  has  no  doubt 
often  been  confounded. 

The  principal  point  in  diagnosis  is  to  distinguish  between  syphilitic 
and  non-syphilitic  pemphigus.  The  latter  usually  occurs  in  well-nourished 
infants,  and  has  a  much  better  prognosis.  In  infants  previously  healthy 
it  usually  ends  in  recovery  when  the  bullge  are  few  in  number ;  but  if  they 
develop  rapidly  over  a  large  surface  the  outlook  is  very  unfavourable. 

The  treatment  consists  in  absolute  cleanliness,  and  in  the  use  of  ab- 
sorbent antiseptic  powders,  such  as  equal  parts  of  boric  acid  and  starch, 
to  dry  up  the  eruption,  or  antiseptic  lotions,  such  as  1  to  10,000  bichloride, 
or  a  one-per-cent  solution  of  ichthyol. 


CHAPTER  V. 
H^MORRHA  OES. 

HEMORRHAGES  are  quite  frequent  during  the  first  days  of  life,  and  are 
important  not  only  from  the  fact  that  they  are  often  the  cause  of  death, 
but,  when  the  brain  is  the  seat,  from  their  remote  effects.  There  are  sev- 
eral conditions  in  the  newly  born  which  predispose  to  bleeding — the 
extreme  delicacy  of  the  blood-vessels,  and  the  great  changes  taking  place 
in  the  blood  itself  and  in  the  circulation  in  the  transition  from  intra- 
uterine to  extra-uterine  life.  IlaMuorrhages  may  complicate  many  of  the 
8 


94  DISEASES  OF  THE  NEWLY  BORK 

diseases  of  the  early  days  of  life,  such  as  syphilis  or  sepsis,  or  they  may 
exist  alone. 

The  cases  may  be  divided  into  two  groups:  (1)  Traumatic  or  Acci- 
dental Haemorrhages,  which  depend  upon  causes  connected  with  delivery ; 
(2)  Spontaneous  Haemorrhages,  or  The  Hemorrhagic  Disease  of  the 
Newly  Born. 

TRAUMATIC   OR  ACCIDENTAL  HEMORRHAGES. 

These  are  mainly  due  to  pressure  in  natural  labour,  or  to  means  em- 
ployed in  artificial  delivery,  but  some  of  them  may  possibly  result  from 
injuries  received  before  birth.  They  are  more  frequent  in  large  children, 
in  difficult  labours,  and  where  from  any  cause  the  body  of  the  child  has 
been  subjected  to  undue  pressure. 

Hsematoma  of  the  Sterno-Mastoid. — Hsematoma,  or,  as  it  is  sometimes 
called,  induration  of  the  sterno-mastoid  muscle,  leads  to  the  formation  of 
a  tumour  in  the  belly  of  the  muscle.  It  is  a  rare  condition,  usually  no- 
ticed in  the  second  or  third  week  of  life,  and  it  disappears  spontaneously, 
without  causing  any  permanent  deformity.  The  tumour  varies  from  three 
quarters  of  an  inch  to  one  inch  and  a  half  in  length,  being  about  the  size 
and  shape  of  a  pigeon's  egg.  It  is  movable,  almost  cartilaginous  to  the 
touch,  and  sometimes  slightly  tender.  The  situation  of  the  tumour  is 
usually  about  the  centre  of  the  muscle.  There  is  no  discoloration  of  the 
skin. 

In  about  two-thirds  of  the  cases  it  occurs  after  breech  presentations. 
It  is  much  more  frequent  upon  the  right  than  upon  the  left  side.  In 
twenty-seven  cases  collected  by  Henoch  the  right  side  was  involved  in 
twenty-one  and  the  left  in  only  six  cases.  The  explanation  of  this  differ- 
ence is  to  be  found  in  the  obstetrical  position.  Earely,  both  sides  may 
be  involved.  The  head  is  usually  inclined  towards  the  shoulder  of  the 
affected  side  and  rotated  towards  the  opposite  side.  The  swelling  slowly 
diminishes  in  size,  and  in  most  cases  by  the  end  of  the  third  month  has 
entirely  disappeared.  Occasionally  a  slight  torticollis  remains  for  a 
longer  time,  but  in  the  majority  of  cases  the  recovery  is  perfect.  Hsema- 
toma of  the  sterno-mastoid  is  due  to  the  twisting  of  the  head  during  par- 
turition. It  is  not  an  evidence  of  the  employment  of  any  improper  force 
in  delivery.  The  twisting  of  the  head  produces  laceration  of  some  of 
the  blood-vessels  of  the  muscle,  and  in  some  cases  there  is  doubtless  rup- 
ture of  some  of  the  fibres  of  the  muscle  itself.  Following  this  there  oc- 
curs a  certain  amount  of  inflammation  of  the  muscle  and  its  sheath. 
The  tumour  is  due  partly  to  blood-extravasation  and  partly  to  inflamma- 
tory products.  In  one  or  two  recent  cases  in  which  the  sheath  of  the 
muscle  has  been  opened  it  has  been  found  filled  with  blood. 

The  condition  requires  no  treatment.  Operative  interference  is  posi- 
tivelv  contra-indicated. 


CEPHALHEMATOMA.  95 

Cephalhaematoma. — This  is  a  tumour  containing  blood,  situated  upon 
the  head,  usually  over  one  parietal  bone,  and  tending  to  spontaneous  dis- 
appearance by  absorption.  The  source  of  the  blood  is  the  rupture  of  the 
small  vessels  of  the  pericranium. 

Etiology. — Cephalhsematoma  is  sometimes  due  to  a  distinct  trauma- 
tism like  the  application  of  forceps  or  to  some  other  injury  during  labour. 
In  the  majority  of  cases,  however,  there  is  no  evidence  of  such  injury. 
Besides  the  conditions  predisposing  to  all  haemorrhages,  there  is  the  in- 
creased pressure  in  the  blood-vessels  of  the  head  during  delivery,  espe- 
cially when  labour  is  prolonged  or  difficult ;  there  may  be  changes  in  the 
bone,  such  as  an  imperfect  development  of  the  external  table,  which 
has  been  found  in  a  few  instances,  and  in  consequence  of  which  the  peri- 
osteum readily  separates  when  the  head  is  subjected  to  the  pressure  of 
the  pelvis  ;  and,  finally,  there  may  be  changes  in  the  blood  itself.  Cephal- 
haematoma is  a  comparatively  rare  condition,  being  present,  accord- 
ing to  the  statistics  of  the  Sloane  Maternity  Hospital,  in  20  of  1,300  con- 
secutive births,  or  1  "6  per  cent.  The  condition  is  more  common  after 
first,  or  difficult  labours,  and  in  vertex  presentations ;  occurring  twice 
as  often  in  males  as  in  females,  probably  from  the  greater  size  of  the 
head. 

Lesions. — In  the  20  Sloane  cases,  the  situation  was  over  the  right 
parietal  bone  in  12;  over  the  left  in  2 ;  over  both  parietals  in  4 ;  over  the 
occipital  in  2.  The  location  of  the  tumour  seems  to  have  a  very  close 
relation  to  the  position  of  the  head  in  the  pelvis.  In  8  of  the  right-sided 
cases  the  head  was  in  the  left  occipito-anterior  position;  in  3  it  was  in 
the  right  occipito-anterior ;  in  1  case  the  position  was  unknown.  Of  the 
cases  with  occipital  tumours,  both  were  breech  presentations.  Of  the  16 
cases  with  a  single  tumour  the  labour  was  natural  in  10,  tedious  in  4,  and 
in  2  forceps  were  used.  Of  the  4  double  cases,  2  were  forceps  deliveries, 
1  a  tedious  labour,  and  but  1  was  natural. 

In  rare  cases  triple  tumours  are  met  with,  one  over  each  parietal  and 
one  over  the  occipital  bone.  The  attachment  of  the  periosteum  along  the 
sutures,  usually  limits  the  tumour  to  the  surface  of  one  bone.  It  never  ex- 
tends across  the  sutures  or  over  the  fontanel.  In  cases  where  there  is  a 
more  definite  injury,  such  as  from  forceps,  the  tumour  may  be  present  over 
any  one  of  the  cranial  bones,  but  more  frequently  over  the  parietal.  The 
seat  of  the  haemorrhage  is  between  the  periosteum  and  the  cranium.  The 
scalp  shows  punctate  haemorrhages  and  sometimes  infiltration  with  blood. 
In  recent  cases  the  blood  is  fluid ;  later  it  is  coagulated.  The  amount  of 
extravasated  blood  is  usually  from  half  an  ounce  to  an  ounce.  In  ex- 
treme cases  it  may  be  from,  four  to  six  ounces.  The  cases  following  natu- 
ral delivery  are  generally  uncomplicated.  The  traumatic  cases  may  be 
complicated  by  extravasations  between  the  bone  and  the  dura  (internal 
cephalhaematoma ) ,  or  by  meningeal  or  cerebral  haemorrhages.    If  there  is 


96 


DISEASES  OF   THE  NEWLY  BORN. 


Double  ceplialhtematoma,  infaut  seven  days  old. 


a  wound,  infection  maj-  be  followed  by  purulent  meningitis  and  even  by 
cerebral  abscess. 

Symptoms. — The  tumour  is  usually  noticed  from  the  first  to  the 
fourth  day  after  birth,  appearing  as  a  slight  prominence  in  one  of 
the  positions  mentioned  (Fig.  19).     Gradually  increasing  in  size,  it  at- 

^^^^^       tains  its  maximum  at 
'  w^HI       f]-^g  Q-j^^  of  a,  week  or 

ten  days,  and  then 
slowly  diminishes.  In 
the  average  case  the 
tumour  is  about  the 
size  of  a  hen's  egg, 
and  is  oval  in  form. 
In  marked  cases  it 
may  be  one-third  the 
size  of  the  child's 
head.  To  the  touch 
it  is  soft,  elastic,  fluc- 
tuating, and  irreduci- 
ble. It  does  not  increase  with  the  cry  or  cough.  There  is  no  extra  heat 
and  no  signs  of  inflammation.  Usually  the  tumour  does  not  pulsate, 
although  in  rare  instances  pulsating  cephalhsematomata  have  been  seen. 
Yery  soon  the  tumour  is  surrounded  by  a  marginal  ridge.  At  first  this  is 
apparently  from  coagulation  of  blood,  but  later  it  may  be  bony.  The 
prominent  ridge  with  the  soft  centre  gives  a  sensation  somewhat  like  that 
of  a  depressed  fracture.  Sometimes  on  pressure  there  is  obtained  a  sort 
of  parchment-crackling.  This  is  generally  found  as  the  swelling  is  sub- 
siding, and  is  sometimes  clearly  due  to  the  formation  of  minute  bony 
plates  upon  the  inner  surface  of  the  periosteum.  It  may  be  found  when 
there  is  nothing  but  thin  coagula  to  explain  it.  In  certain  cases  follow- 
ing severe  traumatism,  cephalhgematoma  may  be  complicated  with 
wounds  of  the  scalp,  fracture  of  the  skull,  and  even  lacerations  of  the 
dura  mater  or  the  brain.  In  such  eases  the  tumour  may  become  inflamed, 
but  in  the  spontaneous  cases  this  is  extremely  rare.  The  usual  signs  of 
abscess  develop,  which  may  open  externally  or  burrow.  Fortunately  this 
termination  is  seldom  seen. 

As  a  rule,  without  any  interference,  the  uncomplicated  cases  go  on  to 
recovery.  The  complete  disappearance  of  the  tumour  may  be  expected  in 
from  six  weeks  to  three  months,  depending  on  its  size  :  but  a  hard,  uneven 
elevation  may  remain  at  its  site  for  a  longer  time.  The  cases  due  to  severe 
traumatism  are  more  serious,  the  gravity  depending  not  upon  the  cephal- 
hematoma but  upon  the  complicating  lesions. 

Diagnosis. — Cephalhsematoma  may  be  confounded  with  eneephalocele. 
This,  however,  occurs  along  the  line  of  the  sutures  or  at  the  fontanels,  is 


VISCERAL  HEMORRHAGES.  97 

partly  reducible,  pressure  causes  cerebral  symptoms,  and  frequently  the 
tumour  increases  with  respiratory  movements.  Hydrocephalus  is  distin- 
guished by  the  symmetrical  enlargement  of  the  head,  the  large  frontanels, 
and  the  widely  separated  sutures.  Caput  succedaneum  often  appears  in  the 
same  jjlace  as  a  cephalhaematoma  and  at  the  same  time,  but  is  an  oedem- 
atous,  not  a  fluctuating  tumour,  is  not  circumscribed,  lacks  the  hard, 
marginal  border,  and  begins  to  disappear  by  the  second  or  third  day. 
From  a  depressed  fracture  of  the  skull,  it  is  differentiated  by  the  fact  that 
in  cephalhaematoma  there  is  a  tumour  and  not  a  depression ;  the  promi- 
nent margin  which  is  raised  above  the  contour  of  the  skull,  is  not  osseous 
and  the  skull  can  be  felt  at  the  bottom  of  the  centre  of  the  tumour. 

The  treatment  in  the  uncomplicated  cases  is  simply  protective,  all 
such  cases  tending  to  spontaneous  recovery.  Xo  local  or  general  treat- 
ment to  promote  absorption  is  required.  The  child  should  be  so  placed 
and  so  handled  that  no  injury  may  be  done  to  the  affected  part.  Com- 
presses are  unnecessary.  If  complications  exist,  such  as  injury  to  the 
bones,  dura,  or  brain,  they  are  to  be  treated  in  accordance  with  general 
surgical  principles.  Operative  interference  is  called  for  only  when  sup- 
puration has  occurred,  or  when  there  are  brain  symptoms  which  point  to 
the  existence  of  internal  as  well  as  external  cephalhitmatoma. 

Visceral  Hsemorrliages. — While  these  are  most  frequent  in  large  chil- 
dren and  following  difficult  labours,  they  may  occur  in  small  children  and 
where  the  labour  has  been  easy  and  normal — their  occurrence  here  being 
due  to  the  feeble  resistance  of  the  blood-vessels.  From  one  hundred  and 
thirty  autopsies  upon  still-born  children  or  those  dying  soon  after  birth, 
Spencer  concludes  that  intracranial  hemorrhages  are  more  frequent  in 
head-f orceins  than  in  breech  cases,  and  more  frequent  in  breech  than  in 
natural  vertex  deliveries.  Other  visceral  heemorrhages  are  much  more 
frequent  in  breech  cases. 

Not  all  visceral  haemorrhages  are  to  be  classed  as  traumatic.  They  are 
often  seen  with  the  spontaneous  hgemorrhages  from  the  skin  or  mucous 
membranes.  When,  however,  they  are  single,  they  seem  to  me  of  trau- 
matic rather  than  of  pathological  origin. 

The  most  important  of  the  visceral  hfemorrhages  are  intracranial. 
These  are  discussed  in  the  chapter  devoted  to  Birth  Paralyses.  Rarely 
there  may  be  large  haemorrhages  into  the  lung.  Here  the  blood  fills  the 
air  vesicles,  the  small  bronchi,  and  coagula  may  be  found  even  in  the 
larger  bronchi.  A  large  part  of  a  lobe  or  an  entire  lobe  may  be  involved. 
On  section  the  condition  resembles  atelectasis,  and  it  may  give  the  physical 
signs  of  consolidation. 

The  abdominal  viscera  suffer  more  than  those  of  the  thorax  because 
less  protected  against  pressure.  Small  haemorrhages  are  not  uncommon 
upon  the  surface  of  any  of  the  viscera  covered  by  peritonaeum.  Intra- 
peritoneal haemorrhages  are  rare,  but  may  be  very  extensive,  amounting  to 


98  DISEASES   OP   THE  NEWLY  BORN. 

one  or  two  pints.  Sometimes  no  ruptured  vessel  can  be  found.  The 
hsemorrhage  may  be  primarily  in  the  peritoneal  cavity,  or  it  may  result 
from  rupture  of  one  of  the  viscera,  especially  the  suprarenal  capsule.  It 
may  be  large  enough  to  produce  death  from  loss  of  blood. 

Small  surface  haemorrhages  of  the  liver  are  not  infrequent.  Occa- 
sionally one  of  considerable  size  occurs  separating  the  peritoneal  covering 
and  forming  a  tumour  generally  upon  the  superior  surface.  Such  lacer- 
ation may  be  produced  during  labour,  and  a  slow  accumulation  of  blood 
may  take  place  beneath  the  capsule,  death  resulting,  as  in  the  case  re- 
ported by  Mendelson  (New  York),  from  rupture  into  the  peritoneal  cavity 
on  the  third  day.  Stetfen  reports  a  case  of  laceration  of  the  capsule  of 
the  liver  in  a  still-born  infant.  Of  the  large  hsemorrhages,  those  into  the 
suprarenal  capsules  are  perhaps  the  most  frequent.  Two  cases  have  re- 
cently occurred  in  the  Sloane  Maternity  Hospital.  In  one  of  these,  the 
specimen  of  which  I  examined,  the  capsule  was  distended  nearly  to  the 
size  of  an  orange,  and  the  kidney  surrounded  by  a  mass  of  blood-clots. 
Blood  was  extravasated  into  the  retroperitoneal  connective  tissue,  and 
rupture  had  taken  place  into  the  peritoneal  cavity,  which  contained  half 
a  pint  of  partly  coagulated  blood.  The  child  died  on  the  fifth  day.  This 
case  has  been  reported  in  full  by  Tuley.*  Ahlfeld  has  reported  a  case  of 
hsemorrhage  into  both  suprarenals. 

Except  in  the  intracranial  variety,  visceral  hsemorrhages  cause  few 
symptoms,  and  in  the  great  majority  of  cases  the  diagnosis  is  not  made. 
Intrapulmonary  heemorrhages  have  given  rise  to  the  signs  of  consolida- 
tion of  the  lung  and  even  to  haemoptysis  (Miram's  case).  The  abdominal 
heemorrhages  are  the  most  obscure.  There  may  be  a  general  abdominal 
distention  with  the  usual  symptoms  of  loss  of  blood,  or  there  may  be  a 
circumscribed  swelling.  In  many  cases  nothing  is  noticed  until  a  rupture 
of  a  subperitoneal  haemorrhage  takes  place  into  the  general  peritoneal 
cavity,  when  there  may  be  sudden  collapse  and  death. 

The  visceral  haemorrhages  are  not  amenable  to  treatment.  The  prog- 
nosis depends  upon  the  size  and  position  of  the  haemorrhage.  In  the  cases 
of  abdominal  haemorrhage  the  diagnosis  is  extremely  obscure  and  is  rarely 
made  during  life. 

SPONTANEOUS   HEMORRHAGES— THE    HEMORRHAGIC    DISEASE    OF 

THE   NEWLY  BORN. 

A  disposition  to  bleeding  is  seen  with  many  diseases  of  the  first  few  days 
of  life,  especially  those  of  an  infectious  character,  like  syphilis  and  pyaemia. 
With  most  of  these,  however,  the  haemorrhages  are  small,  and  the  condi- 
tion may  be  compared  to  the  haemorrhagic  tendency  seen  in  certain  forms 
of  infection  of  later  life,  such  as  measles,  smallpox,  and  malignant  endo- 


*  Archives  of  Psediatrics,  November,  1892. 


THE    HEMORRHAGIC   DISEASE.  99 

carditis.  There  is,  however,  a  class  of  cases  in  which  the  hjemorrhages  are 
not  associated  with  any  other  known  process,  and  in  which  the  escape  of 
blood  from  the  small  blood-vessels  is  the  chief  or  essential  symptom.  In 
these  cases  the  bleeding  is  much  more  extensive  than  in  the  others  men- 
tioned. These  hemorrhages  are  characterized  by  the  fact  that  they  are 
spontaneous  in  origin,  having  no  connection  with  delivery,  they  are  mul- 
tiple in  location,  and,  while  little  influenced  by  treatment,  they  tend  to 
cease  spontaneously  after  quite  a  limited  time.  They  are  most  often  from 
the  umbilicus,  the  mucous  membranes  of  the  stomach  and  intestines,  or 
beneath  the  skin,  but  they  may  be  from  almost  any  mucous  surface  or 
into  any  organ  of  the  body. 

Etiology, — Exactly  what  causes  these  haemorrhages  is  as  yet  unknown, 
but  it  is  something  which  produces  changes  in  the  blood  or  in  the  blood- 
vessels, or  in  both,  whereby  the  vessels  are  no  longer  able  to  hold  their 
contents.  In  this  class,  as  well  as  in  the  traumatic  haemorrhages,  the 
predisposing  causes  of  bleeding  in  early  life  must  be  emphasized — viz.,  the 
fragile  condition  of  the  blood-vessels  and  the  great  changes  taking  place 
soon  after  birth  both  in  the  circulation  and  in  the  blood  itself.  These 
haemorrhages  are  not  common,  and  are  met  with  much  more  often  in  in- 
stitutions than  in  private  practice.  In  5,225  births  in  the  Boston  Lying-in 
Asylum,  Townsend  reports  32  cases  of  hsemorrhage,  or  0*6  per  cent.  In 
the  Lying-in  Asylum  of  Prague,  Eitter  observed  190  cases  in  13,000  births, 
or  1*4  per  cent.  In  the  Foundling  Asylum  of  Prague,  Epstein  reports 
haemorrhages  in  8  per  cent  of  740  infants. 

These  cases,  except  in  very  rare  instances,  are  not  manifestations  of 
hgemophilia.  Of  576  bleeders  collected  by  Grandidier,  only  12  had  a  his- 
tory of  hsemorrhag'e  at  the  time  of  falling  off  of  the  cord,  and  symptoms 
very  rarely  appeared  before  the  end  of  the  first  year.  Hsemorrhages  in  the 
newly  born  are  only  slightly  more  frequent  in  males,  while  in  hemophilia 
they  predominate  13  to  1.  The  haemorrhagic  disease  of  the  newly  born  is 
self-limited,  and  runs  a  definite  course  to  recovery  or  death.  The  tendency 
to  bleed  does  not  extend  beyond  a  few  weeks,  and  often  lasts  but  a  few 
days ;  those  who  survive,  recover  perfectly.  Circumcision  has  been  done 
within  a  few  days  after  the  cessation  of  the  haemorrhages  without  any  un- 
usual bleeding.  In  a  case  lately  under  observation  with  the  most  exten- 
sive subcutaneous  haemorrhages  I  have  ever  seen,  all  tendency  to  bleed 
had  ceased  before  the  separation  of  the  cord,  although  there  had  previous- 
ly been  bleeding  at  the  navel.  A  similar  case  is  reported  by  Townsend. 
These  cases  are  not  associated  with  difficult  delivery.  In  only  G  of  Town- 
send's  *  50  cases  was  the  labour  abnormal.  This  is  borne  out  by  my  own 
experience.  Many  of  the  children  who  bleed  have  previously  been  anaemic 
and  in  poor  general  condition ;  but,  on  the  other  hand,  many  have  been 

*  Archives  of  Pa3cliatrics,  1894,  p.  559. 


100  DISEASES   OF  THE  NEWLY   BORN. 

strong  and  given  ever}-  indication  of  being  well  nourished.  Hereditary 
syphilis  is  associated  in  a  small  proportion  of  the  eases — from  2  to  6  per 
cent,  according  to  the  observations  of  Epstein,  Ritter,  and  Townsend. 
In  132  cases  of  congenital  syphilis  observed  by  Mracek,  1-1  per  cent  suf- 
fered from  hemorrhages. 

A  more  frequent  association  with  sepsis  (pyogenic  infection)  has  been 
observed.  Of  the  61  cases  observed  by  Epstein  not  less  than  29,  and  of 
the  190  cases  of  Eitter,*  24  were  associated  with  sepsis.  During  the  year 
1895  there  were  no  less  than  8  marked  cases  of  haemorrhage  in  the  ISTur- 
sery  and  Child's  Hospital  in  about  225  deliveries.  While  it  is  true  that 
more  cases  of  sepsis  (pyogenic  infection)  occurred  among  the  children 
during  this  period  than  usual,  it  was  striking  that  not  one  of  these  hsem- 
orrhagic  cases  gave  any  evidence  of  sepsis,  and  that  none  of  the  septic 
cases  had  bleeding.  An  epidemic  of  10  cases  of  haemorrhages  among 
54  births  at  the  N"ew  York  Infirmary  for  Women  and  Children  was  stud- 
ied in  1899  by  Kilham  and  Mercelis.f  These  all  occurred  in  the  course- 
of  two  months ;  the  epidemic  ceased  as  soon  as  the  cases  were  properly 
isolated. 

From  the  foregoing  facts  it  is  quite  evident  that  not  all  the  cases  of 
bleeding  are  due  to  the  same  cause,  and  that  while  this  symptom  occurs 
in  some  cases  of  pyogenic  infection,  the  latter  does  not  explain  most  of 
those  seen.  The  circumstances  in  which  the  haemorrhagic  disease  occurs 
point  strongly  to  an  infectious  origin,  but  with  our  present  knowledge  we- 
can  not  believe  this  cause  to  be  the  same  as  in  ordinary  sepsis — viz.,  the 
entrance  of  common  pyogenic  bacteria.  Quite  a  number  of  these  cases 
have  now  been  studied  bacteriologically,  but  with  no  very  uniform  results. 
In  two  cases  by  Gaertner  J  there  was  found  in  the  blood  a  short  bacillus- 
resembling  in  some  respects  the  colon  bacillus,  which,  injected  into  the 
peritoneal  cavity  in  young  animals,  chiefly  dogs  a  few  days  old,  produced 
a  disease  accompanied  by  hsemorrhages  resembling  that  seen  in  the  newly 
born.  The  bacillus  was  recovered  from  the  blood  and  all  the  organs  of 
these  animals.  In  one  of  my  own  cases  at  the  Nursery  and  Child's  Hos- 
pital, cultures  were  made  eight  hours  after  death  by  Dr.  J.  J.  Mapes. 
There  was  found  in  pure  culture  in  the  umbilical  arteries,  in  the  heart's 
blood,  and  in  the  spleen,  a  bacillus  which  in  morphological  and  culture- 
characteristics  was  apparently  identical  with  that  described  by  Gaertner. 
In  two  cases  studied  by  Kilham  and  Mercelis  a  pathogenic  organism  was 
found  which  in  many  respects  resembled  the  pneumococcus.  Other  or- 
ganisms found  are  the  streptococcus,  the  bacillus  pyocyaneus,  or  the 
lactis  aerogenes. 

While  these  haemorrhages  are  not  traumatic,  bleeding  is  exceedingly 
prone  to  occur  in  the  skin  over  pressure  points  such  as  the  back,  the- 

*  Oesterreiches  Jahrbuch  fiir  Padiatrik,  1871,  127. 

f  Archives  of  Paediatrics,  March,  1899.  X  Archiv  fiir  Kinderheilkunde,  1895- 


THE   HEMORRHAGIC   DISEASE.  101 

elbows,  the  occiput,  and  the  sacrum.  It  is  also  common  from  the  mucous 
membranes  which  are  the  seat  of  pathological  processes,  especially  from 
the  eyes,  the  nose,  and  the  genitals. 

Lesions. — In  very  many  of  the  cases  the  autopsy  shows  nothing  except 
the  haemorrhages  in  the  various  situations  and  the  blanching  of  the  organs 
due  to  the  loss  of  blood.  The  haemorrhages  of  the  brain  are  usually  me- 
ningeal and  diffuse.  They  are  considered  more  at  length  in  the  chapter 
upon  Birth  Paralyses.  The  pulmonary  haemorrhages  are  usually  small 
and  unimportant,  amounting  only  to  small  extravasations  into  the  sub- 
stance of  the  lung  or  ecchymoses  of  the  mucous  membrane  of  the  bronchi. 
Ecchymoses  may  be  seen  upon  the  surface  of  the  pleura,  the  pericardium, 
or  the  peritoneum,  but  large  haemorrhages  into  the  pleura  or  pericardium 
are  very  rare.  The  thymus  gland  is  often  the  seat  of  small  extravasa- 
tions. The  stomach  and  intestines  may  contain  considerable  blood  vari- 
ously disorganized  in  the  different  parts  of  the  canal,  and  there  may  be 
ecchymoses  of  the  mucous  membrane.  In  addition,  ulcers  may  be  found 
in  the  stomach  and  duodenum.  In  twenty-four  autopsies  upon  cases 
with  haemorrhage  from  the  stomach  and  intestines  collected  by  Dusser,* 
ulcers  were  found  in  the  stomach  in  nine  cases,  and  in  the  intestines  in 
four.  These  ulcers  are  multiple  and  are  small,  resembling  the  follicular 
ulcers  of  the  colon.  They  are  usually  superficial,  but  may  extend  to  the 
muscular  coat  and  may  even  perforate.  I  have  myself  found  ulcers  in  the 
stomach  in  a  single  case.  They  were  associated  with  a  moderate  amount 
of  follicular  gastritis.  The  intestinal  ulcers  are  found  only  in  the  duode- 
num and  resemble  those  of  the  stomach.  The  cause  of  these  ulcers  is 
somewhat  obscure;  some  of  them  are  undoubtedly  dependent  upon  in- 
flammatory changes  probably  of  infectious  origin  ;  others  have  been  com- 
pared to  the  peptic  ulcers  of  later  life,  and  are  attributed  to  thrombi  in  the 
blood-vessels  of  the  mucous  membrane.  These  ulcers  are  found  in  but  a 
small  proportion  of  the  cases  in  which  bleeding  occurs  from  the  alimen- 
tary tract,  and  they  may  be  wanting  even  where  it  has  been  very  profuse. 

Small  extravasations  may  be  seen  upon  the  surface  of  the  liver,  the 
spleen,  or  the  kidneys.  They  may  also  be  found  in  the  substance  of  these 
organs.  The  large  haemorrhages  upon  the  surface  of  the  liver,  into  the 
suprarenal  capsules  and  other  subperitoneal  extravasations  have  been  in- 
cluded, improperly  perhaps,  in  the  group  of  traumatic  haemorrhages  dis- 
cussed in  the  preceding  chapter.  From  a  rupture  of  any  of  these  there 
may  be  large  extravasations  into  the  peritoneal  cavity.  Microscopical  ex- 
aminations of  the  blood-vessels  have  been  made  in  but  a  small  number  of 
cases.  Mracek  claims  to  have  found  evidences  of  endarteritis  in  some  of 
the  syphilitic  cases  in  which  there  was  bleeding.  The  changes  found 
in  the  blood  have   not   been   uniform  and    have   as   yet   been    only  im- 

*  These,  Paris,  1889. 


102  DISEASES   OF   THE   NEWLY  BORN. 

perfectly  studied.  The  associated  lesions  found  are  most  frequently  those 
due  to  sepsis. 

Symptoms. — The  time  of  beginning  is  most  frequently  in  the  first 
week  of  life,  rarely  after  the  twelfth  day,  although  it  has  been  observed  as 
late  as  the  sixth  week.  As  a  rule,  the  haemorrhages  from  the  stomach 
and  intestines  begin  earlier  than  those  from  the  navel  or  the  skin.  The 
location  of  the  hsemorrhage  in  Kitter's  190  cases  was  as  follows:  Um- 
bilicus, 138  (umbilicus  alone,  97) ;  intestines,  39 ;  mouth,  28 ;  stomach, 
20 ;  conjunctivae,  20  ;  ears,  9.  In  Townsend's  50  cases :  Intestines,  20  ; 
stomach,  14 ;  mouth,  14  ;  nose,  12 ;  umbilicus,  18  (umbilicus  alone,  3) ; 
subcutaneous  ecchymoses,  21  ;  abrasion  of  skin,  1 ;  meninges,  4 ;  cephal- 
haematoma,  3 ;  abdomen,  2 ;  pleura,  lungs,  and  thymus,  1  each. 

In  many  cases  nothing  is  noticed  until  the  haemorrhage  begins.  The 
child  may  be  previously  healthy  or  feeble.  The  first  bleeding  noticed  may 
be  from  the  stomach,  intestines,  or  any  of  the  mucous  surfaces,  beneath 
the  skin,  or  from  the  umbilicus.  The  amount  of  blood  lost  in  most  cases 
is  not  great,  but  there  is  a  continuous  oozing.  The  total  haemorrhage 
may  be  only  one  or  two  drachms  or  it  may  reach  several  ounces.  The 
skin  is  usually  pale,  the  pulse  feeble,  and  the  general  condition  one  of  con- 
siderable prostration,  often  from  the  outset.  In  all  cases  there  is  rapid 
loss  of  weight.  The  temperature  may  be  high,  low,  or  subnormal.  A 
marked  elevation  of  temperature  may  depend  not  upon  the  haemorrhage 
but  upon  associated  conditions.  Fluctuations  in  temperature  during  the 
first  three  days  are  so  common  from  disturbances  of  nutrition,  that  I  attach 
much  less  importance  than  have  some  writers  to  this  symptom.  Icterus  is 
not  more  frequent  than  among  other  infants.  In  a  large  number  of  the 
cases  there  is  diarrhoea.    Convulsions  often  occur  at  the  close  of  the  disease. 

The  duration  of  the  disease  in  cases  which  recover  is  usually  but  one 
or  two  days.  In  fatal  cases  it  is  rarely  more  than  three  days,  and  often 
less  than  one.  Death  more  frequently  results  from  the  gradual  failure  of 
all  the  vital  forces  than  from  a  rapid  loss  of  blood. 

Umhilical  licemorrhage. — A  slight  oozing  from  the  umbilicus  not  in- 
frequently occurs  when  the  ligature  has  been  improperly  applied,  or  when 
there  is  so  much  shrinking  of  the  cord  that  the  ligature  has  loosened. 
Sometimes  rough  handling  at  the  time  of  the  separation  of  the  cord  may 
excite  a  little  bleeding.  All  the  above  conditions,  however,  are  usually  of 
trivial  importance  and  are  readily  controlled  by  simple  measures.  Spon- 
taneous haemorrhage  is  quite  a  different  matter.  It  is  rather  later  than 
bleeding  from  the  mucous  membranes,  usually  occurring  between  the 
fourth  and  the  seventh  day.  There  may  be  bleeding  into  the  cord  as  well 
as  from  its  free  extremity  before  it  separates ;  after  separation,  from  the 
stump.  A  slight  stain  upon  the  dressing  is  usually  the  first  note  of  warn- 
ing, but  in  exceptional  circumstances  a  gush  of  blood  is  the  first  symptom. 
The  haemorrhage  may  be  temporarily  arrested  by  various  means,  but  it 


THE  HEMORRHAGIC  DISEASE.  lOa 

shows  a  strong  tendency  to  occur  in  spite  of  everything  which  is  done. 
The  general  symptoms  depend  upon  the  amount  of  bleeding  and  the  ra- 
pidity with  which  it  occurs.  It  is  the  same  as  in  other  ha?morrhages  of 
the  newly  born.  The  usual  duration  is  two  or  three  days.  It  has  been 
known,  however,  to  persist  for  twelve  or  fourteen  days,  and  it  may  be 
fatal  in  less  than  twenty-four  hours  from  the  time  it  is  noticed. 

Hcemorrliage  from  the  stomach  and  intestines. — Bleeding  occurs  much 
less  frequently  from  the  stomach  than  from  the  intestines.  The  latter 
is  called  mel«na.  Gastro-enteric  haemorrhages  begin,  in  the  great  ma- 
jority of  cases,  during  the  first  three  days  of  life.  Of  Dusser's  75  cases,  the 
haemorrhage  began  on  the  first  day  in  24  cases ;  on  the  second  day  in  22 
cases ;  on  the  third  day  in  9  cases ;  in  only  10  cases  later  than  the  ninth 
day,  and  in  no  instance  later  than  the  twelfth  day.  The  appearance  of 
the  blood  vomited  depends  upon  the  length  of  time  it  has  remained  in 
the  stomach.  Usually  it  is  in  dark  brown  masses,  and  not  very  abun- 
dant; more  rarely  bright  red  blood  may  be  ejected.  The  quantity  varies 
from  one  drachm  to  half  an  ounce.  Vomiting  is  liable  to  be  excited  by 
nursing.  The  blood  discharged  from  the  bowels  is  always  dark  coloured, 
usually  intimately  mixed  with  the  stool,  very  rarely  in  clots.  If  in  doubt 
between  blood  and  meconium,  one  should  look  for  the  corpuscles  with  the 
microscope.  When  this  is  not  conclusive  on  account  of  the  disorganiza- 
tion of  the  corpuscles,  a  chemical  test  for  haemoglobin  should  be  made. 
Concealed  hsemorrhage  into  the  stomach  may  take  place,  which  may  even 
be  sufficient  to  produce  death,  no  blood  being  vomited  or  passed  by  the 
bowels.  In  such  cases  the  autopsy  may  reveal  quite  a  large  quantity  of 
blood,  both  in  the  stomach  and  intestines. 

HcBmor7'hage  from  the  mouth. — The  quantity  of  blood  is  rarely  large ; 
but  it  is  here  that  it  is  often  first  seen.  Its  source  may  be  the  mucous 
•membrane  of  the  mouth,  pharynx,  cesoiDhagus,  stomach,  or  bronchi.  It 
may  be  associated  with  ulceration  of  the  hard  palate,  with  thrush,  or  with 
fissures  of  the  lips. 

Hmmorrhages  from  the  nose  are  infrequent,  and  are  more  often  due  to 
syphilis  than  to  other  causes.  These  are  rarely  profuse,  but  are  frequently 
repeated. 

Subcutaneous  hcemorrhages. — These  may  appear  in  places  exposed  to 
pressure,  such  as  the  sacrum,  heels,  occiput,  or  back ;  or  in  others  which 
are  not  so  exposed,  as  the  abdomen,  axilliB,  or  thighs.  They  may  follow 
other  lesions  of  the  skin,  such  as  pemphigus,  eczema,  or  furunculosis.  In 
some  cases  these  haemorrhages  are  very  extensive,  as  in  one  recently 
under  observation,  where  nearly  one  third  of  the  thorax  was  covered. 
The  extravasations  are  surrounded  by  an  indurated  border.  Where  they 
occur  alone  or  form  the  principal  lesion,  tlie  prognosis  is  favourable. 

HcBmaturia. — The  urine  is  not  only  stained  with  blood,  but  sometimes 
contains  clots.     This  haemorrhage  may  have  its  origin  in  the  bladder,  ure- 


104  DISEASES  OF   THE  NEWLY  BORN. 

thra,  or  kidney.  Blood  coming  from  the  kidney  is  sometimes  due  to  tlie 
irritation  of  uric-acid  infarctions,  and  may  have  nothing  to  do  with  the 
general  haBmorrhagic  disease. 

Hmmorrhage  from  the  conjunctiva. — The  blood  usually  comes  in  drops 
from  between  the  eyelids,  chiefly  from  the  tarsal  surface.  It  is  generally 
preceded  by  conjunctivitis. 

HcBinorrliage  from  the  ears  may  originate  in  the  external  meatus  or 
the  middle  ear.     It  is  generally  preceded  by  otitis. 

Hmmorrhage  from  the  female  genitals. — This  not  infrequently  occurs 
without  haemorrhages  elsewhere,  and  under  such  circumstances  is  rarely 
serious.  Cullingsworth  has  collected  thirty-two  cases  in  children  under 
six  weeks  of  age — no  case  having  resulted  fatally.  These  are  not  to  be  re- 
garded as  cases  of  precocious  menstruation.  They  are  frequently  preceded 
by  catarrhal  inflammations  of  the  vagina. 

Diagnosis. — This  is  generally  easy,  as  the  hgemorrhages  are  usually 
multiple  and  some  of  them  external.  A  slight  haemorrhage  from  the 
intestine  may  be  easily  overlooked.  Large  haemorrhages  into  the  internal 
organs  also  are  obscure  and  not  often  recognised.  Spurious  haemorrhages 
from  the  stomach  may  oceur^  blood  being  vomited  which  has  been  swal- 
lowed during  birth  or  nursing.  The  source  of  bleeding  may  also  be  the 
mouth,  nose  or  pharynx,  and  sometimes  blood  is  swallowed  in  large  quan- 
tities and  afterward  vomited.  These  cavities  should  therefore  always 
be  examined,  since  local  treatment  may  be  efficacious.  Syphilis  should 
be  suspected  when  the  bleeding  is  chiefly  nasal. 

Prognosis. — In  all  circumstances  the  haemorrhagic  disease  in  the 
newly  born  has  a  bad  prognosis.  Of  seven  hundred  and  nine  cases  col- 
lected by  Townsend,  the  mortality  was  seventy-nine  per  cent.  No  ob- 
server has  seen  more  than  one  third  of  his  cases  recover.  In  any  single 
case  the  prognosis  depends  upon  the  extent  and  severity  of  the  haemor-  . 
rhage,  upon  the  vigour  of  the  child,  and  upon  how  well  it  can  be  nour- 
ished. No  case  should  be  looked  upon  as  hopeless,  for  perfect  recovery 
has  repeatedly  taken  place  where  it  seemed  impossible. 

Treatment. — The  only  drug  which  appears  to  have  any  influence  upon 
these  hgemorrhages  is  the  supra -renal  extract;  even  this  is  of  doubtful 
value  except  for  its  local  effect  upon  accessible  mucous  membranes.  It 
should  be  applied  for  bleeding  from  the  mouth,  nose,  or  pharynx.  I  have 
had  one  case  in  which  it  appeared  to  control  promptly  a  severe  gastric 
haemorrhage  in  an  infant  a  day  old.  It  d"eserves  further  trial.  From  one- 
quarter  of  a  grain  to  one-half  a  grain  may  be  given  every  hour  suspended 
in  water.  The  general  treatment  should  have  reference  to  maintain- 
ing the  nutrition  by  careful  feeding,  judicious  stimulation,  and  atten- 
tion to  the  circulation,  the  body  temperature,  and  the  general  condition 
of  the  child.  External  haemorrhages  may  be  treated  locally.  Bleeding 
points  on  the  skin  or  mucous  membranes  within  reach,  are  best  treated  by 
the  application  of  chromic  acid  fused  on  a  probe,  or  of  nitrate  of  silver. 


BIRTH   PARALYSES.  105 

Umbilical  hfemorrhage  is  best  controlled  by  covering  the  nnibilicns  with  a 
small  pad  of  sterile  cotton,  over  which  is  folded  from  either  side  the  skin 
of  the  abdominal  wall.  This  is  held  in  place  by  two  strips  of  adhesive 
plaster  crossing  the  umbilicus  obliquely.  After  ligature  en  masse  sec- 
ondary haemorrhage  often  occurs  at  the  separation  of  the  slough,  so  that 
the  procedure  is  frequently  unsuccessful.  Astringents  are  applicable  to 
all  cases  of  external  hsemorrhage — from  the  nose,  skin,  vagina,  and  the 
eyes.  Astringent  injections  for  intestinal  haemorrhages  are  practically 
useless,  as  the  blood  is  almost  invariably  either  from  the  stomach  or  from 
the  upper  part  of  the  small  intestine. 

CHAPTER  VI. 

BIRTH  PARALYSES. 

BiETH  paralyses  are  chiefly  due  either  to  pressure  upon  the  child  by 
the  parts  of  the  mother  or  to  artificial  means  employed  in  delivery.  They 
may  be  cerebral,  spinal,  or  peripheral. 

Cerebral  paralyses  are  in  almost  every  instance  due  to  meningeal  hsem- 
orrhage.  Very  infrequently  they  depend  upon  cerebral  haemorrhage, 
laceration  of  the  brain,  or  pressure  from  a  depressed  fracture. 

Spinal  paralyses  are  extremely  rare,  and  only  a  few  examples  are  on 
record.  They  are  due  to  laceration  of,  or  haemorrhage  into  the  cord  or  its 
membranes.  These  lesions  produce  paraplegia,  the  exact  distribution  of 
which  depends  upon  the  point  at  which  the  cord  is  injured. 

Peripheral  paralyses  usually  affect  the  face  or  the  upper  extremity. 
Paralysis  of  the  face  is  due  in  most  cases  to  the  application  of  the 
forceps.  Paralysis  of  the  upper  extremity  is  most  frequently  of  the 
"  upper-arm  type,"  and  is  known  as  Erb's  paralysis.  It  usually  follows 
extraction  iu  breech  presentations.  Peripheral  paralysis  of  the  lower 
extremity  is  almost  unknown. 

CEREBRAL   PARALYSIS. 

Cerebral  paralysis  is  often  used  synonymously  with  meningeal  haemor- 
rhage. This  lesion  is  not  infrequent,  and  is  of  great  importance  not  only 
from  its  immediate  effects,  but  because  upon  it  depend  many  of  the  cere- 
bral paralyses  seen  in  later  life.  According  to  Cruveilhier,  at  least  one 
third  of  the  deaths  of  infants  which  occur  during  parturition  are  due  to 
this  cause. 

Etiology. — The  same  predisposing  causes  exist  in  the  cases  of  menin- 
geal hcfimorrhages  as  in  others  occurring  at  this  time.  A  small  number  of 
cases  are  associated  with  syphilis ;  others  with  pyogenic  infection.  In  a 
few  cases  there  is  a  history  of  an  injury — usually  a  fall  or  blow  upon  the 
abdomen — during  the  last  months  of  pregnancy.    Meningeal  hsemorrhage 


106  DISEASES   OF   THE   NEWLY  BORN. 

may  occur  as  one  of  the  lesions  in  the  haemorrhagic  disease  of  the  newly 
born.  The  most  important  causes,  however,  are  connected  with  parturi- 
tion. These  haemorrhages  are  essentially  mechanical,  and  are  favoured 
by  everything  which  increases  or  prolongs  pressure  upon  the  head.  The 
conditions  with  which  they  are  associated  are  tedious  labour,  breech  pres- 
entations with  difficulty  in  extracting  the  head,  instrumental  deliveries, 
and  premature  births.  The  majority  occur  in  first-born  children.  Certain 
cases  are  associated  with  cardiac  malformations — according  to  Bednar,  a 
small  aorta  with  hypertrophied  heart,  or  the  transposition  of  the  large 
blood-vessels.  In  many  of  the  cases  there  is  also  a  haemorrhage  outside 
the  skull. 

Lesions. — These  haemorrhages  are  very  much  more  common  at  the 
base  than  at  the  convexity,  and  at  the  posterior,  than  at  the  anterior  part 
of  the  skull.  They  are  most  frequently  found  over  the  cerebellum  and 
the  occipital  lobes  of  the  cerebrum.  The  entire  extravasation  is  often 
beneath  the  tentorium.  The  extent  of  the  hsemorrhage  is  exceedingly 
variable.  There  may  be  a  single  large  clot  at  the  convexity  or  at  the  base 
(Plate  II),  the  haemorrhage  may  be  limited  to  the  convexity  of  one 
hemisphere,  or  it  may  cover  nearly  the  entire  surface  of  the  brain.  Dif- 
fuse haemorrhages  are  more  common  than  a  single  circumscribed  clot. 
Of  eleven  recent  cases  collected  by  McNutt  (New  York),  in  seven  cases 
with  vertex  presentations  the  lesion  was  principally  at  the  base,  and  usu- 
ally limited  to  that  region.  In  four  breech  cases,  however,  it  was  prin- 
cipally at  the  convexity.  The  source  of  the  blood  may  be  a  laceration  of 
one  of  the  sinuses  of  the  dura  mater  caused  by  the  overlapping  of  the 
parietal  bones.  This  was  found  in  one  of  the  cases  of  Hirst  (Phila- 
delphia). Much  more  frequently  the  blood  comes  from  one  of  the  cere- 
bral veins,  or  from  the  capillary  vessels  of  the  pia  mater.  In  thirty- 
seven  of  Bednar's  fifty-two  cases,  the  extravasation  was  beneath  the  pia 
mater.  In  the  remainder  it  was  between  the  pia  mater  and  the  dura — 
1.  e.,  in  the  arachnoid  cavity.  Haemorrhages  between  the  dura  and  the 
skull  may  be  said  never  to  occur  except  when  associated  Avith  fracture. 
If  the  child  is  still-born,  or  if  death  has  occurred  on  the  first  or  second 
day,  the  blood  is  partly  fluid  and  partly  coagulated  ;  later  it  is  entirely 
coagulated  and  may  have  undergone  partial  absorption.  The  amount  of 
extravasated  blood  varies  between  one  drachm  and  four  ounces,  the  aver- 
age amount  being  about  one  ounce.  The  blood  extends  into  the  fissures 
between  the  convolutions  and  sometimes  into  the  ventricles  along  the 
choroid  plexus,  although  this  is  rare.  In  large  haemorrhages  the  brain 
substance  is  softened  and  in  places  may  be  quite  disintegrated ;  but  with 
small  extravasations  these  changes  are  very  slight.  In  cases  which  survive 
for  two  or  three  weeks  there  is  usually  a  certain  amount  of  meningitis. 
The  later  changes — those  of  arrested  development  of  the  cortex  aud  cere- 
bral sclerosis — will  be  considered  in  the  chapter  devoted  to  Cerebral  Pa- 


PLATE  II. 


•■cr^!:*'?V 


Meningeal  Hemorrhage  in  the  Newly  Born. 

From  a  patient  in  the  Nursery  and  Child's  Hospital,  dying  on  the  sixth  day. 
Primary  respirations  poor;  child  very  dull  and  apathetic,  refused  to  nurse;  once  vom- 
ited blood  and  had  an  ecchymosis  of  the  right  conjunctiva.  On  the  last  day.  high 
temperature  (105'  F.)  and  general  convulsions.  Some  changed  blood  found  in  the 
stomach  and  intestines  at  the  autopsy ;  brain  greatly  congested,  and  at  the  base  was 
the  clot  shown  in  the  picture. 


CEREBRAL   PARALYSIS.  107 

ralyses  in  the  section  on  Diseases  of  the  Xervous  System.  Haemorrhages 
into  the  membranes  of  the  upper  part  of  the  cord  are  found  in  a  large 
proportion  of  the  fatal  cases.  Associated  haemorrhages  of  the  lungs  and 
other  organs  are  not  uncommon. 

Symptoms. — If  the  haemorrhage  is  large,  the  child  is  usually  still-born, 
although  its  movements  may  have  been  active  up  to  the  commencement  of 
labour.  When  the  haemorrhage  is  not  so  large  as  to  be  immediately  fatal, 
the  child  may  show  no  symptoms  except  dulness  or  torpor,  with  feeble 
or  irregular  respiration,  death  following  within  the  first  twenty-four 
hours.  A  large  proportion  of  the  cases  are  born  asphyxiated,  and  fre- 
quently they  are  resuscitated  only  after  considerable  effort.  They  nurse 
feebly,  often  with  great  difficulty.  Convulsions  are  common  in  cases 
which  last  for  four  or  five  days,  and  more  with  hsemorrhages  at  the  con- 
vexity than  with  those  at  the  base.  Opisthotonus  is  often  present,  also 
general  rigidity  of  the  extremities,  clenching  of  the  hands,  and  increased 
knee-jerks.  Earely  there  is  complete  relaxation  of  all  the  muscles.  Some- 
times there  are  automatic  movements.  The  respiration  is  usually  dis- 
turbed; in  most  cases  it  is  slow  and  irregular.  The  pulse  is  feeble  and 
slow.  The  pupils  are  more  frequently  contracted  than  dilated,  and  there 
may  be  oscillation  of  the  eyeballs.  In  large  hemorrhages  there  is  marked 
bulging  of  the  fontanel,  and  often  separation  of  the  sutures.  If  the  haem- 
orrhage covers  one  hemisphere,  there  is  complete  hemiplegia  of  the  oppo- 
site side.  Small  localized  cortical  hsemorrhages  may  cause  paralysis  of 
the  face,  arm,  or  leg,  according  to  the  position  of  the  lesion,  or  localized 
convulsions.  In  large  haemorrhages  at  the  base  convulsions  are  rare,  and 
death  occurs  early,  usually  in  the  first  two  days.  In  extensive  cortical 
hemorrhages  convulsions  and  rigidity  of  the  extremities  are  frequent, 
and  life  is  prolonged  indefinitely. 

The  majority  of  the  fatal  cases  die  within  the  first  four  days.  In 
those  lasting  a  longer  time  the  symptom  is  tonic  spasm  of  the  trunk,  or 
of  one  or  more  of  the  extremities,  with  localized  paralysis— monoplegia, 
diplegia,  or  hemiplegia,  according  to  the  lesion — and  localized  or  general 
convulsions  often  continuing  for  two  or  three  weeks  and  gradually  sub- 
siding. In  the  mildest  cases  nothing  abnormal  may  be  noticed  until  the 
child  is  old  enough  to  walk  or  talk.  In  those  more  severe  there  may  be 
gradual  and  continuous  improvement  of  the  early  symptoms,  and  the 
case  may  go  on  to  apparent  recovery,  but  usually  there  is  some  perma- 
nent damage  to  the  brain.  The  following  observation  of  McNutt  illus- 
trates the  course  and  termination  of  one  of  the  severe  cases  of  meningeal 
haemorrhage : 

Breech  presentation,  tedious  labour,  head  delivered  by  forceps,  almost 
continuous  convulsions  for  the  first  nine  days.  After  the  convulsions 
there  was  complete  paralysis  of  both  sides  of  the  body,  not  involving  the 
face.  The  child  never  walked  or  spoke ;  tlie  physical  development  was 
very  backward ;  the  limbs  became  contractured ;  death  occurred  at  two 


108  DISEASES  OF  THE  NEWLY  BOEK 

and  a  half  3'ears,  from  pneumonia.  The  autopsy  showed  atrophy  of  the 
brain  on  both  sides  about  the  fissure  of  Eolando. 

The  main  diagnostic  symptoms  in  recent  cases  are  stupor,  rigidity, 
increased  reflexes,  convulsions,  paralysis,  and  opisthotonus.  These  vary 
with  the  extent  and  situation  of  the  lesion.  The  minor  symptoms  are 
changes  in  the  pupils,  oscillation  of  the  eyes,  and  bulging  of  the  fonta- 
nels. 

Prognosis. — A  large  haemorrhage  at  the  base  quickly  causes  death; 
if  it  is  located  at  the  convexity,  although  the  child  may  survive,  there  is 
always  serious  damage  to  the  brain.  Even  from  small  hsemorrhages 
some  permanent  injury  usually  results,  though  the  extent  of  this  may 
not  be  evident  for  years. 

Treatment. — This  is  mainly  prophylactic,  the  chief  indication  being  to 
shorten  tedious  labours  by  the  early  use  of  thp  forceps.  In  a  large  num- 
ber of  cases  where  the  hsemorrhage  has  been  attributed  to  the  forceps,  the 
damage  has  rather  been  the  result  of  the  long-continued  pressure  before 
they  were  used.  Nothing  can  be  done  after  delivery  to  limit  the  amount 
of  the  haemorrhage,  except  to  keep  the  child  as  quiet  as  possible  and  to 
relieve  individual  symptoms  as  they  arise.  The  removal  of  the  clot  by 
surgical  operation,  so  far  as  I  am  aware,  has  not  yet  been  attempted. 
There  seems,  however,  to  be  no  reason  why  this  should  not  in  certain  cases 
be  done  with  good  prospects  of  success. 

FACIAL   PARALYSIS. 

The  usual  cause  of  facial  paralysis  is  the  use  of  the  forceps,  but  this 
does  not  explain  all  the  cases.  The  etiology  of  those  in  which  the  forceps 
have  not  been  used  is  still  somewhat  obscure.  In  peripheral  facial  palsy 
the  nerve  is  pressed  upon  either  near  its  exit  from  the  stylo-mastoid  fora- 
men, or  where  it  crosses  the  ramus  of  the  jaw,  at  which  point  the  parotid 
gland  gives  it  but  little  protection  in  the  newly  born.  If  the  lesion  is  in 
front  of  this  point,  any  one  of  the  terminal  branches  may  be  affected ; 
most  frequently  it  is  the  temporo-facial  branch.  As  only  one  blade  of  the 
forceps  commonly  touches  the  face  in  this  region,  the  paralysis  is,  as  a 
rule,  unilateral. 

Eoulland  has  reported  several  cases  not  due  to  the  forceps.  In  these 
the  pressure  is  believed  to  have  been  produced  by  the  promontory  of  the 
sacrum  at  the  superior  strait,  or  by  the  ischium  at  the  inferior  strait,  as 
paralysis  followed  when  the  head  was  long  arrested  at  one  of  these  points. 
It  was  not  seen  with  face  or  breech  presentations.  When  facial  paralysis 
is  of  central  origin  it  depends  generally  upon  a  meningeal  haemorrhage, 
and  the  arm  and  leg  of  the  same  side  as  the  face  are  involved.  It  is,  how- 
ever, possible  for  a  very  small  cortical  haemorrhage  to  produce  paralysis  of 
the  face  only.     This  occurred  in  a  case  reported  by  McNutt. 

In  repose,  the  only  symptom  noticed  may  be  that  the  eye  remains  open 
upon  the  affected  side,  owing  to  paralysis  of  the  orbicularis  palpebrarum. 


PARALYSIS   OF   THE   UPPER  EXTREMITY.  109 

When  the  muscles  are  called  into  action,  as  in  crying,  the  whole  side  of 
the  face  is  seen  to  be  affected.  The  paralyzed  side  is  smooth,  full,  and 
often  appears  to  be  somewhat  swollen.  The  mouth  is  drawn  to  the  side 
not  affected.  In  this  paralysis,  the  tongue,  of  course,  is  not  implicated.  It 
is  therefore  rare  that  nursing  is  seriously  interfered  with.*  If  the  pa- 
ralysis is  of  central  origin,  only  the  lower  half  of  the  face  is  involved, 
while  in  peri]3heral  paralysis,  as  the  trunk  of  the  nerve  is  injured,  the 
upper  half  of  the  face,  including  the  orbicularis  jDalpebrarum,  is  also 
affected. 

The  paralysis  is  generally  noticed  on  the  first  or  second  day  of  life, 
and  does  not  increase  in  severity.  Its  course  and  termination  depend 
upon  the  extent  of  the  injury  done  to  the  nerve.  Some  idea  of  this  may 
often  be  gained  by  the  amount  of  injury  to  the  soft  parts,  although  this 
is  not  an  infallible  guide.  In  cases  not  due  to  the  forceps,  the  paralysis  is 
slight  and  disappears  in  a  few  days ;  the  great  majority  of  the  forceps 
cases  follow  the  same  favourable  course,  the  paralysis  gradually  disappear- 
ing without  treatment  in  about  two  weeks.  In  more  serious  cases  it  may 
last  for  months,  or  it  may  even  be  permanent.  The  reaction  of  degenera- 
tion is  present  in  these  severe  cases,  and  there  may  even  be  perceptible 
atrophy  of  the  muscles.     This  symptom  is  fortunately  extremely  rare. 

Treatment. — Nothing  should  be  done  for  the  first  ten  days  except  to 
protect  the  eye  and  keep  it  clean.  If  improvement  has  begun  by  the  end 
of  this  time,  the  probabilities  are  that  the  case  will  require  no  treatment. 
If  no  improvement  has  taken  place  by  the  end  of  the  third  or  fourth  week, 
electricity  should  be  used  regularly  and  systematically.  If  the  muscles 
respond  to  it,  the  faradic  current  may  be  employed  ;  if  not,  galvanism 
should  be  used.  The  electrical  treatment  should  be  continued  for  several 
months,  or  until  recovery  has  taken  place. 

PARALYSIS  OF  THE  UPPER  EXTREMITY. 

"When  this  is  due  to  a  peripheral  lesion  it  probably  never  involves  the 
entire  arm,  but  affects  only  certain  muscles  or  groups  of  muscles.  Al- 
though commonly  occurring  after  an  artificial  delivery,  it  may  be  seen  in 
cases  where  the  labour  has  terminated  naturally.  Roulland  f  has  reported 
a  case  in  Avhich  deltoid  paralysis,  occurring  in  a  large  child,  was  attributed 
to  pressure  upon  the  shoulder  during  labour.  In  vertex  presentations, 
paralysis  is  most  frequently  due  to  the  forceps  where  one  of  the  blades 
has  extended  down  upon  the  neck,  injuring  the  lower  cervical  nerves.  It 
may  be  produced  by  traction  with  the  finger  in  the  axilla.  Roulland 
reports  a  unique  case  of  paralysis  of  both  extremities,  apparently  due  to 


*  In  this  connection  it  is  to  be  remembered  that  the  princi[iiil  piirt  in  nursing  is 
done  by  the  tongue,  and  not  by  the  lips, 
f  Paralysies  des  nouveau-nes,  Paris,  1887. 
8 


110 


DISEASES  OF  THE  NEWLY  BORN. 


the  cord  being  very  tightly  wound  around  the  neck.  The  great  propor- 
tion of  all  cases  of  paralysis  of  the  upper  extremity  follow  extraction  in 
breech  presentations.  The  injury  is  usually  inflicted  by  traction  upon  the 
shoulder  in  the  delivery  of  the  head,  or  in  bringing  down  the  arms  when 
they  are  above  the  head.  In  the  latter  case  the  paralysis  may  be  double 
and  associated  with  fracture  of  the  clavicle  or  humerus.  In  shoulder 
presentations,  paralysis  may  be  produced  by  traction  upon  the  arm  itself. 

The  most  common  form  of  peripheral  paralysis  is  that  known  as  the 
"upper-arm  type,"  or  Erb's  paralysis,  in  which  the  injury  is  inflicted  at 
the  anterior  border  of  the  trapezius  muscle  at  the  lower  part  of  the  neck,. 

usually  in   such  a   position 
.-  ■  as  to  affect   the   fifth  and 

,     "  sixth  cervical  nerves.     The 

muscles  paralyzed  are  the- 
deltoid,  biceps,  brachialis  an- 
ticus,  supinator  longus,  and 
sometimes  the  supra-  and  in- 
fra-spinatus.  All  these  mus- 
cles may  be  involved,  or  only 
part  of  them,  and  in  varying^ 
degrees.  In  case  the  injury 
is  slight,  the  paralysis  may 
not  be  noticed  for  some 
weeks.  If  severe,  it  is  evi- 
dent in  the  first  few  days. 
The  arm  hangs  lifeless  by 
the  side ;  it  is  rotated  in- 
ward, the  forearm  pronated,, 
the  palm  looking  outward 
(Fig.  20).  The  forearm  and 
hand  are  not  affected.  In 
severe  cases  there  may  be- 
anaesthesia  of  the  outer  surface  of  the  arm,  in  the  region  supplied  by 
the  circumflex  and  external  cutaneous  nerves.  This  is  rarely  marked,, 
and  in  its  slighter  degrees  it  is  very  difficult  to  determine.  It  is  char- 
acteristic of  this  paralysis  that  the  triceps  is  not  affected,  so  that  power- 
to  extend  the  forearm  remains,  although  it  cannot  be  flexed.  Atrophy 
of  the  paralyzed  muscles  occurs  after  a  few  weeks,  but  the  muscles  are 
so  small  and  so  covered  with  fat  that  it  is  rarely  noticeable  before 
the  second  year.  It  is  most  conspicuous  in  the  deltoid.  In  all  severe 
cases  the  reaction  of  degeneration  is  present.  In  some  of  the  cases  of 
long  standing  there  occurs  a  shortening  of  the  tendon  of  the  siibscapu- 
laris  muscle,  often  associated  with  subluxation  of  the  humerus.  The 
paralysis  may  be  complicated  with  fracture  of  the  clavicle,  the  neck  of 


¥iQ.  20. — Erb's  paralysis,  infant  two  months  old. 


TUMOURS  OP   THE   UMBILICUS.  HI 

tlie  scapula,  or  the  shaft  of  the  humerus,  or  with  epiphyseal  separation  of 
its  head. 

The  jtJro^wosis  depends  upon  the  severity  of  the  injury  and  also  upon 
the  time  when  treatment  is  begun.  The  great  majority  of  cases  recover 
spontaneously  in  two  or  three  months,  improvement  being  observed  within 
a  few  weeks,  first  in  the  biceps  and  last  in  the  deltoid.  Spontaneous  re- 
covery is  not  to  be  looked  for  unless  it  occurs  within  the  first  three 
months.  Not  infrequently  some  degree  of  paralysis  persists  until  the 
third  or  fourth  year,  and  in  some  of  the  muscles,  usually  the  deltoid,  it 
may  even  be  permanent.  If  the  muscles  respond  to  faradism,  rapid  im- 
provement can  generally  be  prophesied.  If  the  reaction  of  degeneration 
is  present,  improvement  will  be  slow  and  the  paralysis  may  be  permanent. 

The  diagnosis  is  usually  not  difficult,  since  the  great  majority  of  cases 
are  of  the  "  upper-arm  type  "  with  classical  symptoms.  Peripheral  palsy 
of  the  arm  can  scarcely  be  confounded  with  that  of  cerebral  origin.  If 
the  lesion  is  central  it  is  one  of  the  rarest  occurrences  for  the  arm  alone  to 
be  involved ;  either  the  leg  or  face,  or  both,  are  generally  likewise  affected. 
If  the  case  does  not  come  under  observation  until  the  child  is  a  year  old, 
it  may  be  difficult,  or  without  a  good  history,  it  may  be  impossible  to  dis- 
tinguish peripheral  paralysis  from  that  due  to  polio-myelitis.  The  peculiar 
group  of  muscles  involved  in  Erb's  paralysis  is  the  only  diagnostic  point. 

In  recent  cases  the  disability  resulting  from  the  tenderness  or  pain  of 
.syphilitic  epiphysitis  may  simulate  paralysis,  but  there  is  lacking  the 
characteristic  position  of  the  arm,  and  a  careful  examination  discloses  the 
fact  that  the  paralysis  is  only  apparent.  This  may  affect  both  sides. 
Fracture  of  the  clavicle  or  epiphyseal  separation  of  the  head  of  the  hu- 
merus may  also  be  mistaken  for  paralysis.  In  cases  of  long  standing, 
paralysis  of  the  deltoid  may  resemble  dislocation  of  the  humerus.  The 
reaction  of  degeneration  differentiates  paralysis  from  surgical  injuries 
with  similar  deformities. 

The  treatment  consists  in  the  use  of  electricity,  which  should  be  begun 
at  the  end  of  the  first  montli  at  the  latest,  and  used  regularly.  If  the  mus- 
cles respond  to  faradism  this  may  be  employed,  but  in  most  severe  cases 
they  do  not,  and  galvanism  must  be  used,  according  to  the  rules  laid  down 
for  facial  paralysis. 


CHAPTER  VII. 

TUMOURS  OF  THE   UMBILICUS. 

Qranuloma. — This  is  nothing  more  than  a  mass  of  exuberant  granula- 
tions at  the  umbilical  stump.  The  mass  is  generally  about  the  size  of  a 
pea — sometimes  larger — bleeds  readily,  and  has  a  thin,  purulent  discharge. 


112 


DISEASES   OF   THE  NEWLY  BORN. 


It  is  promptly  cured  by  the  application  of  any  simple  astringent;  pow- 
dered alum  is  probably  the  best.  In  case  this  is  not  successful,  the  granu- 
lations may  be  touched  with  nitrate  of  silver  or  snipped  off  with  scissors. 

Adenoma,  Mucous  Polypus,  or  Diverticulum  Tumour — Umbilical  Fis- 
tula.— The  first  three  terms  are  used  synonymously  to  describe  an  um- 
bilical tumour  covered  with  a  mucous  membrane  which  is  similar  in 
structure  to  that  of  the  small  intestine.  It  is  usually  associated  with  an 
umbilical  fistula.  This  tumour  is  formed  by  a  prolapse  at  the  navel  of  the 
mucous  membrane  of  ^Meckel's  diverticulum.  This  diverticulum  is  the 
remains  of  the  omphalo-mesenteric  duct.  When  it  is  present  in  infants, 
it  is  found  in  various  stages  of  development.     Most  frequently  there  is  a 


Fig.  21. — Umbilical  fistula  and  tumours  produced  by  prolapse  of  Meckel's  diverticulum.  (Barth.) 


blind  pouch  a  few  inches  long  given  off  from  the  lower  part  of  the  ileum. 
In  other  cases  it  may  remain  patent  quite  to  the  umbilicus,  causing  a 
f&ecal  fistula  (Fig.  21,  A).  As  the  intestine  below  it  is  generally  normal, 
this  fistula  may  persist  for  months  or  even  years,  giving  rise  to  no  symp- 
toms except  a  slight  feecal  discharge  from  the  umbilicus.  In  certain  cases 
intestinal  w^orms  have  been  discharged  through  it.  It  may  close  sponta- 
neously or  be  closed  by  operation. 

A  prolapse  of  the  mucous  membrane  lining  the  diverticulum  produces 
an  umbilical  tumour  with  a  fistula  at  its  summit  (Fig.  21,  B).  This  is  the 
most  common  form.  A  cross-section  shows  under  the  microscope  the 
structure  of  the  intestinal  mucous  membrane  both  as  an  external  covering 
and  lining  of  the  fistulous  tract.  The  prolapse  may  involve  not  only  the 
mucous  membrane  but  the  entire  intestinal  wall.  There  then  exists  a 
conical  tumour  with  a  fistula  which  has  but  one  external  opening,  but  at 
a  short  distance  from  the  surface  it  bifurcates,  one  branch  leading  upward 
and  one  downward  (Fig.  21,  C).  A  continuation  of  the  prolapse  gives  a 
broad  pedunculated  tumour  (Fig.  21,  D),  which  may  reach  the  size  of  a 
man's  fist.  Its  covering  is  the  same  as  in  the  other  forms.  It  may  con- 
tain several  coils  of  intestine.  In  this  form  there  are  usually  two  fistulous 
openings  (a,  h)  which  communicate  with  the  intestine. 

In  all  of  these  cases  the  tumour  is  smooth,  irreducible,  of  a  rosy  pink 


UMBILICAL  HERNIA.  113 

colour,  and  from  its  surface  there  oozes  a  mucous  discharge.  Microscop- 
ical examination  shows  the  external  covering  to  be  the  same  in  structure 
as  the  intestinal  mucous  membrane.  These  tumours  are  generally  small, 
varying  in  size  from  a  pea  to  a  small  cherry,  but  they  may  be  very  much 
larger.  A  faecal  fistula  usually,  but  not  invariably,  coexists.  In  the  con- 
dition represented  in  Fig.  21,  B,  it  is  easy  to  see  how  an  obliteration  of  the 
fistula  may  occur.  The  small  tumours  are  readily  cured  by  the  ligature. 
The  larger  ones  are  usually  associated  with  other  serious  malformations 
of  the  intestines,  which  make  the  outlook  bad  in  almost  every  instance. 

UMBILICAL  HERNIA. 

Hernia  into  the  umbilical  cord  is  a  rare  congenital  condition  of  a 
most  serious  nature.  It  is  due  to  some  fcetal  defect,  and  varies  in  size 
from  a  small  protrusion  to  complete  eventration  in  which  nearly  all  the 
abdominal  organs  are  outside  the  body.  There  is  no  hernial  sac.  The 
prognosis  is  very  bad. 

The  common  umbilical  hernia  is  quite  a  different  condition,  and 
while  a  source  of  much  annoyance  it  is  rarely  serious.  It  is  much  more 
common  in  females  than  in  males,  and  occurs  especially  in  those  who  are 
poorly  nourished  and  rachitic.  The  tumour  is  usually  from  one-fourth  to 
one-half  an  inch  in  diameter;  it  may,  however,  be  very  large,  and  may 
even  become  strangulated,  when  a  surgical  operation  may  become  neces- 
sary. The  ordinary  cases,  however,  require  only  mechanical  treatment. 
The  most  important  thing  is  prevention.  For  this  purpose  it  is  neces- 
sary, after  the  cord  has  separated,  to  place  a  firm  pad  over  the  navel,  and 
to  use  a  snug  abdominal  band  for  the  first  two  or  three  months.  After 
this  period  it  is  uncommon  for  hernia  to  develop.  In  cases  coming  under 
observation  after  the  third  or  fourth  month,  the  pad  and  abdominal 
bandage  are  inadequate,  and  other  means  must  be  employed  to  retain 
the  hernia.  The  best  of  these  consists  in  the  use  of  two  adhesive  strips 
applied  obliquely  over  the  abdomen,  crossing  at  the  umbilicus,  the  skin 
along  the  median  line  being  folded  inward  so  as  to  overlap  the  tumour. 
this  forming  the  retention  pad.  A  simple  method  of  retention  is  to  place 
over  the  tumour  a  coin  or  button  covered  with  kid  and  hold  it  in  position 
by  a  strip  of  adhesive  plaster  ten  or  twelve  inches  long.  If  the  skin  is 
made  absolutely  clean  and  zinc-oxide  plaster  used,  excoriations  are  rare. 
The  dressing  should  be  changed  every  few  days  and  worn  for  several 
months.  After  the  first  year  all  mechanical  treatment  is  unsatisfactory. 
For  the  very  small  tumours  it  is  really  unnecessary  to  use  any  form  of 
apparatus,  since  these  cases  ordinarily  show  little  or  no  tendency  to  in- 
crease in  size,  and  the  retention  apparatus  causes  more  annoyance  than 
the  hernia.  These  small  hernijB  seem  to  disappear  spontaneously  during 
childhood,  as  they  certainly  are  not  often  seen  in  children  over  seven 
years  of  age. 


114  DISEASES   OF   THE   NEWLY  BORX. 


MASTITIS. 

According  to  Guillot,  a  certain  amount  of  secretion  in  the  breasts  of 
the  newly  horn  is  physiological.  It  is  certainly  very  common.  It  is  most 
abundant  between  the  eighth  and  fifteenth  days,  but  may  continue  in 
small  quantities  as  late  as  the  third  month.  It  is  seen  with  equal  fre- 
quency in  both  sexes.  The  quantity  of  the  secretion  amounts  in  most 
case's  only  to  a  few  drops ;  in  some,  however,  as  much  as  a  drachm  has 
been  obtained.  Chemical  analysis  has  shown  this  secretion  to  be  essen- 
tially the  same  as  the  adult  milk — containing  fat,  sugar,  proteids,  and 
salts.  In  gross  aj)pearance  it  resembles  colostrum.  The  researches  of 
Sinety  *  have  shown  that  the  mammary  gland  of  the  newly  born  contains 
cul-de-sacs  lined  with  secreting  cells,  resembling  those  of  the  adult.  Dur- 
ing the  period  of  secretion  the  gland  is  slightly  reddened,  its  vessels  turgid, 
and  all  the  signs  of  functional  activity  are  present.  This  condition  in  it- 
self is  of  no  practical  importance,  and  in  most  cases,  if  left  alone,  the 
secretion  ceases  sjoontaneously  after  a  week  or  ten  days.  If  abundant,  it 
can  usually  be  dried  up  by  painting  the  gland  with  tincture  of  belladonna. 
It  sometimes  happens,  however,  that  the  presence  of  this  secretion  tempts 
the  nurse  or  attendant  to  rub  or  squeeze  the  breast.  Such  manipulation 
occasionally  leads  to  serious  results  by  exciting  a  mastitis  which  may  ter- 
minate in  abscess.  Mastitis  is  not  a  very  rare  condition,  and  although 
the  inflammation  is  not  usually  severe,  it  may  be  serious  and  even  fatal. 
The  predisposing  cause  is  the  congestion  which  accompanies  functional 
activity,  usually  in  the  second  week.  The  exciting  cause  is  most  often 
some  form  of  traumatism — undue  pressure,  the  squeezing  of  the  breasts, 
or  rough  handling  by  the  nurse.  Through  abrasions  or  fissures  thus  pro- 
duced, micro-organisms  find  a  ready  entrance  with  the  same  result  as  in 
the  adult.  It  seems  possible  that  the  germs  may  enter  through  the  lactif- 
erous ducts  without  any  abrasion  of  the  skin.  Want  of  cleanliness  is  al- 
ways a  favourable  condition  for  such  infection. 

The  symptoms  of  mastitis  usually  begin  during  the  second  week  of 
life.  There  are  redness,  swelling,  and  the  usual  signs  of  inflammation, 
which  may  terminate  in  resolution  or  in  suppuration.  The  process  may 
be  limited  to  the  mammary  region,  or  a  diffuse  phlegmonous  inflammation 
may  be  set  up,  as  in  a  case  reported  by  Bush,f  in  which  there  was  ex- 
tensive sloughing  of  the  tissues  of  the  whole  of  one  side  of  the  chest,  with 
a  fatal  result.  In  the  great  majority  of  cases  the  process  does  not  reach 
this  degree  of  intensity,  but  suppuration  with  the  formation  of  single  or 
multiple  abscesses  is  not  uncommon.  In  the  female  it  is  possible  for  the 
cicatrization  which  follows  such  an  inflammation  to  interfere  with  the  sub- 


*  Gazette  Medicale,  No.  17,  1885. 

t  New  York  Medical  Journal,  March,  1881. 


INTESTINAL   OBSTRUCTION.  115 

sequent  development  of  the  gland.  The  general  SA'mptoms  are  restlessness, 
loss  of  sleep,  disinclination  to  nurse,  and  loss  of  weight.  In  cases  of  diffuse 
phlegmonous  inflammation  the  general  symptoms  are  those  of  pyogenic 
infection.  Jourda*  has  collected  fifteen  cases  of  mammary  abscess,  twelve 
■of  which  recovered.  They  began  between  the  fourth  and  the  forty-second 
days.     In  eleven  cases,  only  one  side  was  involved  ;  in  four,  both  sides. 

Mastitis  is  usually  due  to  want  of  cleanliness  or  to  meddlesome  inter- 
ference ;  the  parts  should  therefore  be  kept  scrupulously  clean,  and  on  no 
-account  should  squeezing  of  the  breasts  be  permitted.  They  should  be  pro- 
tected by  a  simple  cotton  pad.  If  acute  inflammation  develops,  it  should  be 
treated  in  the  beginning  by  hot  applications.  Should  pus  form,  early  in- 
cision with  free  drainage  and  general  tonic  and  stimulant  treatment  are 

indicated. 

INTESTINAL  OBSTRUCTION. 

The  most  frequent  causes  of  intestinal  obstruction  in  the  newly  born 
are  malformations  of  the  intestine ;  rarely  it  may  be  due  to  pressure  from 
tumours,  or  from  a  persistent  omphalo-mesenteric  duct  or  artery.  The  vari- 
ous pathological  conditions  present  in  intestinal  malformations  are  consid- 
ered in  the  chapter  on  Diseases  of  the  Intestines.  The  most  common  seat 
of  obstruction  is  at  the  anus,  the  bowel  being  normally  formed  through- 
out, lacking  only  the  external  orifice.  The  next  most  frequent  condition 
is  obstruction  in  the  rectum,  which  may  be  due  either  to  a  membranous 
-septum  in  the  gut,  or  to  obliteration  of  the  tube  for  some  distance. 
These  rectal  obstructions  are  readily  recognised.  By  the  examining  finger 
or  a  bougie  the  lower  limit  of  the  obstruction  can  be  made  out,  but  there 
is  no  means  by  which  the  upper  limit  can  be  determined  except  by  open- 
ing the  abdomen.  When  the  obstruction  is  above  the  rectum,  localization 
is  more  difficult ;  but  the  most  frequent  seat  is  the  duodenum.  Of  38 
•cases  collected  by  Gaertner,  the  seat  of  obstruction  was  the  duodenum  in 
19  cases,  the  jejunum  in  3,  the  ileum  in  11,  the  colon  in  G,  the  ileum  and 
colon  in  1.     There  is  often  obstruction  at  more  than  one  point. 

The  symptoms  vary  with  the  seat  and  the  degree  of  the  obstruction. 
In  atresia  of  the  anus  or  rectum  there  is  at  first  simply  an  absence  of  all 
discharges  from  the  bowel.  Later  there  is  abdominal  distention  from 
dilatation  of  the  sigmoid  flexure  and  colon.  After  several  days  vomiting 
begins.  If  there  is  atresia  of  the  duodenum  or  any  part  of  the  small 
intestine,  vomiting  begins  early — usually  by  the  second  day  of  life — and  it 
is  persistent.  Nothing  is  passed  from  the  bowels  after  the  first  dark  dis- 
charge of  the  contents  of  the  colon,  which  is  chiefly  mucus.  There  is 
rapid  asthenia,  and  death  from  inanition  usually  occurs  in  four  or  five  da3's. 
The  higher  the  obstruction  the  shorter  the  duration  of  life.  If  the  con- 
dition is  one  of  stenosis  only,  the  symptoms  are  similar  to  those  described 

*  These,  Paris,  1889. 


IIQ  DISEASES  OP  THE   NEWLY  BORN. 

but  less  severe,  and  life  may  be  prolonged  for  several  weeks,  or  even 
months.  The  constipation  in  these  cases  is  not  absolute.  When  the 
cause  of  obstruction  is  external  pressure,  the  symptoms  do  not  always  be- 
gin immediately  after  birth.  I  have  recently  seen  a  child  in  whom  noth- 
ing abnormal  was  noticed  for  the  first  three  weeks,  but  at  the  end  of  that 
time  there  developed  all  the  signs  of  acute  intestinal  obstruction.  Lapa- 
rotomy revealed  a  loop  of  intestine  constricted  by  a  tiny  cord,  which  was 
probably  the  remains  of  the  omphalo-mesenteric  duct. 

Cases  of  imperforate  anus  and  membranous  septum  in  the  rectum  are 
readily  relieved  by  proper  surgical  treatment.  In  the  other  varieties  of 
obstruction,  whether  in  the  rectum,  in  the  colon,  or  in  the  small  intestine, 
although  life  may  be  prolonged  by  the  formation  of  an  artificial  anus,  the 
ultimate  result  is  almost  invariably  fatal,  death  usually  occurring  from 
marasmus  during  the  early  weeks  of  life. 

DIAPHRAGMATIC  HERNIA. 

This  is  due  to  a  congenital  deficiency  in  the  diaphragm,  which  is  usu- 
ally on  the  left  side.  Of  118  cases  collected  by  Livingston,  83  were 
on  the  left  side,  18  on  the  right,  4  were  central,  2  were  double,  in  1 
the  diaphragm  was  absent.  With  small  openings  only  a  single  coil 
of  intestine,  with  large  ones  a  considerable  part  of  the  abdominal  con- 
tents, may  be  found  in  the  thorax.  This  causes  displacement  of  the 
heart,  usually  to  the  right  side,  prevents  the  full  expansion  of  the  left 
lung,  and  if  the  deformity  occurs  early  in  intra-uterine  life  the  lung  may 
remain  rudimentary.  If  a  large  deficiency  exists,  infants  may  live  but 
a  few  hours ;  with  smaller  ones,  life  may  be  prolonged  indefinitely.  Book- 
er's *  patient  lived  two  and  a  half  months  with  nearly  all  the  small  intes- 
tine and  omentum  and  the  transverse  colon  in  the  thorax;  and  North- 
rup's  f  patient,  who  died  at  three  years  and  a  half  of  intercurrent  disease, 
had  several  coils  of  the  ileum,  the  caecum,  and  the  appendix  in  the  chest. 

The  symptoms  are  in  all  cases  obscure,  the  only  frequent  one  being 
dyspnoea,  sometimes  constant,  sometimes  in  severe  paroxysms  resembling 
asthma,  these  being  apparently  produced  by  an  accumulation  of  gas  in 
the  thoracic  part  of  the  intestine.  The  physical  signs  are  those  of  pneu- 
mothorax, generally  on  the  left  side,  with  displacement  of  the  heart  to 
the  right.     The  condition  is  not  amenable  to  treatment. 

SCLEREMA. 

Sclerema  is  a  condition  characterized  by  hardening  of  the  skin  and 
subcutaneous  tissues.  It  may  occur  in  circumscribed  areas  or  extend  over 
nearly  the  entire  body.  It  affects  infants  who  are  very  feeble  and  usually 
terminates  fatally.    Although  sclerema  is  chiefly  seen  in  the  first  days  of 


*  Archives  of  Paediatrics,  vol.  xiv,  p.  649.  f  Ibid.,  vol.  ix,  p.  130. 


SCLEREMA.  117 

life,  it  is  not  limited  to  the  newly  born,  but  may  occur  at  any  time  during 
the  first  few  months.  It  is  not  to  be  confounded  with  oedema  of  the 
newly  born,  with  which  condition  it  is,  however,  sometimes  associated. 
From  published  reports  it  appears  to  be  of  not  very  infrequent  occur- 
rence in  Europe,  chiefly  in  large  foundling  asylums.  In  America,  sclerema 
is  an  extremely  rare  disease.  In  a  discussion  in  the  American  Pediatric 
Society,  in  1889,  following  the  report  of  a  case  by  Northrup,  scarcely  a 
dozen  cases  could  be  recalled  by  the  members  present.  I  have  seen  but 
five  cases.  In  the  newly  born,  sclerema  affects  those  who  are  premature 
or  very  feeble,  sometimes  those  who  are  syphilitic.  Later  it  may  follow 
any  condition  leading  to  extreme  exhaustion,  especially  the  different  forms 
of  diarrhoeal  disease. 

The  first  thing  to  attract  attention  is  usually  the  induration  of  the 
skin.  It  is  often  seen  first  in  the  calves  or  the  dorsum  of  the  feet,  some- 
times first  in  the  cheeks,  but  soon  extends  over  the  greater  part  of  the 
body.  It  is  especially  marked  in  the  cheeks,  buttocks,  thighs  and  back, 
and  regions  where  adipose  tissue  is  abundant.  It  may  affect  the  body  uni- 
formly or  in  circumscribed  areas.  The  skin  may  be  smooth  or  it  may  ap- 
pear somewhat  lobulated.  The  colour  is  normal  or  slightly  bluish,  often 
tinged  with  yellow.  The  lips  are  blue,  and  the  capillary  circulation  so 
feeble  that  after  pressure  upon  the  nails  the  blood  returns  slowly  or  not 
at  all.  The  limbs  are  stiff  and  board-like.  The  skin  is  cold  to  the  touch, 
and  often  the  thermometer  in  the  axilla  will  not  rise  above  90°  F.  In 
cases  reported  by  Koger  and  Parrot,  an  axillary  temperature  of  71°  F.  was 
recorded.  The  general  feeling  of  the  body  has  been  well  likened  by 
Northrup  to  that  of  a  half-frozen  cadaver.  The  tongue  and  the  mucous 
membrane  of  the  mouth  are  cold  ;  no  radial  pulse  can  be  felt ;  the  respira- 
tion is  slow,  irregular,  embarrassed,  and  at  times  the  movements  of  the 
thorax  are  scarcely  perceptible.  The  cry  is  a  feeble  whine,  scarcely  au- 
dible. The  duration  of  the  disease  is  usually  from  three  to  four  days. 
Death  occurs  slowly  and  quietly.  If  recovery  takes  place  there  is  gradual 
improvement  in  the  circulation  and  nutrition,  and,  later,  a  disappearance 
of  the  areas  of  induration. 

The  causes  of  sclerema  are  general,  the  most  important  factors  being 
loss  of  fluids,  great  feebleness  with  lowering  of  the  body  temperature,  and, 
in  consequence,  hardening  of  the  subcutaneous  fat.  If  it  be  true,  as 
•stated  by  Langer,  that  the  fat  of  early  infancy  contains  more  palmitine 
and  stearine  than  that  of  adults,  it  is  easy  to  see  how  this  may  occur. 
There  are  no  essential  lesions  in  this  disease.  Atelectasis  is  often  pres- 
ent, and  may  have  something  more  than  an  accidental  association,  as 
incomplete  aeration  of  the  blood  is  no  doubt  a  factor  in  the  production 
of  the  symptoms.  In  Northrup's  case,  the  skin  after  being  injected  was 
studied  with  great  care  microscopically,  with  absolutely  negative  results. 
The  prognosis  is  very  bad,  because  of  the  grave  conditions  of  which  it 


118  DISEASES   OP   THE   NEWLY  BORX. 

is  the  expression,  but  it  is  not  invariably  fatal.  In  its  milder  forms, 
where  treatment  is  begun  early,  recovery  may  take  place.  The  diagnosis 
is  to  be  made  from  oedema  by  the  fact  that  there  is  no  pitting  upon  pres- 
sure, by  the  rigidity  of  the  body,  and  by  the  great  reduction  in  the  tem- 
perature. The  most  important  thing  in  treatment  is  artificial  heat ;  noth- 
ing but  the  incubator  is  efficient.  In  addition  to  this,  care  should  be  taken 
to  promote  the  general  nutrition  by  careful  feeding  and  by  all  other 
means  possible. 

CEDEMA. 

(Edema  has  often  been  confounded  with  sclerema,  but,  although  they 
may  sometimes  exist  together,  the  conditions  are  quite  distinct.  (Edema 
occurs  in  delicate  infants,  and  is  associated  with  a  feeble  heart,  especially 
of  the  right  side,  in  consequence  of  which  there  are  insufficient  aeration  of 
the  blood,  overfilling  of  the  veins,  and  often  a  lowering  of  the  body  tem- 
perature. It  also  depends  upon  poor  blood  states,  like  severe  anaemia,  and 
I  have  seen  it  occur  after  haemorrhages.     The  kidneys  are  unaffected. 

The  swelling  is  first  noticed  in  the  eyelids,  the  dorsum  of  the  feet,  the 
hands,  or  in  dependent  parts  of  the  body.  It  may  come  on  quite  sud- 
denly. In  severe  cases  there  may  be  general  anasarca,  but  dropsy  into  the 
serous  cavities  is  rare.  Sometimes  the  first  thing  observed  may  be  a  sud- 
den increase  in  weight  before  the  oedema  of  any  part  is  striking  enough 
to  be  noticed.  The  general  condition  is  feeble ;  the  surface  of  the  body 
cool ;  the  temperature  often  subnormal ;  the  cry  weak  ;  the  urine  often 
scanty,  but  rarely  albuminous.  The  diagnosis  of  oedema  is  quite  easy,  the 
parts  having  the  same  appearance  as  in  older  patients.  They  are  soft  and 
waxy-looking,  and  pit  upon  pressure.  "While  in  most  cases  the  prognosis 
is  unfavourable,  the  disease  is  not  necessarily  fatal,  since  some  even  of  the 
severe  cases  recover.  The  usual  duration  is  five  or  six  days  ;  but  there  are 
frequently  relapses. 

The  object  of  treatment  is  first  to  promote  the  general  nutrition  by  all 
available  means,  and  then  to  improve  the  circulation  by  the  administra- 
tion of  heart  stimulants,  particularly  digitalis  and  alcohol.  In  cases  of 
extensive  oedema,  alkaline  diuretics,  like  the  citrate  of  potash,  may  be 
combined  with  digitalis.  The  body-temperature  must  be  carefully  main- 
tained by  artificial  heat.  The  principal  complications  are  diseases  of  the 
lungs  and  of  the  intestines, 

INACTION  FEVER. 

The  term  inanition  fever  is  not  altogether  a  satisfactory  one  ;  but, 
until  these  cases  are  better  understood,  it  is  adopted  because  it  empha- 
sizes the  very  close  connection  which  exists  between  the  rise  of  tem- 
perature and  the  condition  of  inanition  or  starvation.  Under  this  head- 
ing are  included  cases  seen  during  the  first  five  days  of  life — generally 
from  the  second  to  the  fourth  dav — in  which  there  is  an  elevation  of  tern- 


INANITION  FEVER.  II9 

perature,  apparently  due  to  the  fact  that  the  infant  gets  very  little,  fre- 
quently nothing  at  all  from  the  breast  at  which  it  is  being  suckled.  It 
is  further  characteristic  of  these  cases  that  the  temperature  falls  when  the 
child  is  put  upon  a  full  breast,  or  when  artificial  feeding  is  begun,  or  even 
when  water  is  administered,  if  freely  given.  Some  have  ascribed  the 
symptoms  to  uric-acid  infarction  of  the  kidneys. 

So  far  as  my  knowledge  goes,  the  first  to  call  attention  to  this  condi- 
tion was  McLane  (New  York),  who  in  1890  reported  to  one  of  the  med- 
ical societies  an  extraordinary  .case  of  hyperpyrexia  in  a  newly-born  child. 
The  infant  was  found  on  the  sixth  day  with  a  temperature  of  106°  P., 
near  which  point  it  had  remained  for  three  days.  The  child  was  being 
suckled  at  a  breast  which  was  found  to  be  absolutely  dry.  A  wet-nurse 
was  procured,  the  temperature  fell  to  normal  in  a  few  hours,  and  the  child, 
which  when  first  seen  was  apparently  in  a  hopeless  condition,  was  soon 
perfectly  well. 

Since  that  time  very  extensive  observations,  extending  to  upward  of 
three  thousand  cases,  have  been  made  at  the  Sloaue  Maternity  and  Nurs- 
ery and  Child's  Hospitals,  which  have  established  the  fact  that  a  rise  of 
temperature  to  102°  or  even  104°  F,  is  quite  common  in  newly-born  in- 
fants during  the  first  few  days.  This  fever  is  accompanied  by  no  evi- 
dences of  local  disease,  and  ceases  in  nursing  infants  with  the  establish- 
ment of  the  free  secretion  of  milk.  The  fall  in  temperature  is  often 
rapid,  dropping  to  the  normal  in  a  few  hours  after  having  continued  for 
three  or  four  days,  and  in  a  large  number  of  cases  it  does  not  rise  again. 
The  following  case  is  a  fairly  typical  one  of  the  more  severe  form : 
The  patient  was  the  second  child,  the  first  having  died  at  the  age  of 
ten  days,  from  no  disease  it  was  said,  but  simply  from  exhaustion.  At 
birth  the  infant,  a  boy,  weighed  eight  and  a  quarter  pounds  and  was 
apparently  vigorous.  During  the  first  forty-eight  hours  his  loss  in  weight 
was  five  and  a  half  ounces  and  his  condition  good.  I  saw  him  on  the 
evening  of  the  third  day.  In  the  preceding  twenty-four  hours  he  had  lost 
eight  ounces  in  weight,  and  the  temperature  had  gradually  risen,  until 
at  the  time  of  my  visit  it  was  102-8°  F.  The  body  was  limp,  the  child 
making  no  resistance  to  examination.  He  cried  with  a  feeble  whine ; 
the  restlessness  of  the  early  part  of  the  day  having  given  place  to  complete 
apathy.  The  lips  and  skin  were  very  dry,  the  fontanel  sunken,  the  pulse 
weak.  As  the  father,  a  physician,  expressed  it,  "  he  had  been  wilting 
through  the  day  like  a  flower  in  the  sun."  Although  put  to  the  breast 
regularly,  the  child  had  apparently  got  very  little.  It  was,  in  fact,  impos- 
sible to  squeeze  any  milk  from  the  mother's  breasts.  Water  was  freely 
given  and  a  wet-nurse  secured  in  a  few  hours.  The  first  milk  was  taken 
from  the  wet-nurse  at  11  p.  m.,  and  the  temperature,  which  fell  gradually 
during  the  night,  was  normal  the  next  morning  and  did  not  rise  again. 
(See  chart,  Fig.  22).     During  the  succeeding  four  days  the  child  gained 


120 


DISEASES  OF   THE  NEWLY  BORN. 


104° 


103' 


eighteen  ounces  in  weight,  and  at  the  end  of  a  week  was  as  well  as  an- 
average  infant  "of  his  age. 

The  symptoms  are  so  uniform  and  so  characteristic  that  they  make 
for  these  cases  of  fever  a  class  by  themselves.  The  frequency  with  which 
this  is  seen  is  shown  by  the  following  statistics  :  Among  200  infants  taken 
successively  at  the  Nursery  and  Child's  Hospital,  20  had  fever  during  the 
first  five  days,  reaching  101°  F.  or  over,  which  was  not  explained  by 
ordinary  causes  and  followed  the  course  above  described.  In  500  suc- 
cessive children  born  at  the  Sloane  Maternity  Hospital,  there  were  135 
with  a  similar  fever.     It  was  seen  in  vigorous  infants  as  well  as  in  those 

who  were  delicate.  The  usual 
duration  of  the  fever  was  three 
days,  the  temperature  generally 
touching  the  highest  point  upon, 
the  third  or  fourth  day  of  life> 
In  about  two  thirds  of  the  cases 
the  temperature  did  not  rise  above- 
102°  F. ;  in  9  it  was  104°  F.  or 
over,  the  highest  recorded  being 
106°  F.  The  fall  was  generally 
quite  abrupt,  although  not  always. 
so.  Daily  weighings,  which  were 
made  in  these  cases,  showed  that 
the  infants  continued  to  lose 
weight  while  the  fever  continued, 
and  that  the  loss  almost  invariably" 
exceeded  by  several  ounces  that  of 
the  children  who  had  no  fever. 
(See  p.  16.)  The  maximum  loss 
noted  was  twenty-eight  ounces.  In  quite  a  large  number  of  cases  it  ex- 
ceeded twenty  ounces.  As  a  rule  the  infants  began  to  gain  in  weight  when 
the  temperature  remained  at  the  normal  point,  but  not  until  then. 

The  symptoms  presented  by  these  infants  were  a  hot,  dry  skin,  marked 
restlessness,  dry  lips,  and  a  disposition  to  suck  vigorously  anything  within 
reach.  With  very  high  temperature  there  were  considerable  prostration- 
and  weakened  pulse.  In  the  less  severe  cases  there  were  only  crying  and 
restlessness.  The  rapidity  with  which  the  symptoms  disappeared  when 
the  children  were  wet-nursed  or  properly  fed,  was  very  striking. 

It  is  important  that  this  fever  should  be  recognised,  because  it  gives  at 
times  the  first  warning  of  a  condition  which  may  prove  fatal.  The  extra- 
loss  of  ten  or  fifteen  ounces  in  the  first  week,  is  a  serious  handicap  to 
newly-born  infants,  the  effect  of  which  may  last  for  several  weeks.  The 
temperature  of  every  child  should  be  taken  during  the  first  week.  All  the 
usual  local  causes  of  fever  are  first  to  be  excluded  by  a  physical  examina- 


2  3  4  5     I     C  7  8 

iliiiBi: 


99° 


Fio.  22. — Temperature  chart.     Inanition  fever. 


INANITION   FEVER.  121 

tion.  This  fever  can  hardly  be  confounded  with  that  due  to  pyogenic 
infection,  whicli  rarely  begins  before  the  fifth  or  sixth  day. 

The  treatment  is  simple — viz.,  to  give  water  regularly  every  two  hours, 
in  quantities  up  to  an  ounce  at  a  time  if  required  by  the  thirst  of  the 
child.  This  should  be  done  in  every  case  where  the  temperature  reaches 
101°  F.  When  the  temperature  does  not  at  once  begin  to  fall,  the  infant 
should  be  put  upon  another  breast  or  artificial  feeding  should  be  begun. 
Examination  of  the  breasts  from  which  the  child  has  been  nursing  will 
usually  reveal  the  fact  that  the  secretion  of  milk  is  very  scanty  and  often 
entirely  absent. 

Such  a  fever  I  have  occasionally  seen  in  older  infants,  usually  in  those 
who  are  nursing  dry  breasts  or  where  fluid  food  and  water  have  been  with- 
held because  of  some  gastric  disturbance.  It  yields  as  promptly  to  treat- 
ment as  does  the  same  condition  in  the  newly  born. 


SECTION  IL 
NUTRITION. 

CHAPTER   I. 

INTRODUCTORY. 

Nutrition  in  its  broadest  sense  is  the  most  important  branch  of 
pgediatrics.  At  no  time  of  life  does  prophylaxis  give  such  results  as  in 
infancy,  and  no  part  of  prophylaxis  is  worthy  of  more  attention  than  the 
conditions  of  nutrition.  This  study  is  the  first  duty  of  physicians  who 
practise  among  children.  The  importance  of  correct  ideas  regarding  it 
can  hardly  be  overestimated.  The  problem  is  not  simply  to  save  the 
child's  life  during  the  perilous  first  year,  but  to  adopt  those  means  which 
shall,  during  the  plastic  period  of  infancy,  tend  to  the  healthy  and  normal 
growth  of  the  child,  so  that  all  the  organs  of  the  body  shall  have  their 
normal  development  instead  of  impaired  structure  and  deranged  func- 
tion, the  effects  of  which  may  last  throughout  childhood  or  even  through- 
out life. 

The  question  whether  a  child  shall  be  strong  and  robust  or  a  weakling,, 
is  often  decided  by  its  food  during  the  first  three  months.  The  largest 
part  of  the  immense  mortality  of  the  first  year  is  traceable  directly  to  dis- 
orders of  nutrition.  The  child  must  be  fed  so  as  to  avoid  not  only  the 
immediate  dangers  of  acute  indigestion,  diarrhoea,  and  marasmus,  but  the 
more  remote  ones  of  chronic  indigestion,  rickets,  scurvy,  and  general  mal- 
nutrition with  all  its  varied  manifestations,  since  these  conditions  are  the 
most  important  predisposing  causes  of  acute  disease  in  infancy. 

One  of  the  difficulties  has  always  been  that  temporary  success  may 
mean  ultimate  failure.  If  the  injurious  effects  of  improper  feeding  were 
immediately  manifest,  there  would  be  very  much  less  of  it  than  exists  at 
the  present  time.  It  is  because  many  things  are  valuable  as  temporary 
foods,  which  when  used  permanently  are  injurious.  No  better  illustration 
is  seen  than  in  the  too  exclusive  use  of  carbohydrates,  like  most  of  the 
proprietary  foods.  Infants  so  fed  grow  very  fat,  and  for  the  time  appear 
to  be  properly  nourished.  The  absence  from  the  food  of  some  of  those 
elements  which  are  of  vital  importance  may  not  be  evident  for  months ; 
hence  the  mistakes  so  often  made  by  the  laity,  and  even  by  the  profession, 

122 


THE   FOOD   CONSTITUENTS— PROTEIDS.  123 

There  are  certain  plain  rules  regarding  the  requirements  of  the  growing 
organism  which  can  not  be  ignored  without  serious  consequences,  which 
will  sooner  or  later  be  evident.  Another  common  mistake  is  in  the  pro- 
longed use  of  predigested  foods.  These  are  sometimes  continued  until,  as 
in  a  case  under  my  observation,  a  healthy  child  at  two-and-a-half  years  was 
totally  unable  to  digest  the  casein  of  cow's  milk.  A  great  stumbling-block 
to  many  is  the  fact  that  there  are  some  infants  of  robust  constitution  who, 
in  good  surroundings,  have  thriven  exceptionally  well  in  spite  of  very  bad 
methods  of  feeding.  But  it  should  not  be  forgotten  that  there  are  a  very 
much  larger  number  of  perfectly  healthy  infants  whose  lives  are  sacrificed 
every  year,  both  directly  and  indirectly,  as  a  result  of  improper  feeding.  A 
method  of  feeding  is  to  be  judged  not  by  the  few  exceptional  cases  which 
may  do  well,  but  by  the  results  obtained  in  the  majority  of  cases. 

Let  no  one  think  that  he  can  secure  the  best  results  in  infant-feeding 
without  devoting  both  time  and  study  to  the  problem.  Close  attention 
to  details  is  indispensable  to  success  in  this  as  in  all  branches  of  medicine ; 
but  in  none  are  more  satisfactory  results  obtained. 

THE   FOOD   CONSTITUENTS  AND   THE   PURPOSES  THEY  SUBSERVE  IN" 

NUTRITION. 

In  infancy  and  childhood,  as  in  adult  life,  the  elements  of  the  food 
are  five  in  number :  proteids,  fat,  carbohydrates,  mineral  salts,  and  water. 
The  form  in  which  they  must  be  furnished  to  the  child,  and  the  relative 
quantities  in  which  they  are  demanded,  are  different  from  those  required 
by  the  adult.  One  of  the  reasons  for  this  difference  is  the  delicate  condi- 
tion of  the  organs  of  digestion  in  infancy,  and  the  inability  to  assimilate 
certain  forms  of  food.  Another  reason  is  that  provision  must  be  made 
not  only  for  the  natural  waste  of  the  body,  but  for  its  rapid  growth,  nearly 
trebling  in  size,  as  it  does,  during  the  first  twelve  months. 

Proteids. — The  proteids  are  essential  to  life,  since  they  constitute  the 
only  kind  of  food  which  is  capable  of  replacing  the  continuous  nitroge- 
nous waste  of  the  cells  of  the  body,  upon  the  healthy  condition  of  which 
the  digestion  and  assimilation  of  the  other  elements  of  the  food  depend. 
Without  the  aid  either  of  the  fats  or  the  carbohydrates,  the  proteids  may 
sustain  life  and  may  even  prevent  a  loss  of  weight  for  a  time  ;  but  in  so 
doing  a  great  excess  of  such  food  is  required,  as  twenty-two  parts  of  pro- 
teids can  do  the  work  of  only  ten  parts  of  fat.  Such  a  diet  taxes  severely 
the  digestive  organs  and  the  kidneys.  When,  however,  fat  and  carbohy- 
drates are  added  to  the  food,  only  one-half  or  one-third  as  much  proteids 
are  required  to  replace  the  nitrogenous  waste,  as  in  the  case  of  an  exclusive 
proteid  diet  (Munk). 

The  proteids  are  furnished  by  the  casein  and  the  other  albuminoids 
present  both  in  woman's  milk  and  cow's  milk,  in  the  white  of  egg,  muscle- 


124  NUTRITION. 

fibre,  gluten  of  wheat,  etc.  The  proteids  easiest  of  digestion  by  infants 
are  those  of  woman's  milk.  The  greatest  difficulty  in  artificial  feeding 
has  been  to  supply  other  proteids  which  can  take  their  place.  It  is  the 
difference  in  the  digestibility  of  the  proteids  that  causes  most  of  the 
trouble  in  the  substitution  of  cow's  milk  for  woman's  milk. 

The  average  amouut  of  proteids  furnished  in  a  good  sample  of  woman's 
milk  is  1-5  per  cent.  During  the  first  few  months,  infants  fed  upon  cow's 
milk  should  not  receive  a  larger  proportion  than  this,  and  on  account  of 
the  difference  in  the  digestibility  of  the  two,  the  proteids  of  cow's  milk 
must  at  first  be  reduced  below  this  point,  usually  to  1  per  cent,  and  in 
some  instances  to  0*5  per  cent.  Some  infants  fed  upon  milk  appear  to 
thrive  normally  for  a  considerable  period,  even  with  so  small  a  proportion 
of  proteids  as  0-5  per  cent,  provided  the  other  elements  of  the  food  are 
supplied  in  abundance.  But  all  children  fed  on  low  proteids  must  be  very 
closely  watched.  It  is  always  hazardous  to  keep  an  infant  long  upon  a 
food  which  is  low  both  in  proteids  and  fat. 

The  most  constant  symptom  following  insufficient  proteids  in  the 
food  is  anaemia.  Besides  this,  there  may  be  feeble  circulation,  loss  of 
strength,  flabbiness  of  the  tissues,  and  general  failure  of  nutrition.  Later 
there  may  follow  difficulty  in  the  digestion  of  other  elements  of  the  food. 
The  vegetable  proteids  can  not  permanently  take  the  place  of  the  animal 
proteids  in  the  food  of  young  infants. 

Fats. — As  has  already  been  hinted  on  the  previous  page,  the  uses  of 
fat  in  the  body  are  intimately  associated  with  those  of  the  proteids.  Fat 
possesses  the  important  property  of  saving  nitrogenous  waste,  so  that 
when  this  is  supplied  in  the  food  in  proper  proportions,  the  entire  energy 
•of  the  proteids  may  be  expended  upon  the  growth  and  nutrition  of  the 
cells  of  the  body  without  being  used  up  in  the  production  of  animal  heat. 
The  demands  made  upon  the  proteids  by  the  rapid  growth  of  the  body  in 
infancy,  make  it  desirable  that,  whenever  possible,  the  fats  should  do  the 
work  of  the  proteids. 

In  addition  to  their  use  as  a  source  of  animal  heat,  the  fats  add  to  the 
body-weight  by  storing  up.  fat  in  the  body.  They  are  needed  for  the 
growth  of  the  nerve  cells  and  fibres,  and  are  essential  to  the  proper  growth 
of  bone.  Exactly  what  the  part  is  which  the  fats  take  in  the  development 
of  the  osseous  system  is  not  altogether  understood,  but  it  is  probable  that 
their  effect  is  due  to  their  well-known  and  important  function  in  aiding 
the  absorption  from  the  intestines  of  inorganic  salts,  especially  the  earthy 
phosphates.  In  a  patient  upon  a  milk  diet,  when  the  fats  are  Avithheld  or 
greatly  reduced,  these  salts  appear  in  large  quantities  in  the  faeces.  More 
fat  is  supplied  in  the  food  of  the  nursing  infant  than  is  used  up  in  the 
body,  as  a  very  large  amount  is  normally  discharged  in  the  stools.  To 
this  is  due  the  soft  consistence  of  the  stools  of  the  nursing  infant.  Fats 
thus  seem  to  fill  the  role  of  a  natural  laxative ;  constipation  being  one  of 


CARBOHYDRATES.  125 

the  first  and  most  striking  symptoms  following  the  reduction  of  fat  in  the 
milk. 

The  proportion  of  fat  required  in  infancy,  is  therefore  very  much 
greater  than  at  any  other  period  of  life.  Probably  the  most  common  mis- 
take in  artificial  feeding  has  been  to  give  too  little  fat.  The  chief  reason 
for  the  failure  of  most  of  the  proprietary  infant-foods  is  that  they  are  too 
low  in  fat ;  but  an  excess  of  carbohydrates  can  not  supply  this  deficiency. 

Woman's  milk  of  a  good  quality  contains  from  3  to  5  per  cent  fat,  and 
this  may  be  taken  as  representing  the  needs  of  the  body  under  normal 
conditions.  Infants  who  are  fed  upon  cow's  milk  should  get,  on  the 
average,  3  per  cent  fat  for  the  first  few  months  and  4  per  cent  during  the 
latter  part  of  the  first  year.  Infants  who  are  fed  for  a  long  time  upon  a 
food  low  in  fat  are  very  prone  to  develop  rickets.  Clinical  experience 
also  teaches  that  if  the  food  at  the  same  time  is  low  in  proteids  this  result 
follows  much  more  readil}'.  As  such  a  diet  is  in  most  cases  excessive  in 
carbohydrates,  children  so  fed  are  apt  to  be  very  fat,  but  usually  anasmic. 
The  importance  of  fats  in  nutrition  does  not  end  with  the  first  year; 
they  should  be  supplied  liberally  throughout  childhood  in  the  form  of 
cream,  eggs,  butter,  and  cod-liver  oil. 

Carbohydrates. — Although  these,  like  the  fats,  can  not  replace  the 
nitrogenous  waste  of  the  body,  they  are  important  aids  to  the  proteids, 
and  in  this  respect  they  are  even  more  valuable  than  the  fats.  The  car- 
bohydrates are  partly  converted  into  fat,  and  may  thus  increase  the  body- 
weight.  They  are  capable  of  replacing  the  fat-waste  of  the  body.  They 
are  one  of  the  most  important  sources  of  animal  heat. 

Carbohydrates  are  the  most  abundant  of  the  solid  elements  of  the  food, 
although  they  form  a  smaller  percentage  of  the  entire  quantity  of  food  in 
infancy  than  in  adult  life.  The  form  in  which  carbohydrates  are  fur- 
nished to  the  infant,  and  in  fact  to  all  young  mammals,  is  milk-sugar. 
While  this  form  of  sugar  is  to  be  preferred,  it  is  by  no  means  so  essential 
that  it  be  given  as  that  the  fat  and  proteids  of  the  food  should  be  those  of 
milk.  Other  forms  of  sugar  may  often  take  its  place  without  interfering 
with  nutrition.  Sometimes,  when  there  is  difficulty  in  the  digestion  of 
milk-sugar,  a  temporary  change  to  cane-sugar  or  to  maltose  may  even  be 
advantageous.  The  carbohydrates  required  by  young  infants  can  not,  ex- 
cept to  a  very  small  extent,  be  supplied  in  the  form  of  starch,  owing  to 
the  feeble  diastatic  power  of  the  digestive  fluids  during  the  early  months, 
and  in  fact  during  the  greater  part  of  the  first  year.  As  a  rule,  there  is 
less  difficulty  in  the  digestion  of  the  carbohydrates  in  the  form  of  sugar 
than  of  any  other  part  of  the  food.  A  diet  consisting  too  exclusively  of 
carbohydrates  leads  often  to  a  rapid  increase  in  weight,  but  it  is  not  ac- 
companied by  a  proportionate  increase  in  strength.  Such  infants  have 
but  little  resistance,  and  many  of  them  become  rachitic.  The  easy  diges- 
tion of  a  food  consisting  chiefly  of  soluble  carbohydrates,  and  the  rapidity 
10 


126  NUTRITION. 

with  which  children  so  fed  gain  in  weight,  lead  to  a  great  misapprehen- 
sion in  regard  to  their  value  as  foods.  The  ultimate  results  of  such  one- 
sided feeding,  if  long  continued,  are  almost  invariably  disastrous. 

In  building  up  the  cells  of  the  body  the  proteids  are  first  in  impor- 
tance, the  carbohydrates  second,  and  the  fats  third.  In  the  production  of 
animal  heat  the  fats  come  first,  the  carbohydrates  second ;  practically  the 
proteids  should  never  be  called  upon  for  this  purpose.  In  a  proper  diet, 
all  of  these  elements  are  represented. 

Mineral  Salts. — These  are  of  greater  importance  in  infancy  than  later 
in  life,  because  of  the  building  up  of  the  osseous  system  which  is  going  on 
with  such  rapidity  during  infancy  and  early  childhood.  The  most  im- 
portant for  this  purpose  are  the  phosphates  of  lime  and  magnesium. 
These  are  furnished  in  abundance  both  in  woman's  and  cow's  milk. 
These  salts  are  also  necessary  for  cell  growth.  Other  inorganic  salts  fur- 
nish the  elements  from  which  the  mineral  constituents  of  the  blood  and 
digestive  fluids  are  formed,  and  still  others  facilitate  absorption,  excretion, 
and  secretion. 

Water. — The  food  of  all  young  mammals  consists  of  from  eighty  to 
ninety  per  cent  of  water.  This  is  needed  for  the  solution  of  certain  parts 
of  the  food,  such  as  the  sugar  and  some  of  the  proteids,  and  for  the  sus- 
pension of  the  other  proteids  and  the  emulsified  fat.  All  the  food  is  thus 
dissolved  or  very  finely  divided  so  as  to  be  more  readily  acted  upon  by  the 
feeble  digestive  organs  of  the  infant.  Water  is  needed  also  in  large  quan- 
tities for  the  rapid  elimination  of  the  waste  of  the  body.  In  proportion 
to  its  weight,  an  average  infant  during  the  first  year  requires  a  little  more 
than  six  times  as  much  water  as  an  adult.  During  the  time  when  the 
child  is  upon  an  entirely  fluid  diet,  the  addition  of  water  other  than  that 
supplied  by  the  food  is  unnecessary ;  but  when  the  number  of  feedings 
becomes  less  frequent,  and  solid  food  is  given  in  larger  quantities,  water 
should  be  given  freely  between  the  feedings  at  all  seasons,  but  especially 
in  the  summer. 


CHAPTEE   II. 

THE  INFANT'S  DIETARY. 

WOMAN'S  MILK. 

Woman's  milk  is  the  ideal  infant-food.  A  thorough  knowledge  of 
its  character,  exact  composition,  and  variations  is  indispensable,  for  upon 
this  knowledge  are  based  all  our  rules  for  the  preparation  of  foods  used 
as  substitutes  for  woman's  milk  when  this  can  not  be  obtained. 


WOMAN'S   MILK. 


127 


Woman's  milk  is  a  secretion  of  the  mammary  glands  and  not  a  mere 
transudation  from  the  blood-vessels ;  although  under  abnormal  conditions 
it  ma}'  partake  more  of  the  character  of  a  transudation  than  a  secretion. 
A  few  drops  may  be  squeezed  from  the  breasts  before  parturition ;  gener- 
ally speaking,  however,  it  is  only  present  after  delivery.  During  the  first 
two  days  the  secretion  is  scanty.  Usually  upon  the  third  or  fourth  day  it 
becomes  well  established,  although  it  may  be  delayed  until  the  fifth  or 
sixth  day.  During  the  period  of  lactation,  milk  is  constantly  formed  in 
the  mammary  glands,  but  the  process  is  more  active  while  the  child  is  at 
the  breast. 

Physical  Characters. — Woman's  milk  is  of  a  bluish-white  colour  and 
quite  sweet  to  the  taste.  When  freshly  drawn  its  reaction  is  alkaline  or 
amphoteric,  but  under  healthy  conditions  never  acid.  The  specific 
gravity  varies  between  1,026  and  1,036,  the  average  being  1,031  at 
60°  F.  On  the  addition  of  acetic  acid  only  a  slight  coagulation  is  seen, 
this  being  in  the  form  of  small  flocculi,  and  never  in  large  masses  as  is  the 
case  in  cow's  milk.  Microscopically,  there  are  seen  great  numbers  of 
fat-globules  nearly  uniform  in  size  and  some  granular  matter.  Occasion- 
ally there  are  present  epithelial  cells  from  the  milk-ducts  or  from  the 
nipple. 

Colostrum. — The  secretion  of  the  first  three  or  four  days  differs  quite 
markedly  from  the  later  milk.  To  this  the  name  colostrum  has  been 
given.    It  is  of  a  deep  yellow  colour,  which  is  chiefly  due  to  the  colostrum- 


Fig.  23.— Colostrum.     (Funke.) 


Fig.  24. — Woman's  milk  at  a  late  period. 
(Funke.) 


corpuscles.  It  is  not  so  sweet  as  the  later  milk.  It  has  a  specific  gravity 
of  1,030  to  1,040,  a  strongly  alkaline  reaction,  and  is  coagulated  into  solid 
masses  by  heat,  and  sometimes  coagulates  spontaneously.  It  is  very  rich 
in  proteids  and  in  salts.  Microscopically  the  fat-globules  are  of  unequal 
size,  and  there  are  present  large  numbers  of  granular  bodies  known  as 
colostrum-corpuscles  (Fig.  23).    These  are  four  or  five  times  the  size  of 


128  NUTRITION. 

the  milk-globules  (Fig,  24),  and  they  are  probably  epithelial  cells  which 
have  undergone  fatty  degeneration. 

Composition  of  Colostrum* 

Proteids 5-71 

Fat 2-04 

Sugar 3-74 

Salts 0-28 

Water 88-23 

100-00 

The  colostrum-corpuscles  are  very  abundant  during  the  first  few  days, 
but  under  normal  conditions  they  are  not  found  after  the  tenth  or 
twelfth  day. 

Daily  Quantity. — Exact  information  upon  this  point  is  difficult  to 
obtain.  There  are  recorded,  however,  extended  observations  made  with 
great  care  upon  eight  cases,f  from  which  some  deductions  may  safely  be 
drawn.  All  were  healthy  infants,  nursing  exclusively  and  gaining  steadily 
in  weight. 

From  these  observations,  and  others  less  extended,  the  average  daily 

*  From  five  analyses  by  Pfeiffer  of  milk  obtained  during  the  first  three  days. 

f  Haehner's  cases  (Jahrb.  f.  Kinderh.,  xv,  23 ;  xxi,  314).  Case  I.  Female ;  birth- 
weight  7  pounds  14  ounces  (3,100  grammes).  First  week,  lost  1-J  ounce  (41  grammes); 
after  this  gained  steadily  during  the  twenty-three  weeks  of  observation ;  from  second 
to  ninth  week,  average  weekly  gain  8  ounces  (241  grammes) ;  from  tenth  to  eighteenth 
week,  average  gain  4i  ounces  (138  grammes) ;  from  nineteenth  to  twenty-third  week, 
average  gain  4  ounces  (130  grammes) ;  weight  at  the  end  of  twenty-third  week,  14|- 
pounds  (6,690  grammes). 

Case  II.  Male ;  birth-weight  6-J  pounds  (2,950  grammes).  Loss,  first  week,  3  ounces 
(80  grammes);  after  this  gained  steadily  during  the  eleven  weeks  of  observation  ;  from 
second  to  eleventh  week,  average  weekly  gain  7i  ounces  (214  grammes) ;  weight  at  end 
of  eleventh  week,  11  pounds  2  ounces  (5,045  grammes). 

Case  III.  Female;  birth-weight  3  pounds  9  ounces  (1,620  grammes).  Gain,  first 
week,  1^  ounce  (40  grammes) ;  during  the  succeeding  twenty-one  weeks  of  observation, 
average  weekly  gain  of  5  ounces  (141  grammes) ;  weight  at  the  end  of  twenty-second 
week,  10  pounds  3  ounces  (4,620  grammes). 

Laure's case  (These,  Paris,  1889).  Female;  birth-weight  8  pounds  13  ounces  (4,000 
grammes) ;  loss,  first  week,  8  ounces  (225  grammes) ;  after  this  gained  steadily  during 
the  nine  weeks  of  observation,  on  an  average  9^  ounces  (268  grammes)  weekly;  at  the 
end  of  ninth  week,  weight  13  pounds  3^  ounces  (6,000  grammes). 

Ahlfeld's  case  (Deutsch.  Ztschr.  f.  Prakt.  Med.,  1878).  Birth-weight  7  pounds  14 
ounces  (3,100  grammes).  Observations  continued  from  fourth  to  thirtieth  week.  Dur- 
ing first  ten  weeks,  average  weekly  gain  5|  ounces  (161  grammes);  from  eleventh  to 
twentieth  week,  7^  ounces  (214  grammes) ;  from  twenty-first  to  thirtieth  week,  6  ounces 
(168  grammes) ;  at  the  end  of  thirtieth  week,  weight  18  pounds 9^  ounces  (8,485  grammes). 

Feer  (Jahrb.  f.  Kinderh.,  xlii,  195).     Three  cases. 

In  all  these  eases  the  amount  of  milk  was  determined  by  weighing  the  infant  both 


WOMAN'S   MILK. 


129 


quantity  of  milk  secreted  under  normal  conditions  of  health  may  be  as- 
sumed to  be  pretty  nearly  as  follows : 

Approximately. 

At  the  end  of  the  first  week 10  to  16  oz.  (300  to     500  grm.). 

During  the  second  week 13  to  18  oz.  (400  to     550  grm.). 

During  the  third  week 14  to  24  oz.  (430  to     720  grm.). 

During  the  fourth  week 16  to  26  oz.  (500  to     800  grm.). 

From  the  fifth  to  the  thirteenth  week  ...  20  to  34  oz.  (600  to  1,030  grm.). 

From  the  fourth  to  the  sixth  month 24  to  38  oz.  (720  to  1,150  grm.). 

From  the  sixth  to  the  ninth  month 30  to  40  oz.  (900  to  1,220  grm.). 

It  will  be  noted  that  the  amount  increases  very  rapidly  up  to  about 
the  eighth  week,  and  after  this  much  more  slowly.  The  amount  of.  milk 
varies  also  with  the  demands  of  the  child  in  a  very  striking  way.  The 
quantities  mentioned  can  not  be  taken  as  an  absolute  guide  as  to  the 
amount  of  food  to  be  given  to  bottle-fed  infants.  Breast  milk  contains 
an  average  of  twelve  per  cent  solids;  while  the  modification  of  cow's 
milk  best  suited  to  the  early  months  contains  only  from  nine  to  eleven  per 
cent  solids.  For  this  period,  therefore,  somewhat  larger  quantities  are 
needed  than  of  breast  milk. 

A  comparison  of  the  daily  amount  of  milk  taken  with  the  weight  of 
the  child  at  the  different  periods,  showed  that  both  during  the  early  and 
the  later  periods  the  larger  children  took  not  only  more  milk,  but  con- 
siderably more  in  proportion  to  their  body-weight  than  did  the  smaller 


before  and  after  every  nursing  during  the  entire  period  of  observation.     The  follow- 
ing table  gives  in  a  condensed  form  the  daily  quantity  of  milk  in  these  cases : 


1st  day 

2d  day 

3d  day 

4th  day  

5th  day  

6th  day  

7th  day  

Average  2d  week 

Average  3d  week 

Average  4th  week 

Average  5th  week 

Average  6th  week 

Average  7th  week 

Average  8th  week 

Average  9th  week 

Average  10th  to  13th  week 
Average  14th  to  17th  week 
Average  1 8lh  to  23d  week 
Average  24th  to  30th  week 


Haehner's 
1st  case. 


Grammes. 

20 
176 
265 
420 
360 
374 
423 
497 
550 
594 
603 
740 
880 
835 
766 
796 
807 
870 


Haehner's 
2d  case. 


Grammes. 

75 
135 
325 
295 
290 
340 
350 
423 
468 
531 
561 
661 
681 
730 
665 


Haehner's 
3d  case. 


Grammes. 

20 

45 

70 

99 
124 
136 
156 
229 
314 
379 
447 
472 
525 
568 
584 
600 
673 
709 


Laure's 

Ahlfeld's 

case. 

case. 

Grammes. 

Grammes. 

i25 

222 

400 

475 

.  .  . 

500 

556 

730 

810 

576 

944 

655 

978 

791 

1,038 

811 

1,024 

845 

1,085 

810 

869 

983 

1.029 

1,145 

Feer's 
3  cases. 
Average. 


256 

;iverage 
1st  week) 


610 
607 
753 
802 
815 
820 
795 
845 
910 
1,002 


130 


NUTRITION. 


ones.     This  harmonizes  with  the  common  observation  that  small  chil- 
dren are  much  more  likely  to  be  overfed  than  large  ones. 

The  average  quantity  taken  at  one  nursing  by  five  children  previ- 
ously mentioned  was  as  follows : 

Approximately. 

During  the  first  week |  to  1|^  oz.    (18  to    50  grin.). 

During  the  second  week 1    to  3    oz.    (30  to    90  grm.). 

During  the  third  week 1|  to  4    oz.    (45  to  120  grm.). 

During  the  fourth  week 1^  to  4^  oz.    (45  to  140  grm.). 

From  the  fifth  to  the  seventh  week 2    to  5    oz.    (64  to  150  grm.). 

From  the  eighth  to  the  eleventh  week ....  2^  to  5^  oz.    (75  to  160  grm.). 

During  the  fourth  month 3    to  6    oz.    (90  to  180  grm.). 

During  the  fifth  month 3^  to  6J  oz,  (110  to  200  grm.). 

During  the  sixth  month 4    to  7   oz.  (120  to  230  grm.). 

Between  the  limits  mentioned  the  greater  number  of  cases  will 
undoubtedly  fall.  The  amount  taken  at  one  time  is,  however,  modi- 
fied by  the  frequency  of  nursing,  and  is  therefore  not  so  good  a  guide 
"to  the  amount  of  food  required,  as  is  the  quantity  taken  in  twenty-four 
lours. 

Composition. — Many  of  the  older  analyses  of  milk  gave  erroneous  re- 
isults  because  of  imperfect  methods  of  examination.  According  to  the 
most  recent  analyses  of  Pfeiffer,  Koenig,  Leeds,  Harrington,  Adriance, 
and  others,  the  composition  of  human  milk  is  as  follows : 


Average. 

Common  healthy  variations. 

Fat 

Per  cent. 

4-00 
7-00 
1-50 
0-20 

87-30 

Per  cent. 

3-00    to    5-00 

Sugar 

6-00     "     7-00 

Proteids 

1-00    "    2-25 

Salts 

0-18     "     0-25 

Water 

89-82    "  85-50 

100-00 

100-00       100-00 

In  the  older  analyses,  the  percentage  of  proteids  is  almost  invariably 
too  high  and  the  sugar  too  low. 

The  milk  varies  in  composition  somewhat  with  the  period  of  lacta- 
tion. That  of  the  colostrum  period  is  high  in  proteids  and  salts  and  low 
in  sugar.  By  the  end  of  the  second  week  all  these  elements  have  usu- 
ally reached  their  normal  averages.  After  this  time  until  near  the 
end  of  lactation  the  regular  variations  are  slight.  However,  there  is 
seen,  according  to  Adriance,  a  slow  but  steady  fall  in  the  proteids  and 
salts  and  a  very  slight  rise  in  the  sugar,  while  the  fat  is  scarcely  affected 
at  all. 

Proteids. — The  proteids  are  as  yet  very  imperfectly  understood.  The 
most  important  ones  are  casein  and  lactalbumin,  although  some  writers 


WOMAN'S  MILK.  131 

give  a  third — lactoglobulin.  The  casein  is  in  suspension  by  virtue  of  the 
presence  of  lime  phosphate  in  the  milk,  with  which  it  is  probably  in  com- 
bination. It  does  not  coagulate  appreciably  with  rennet,  and  acetic  acid 
produces  only  a  loose  flocculent  precipitate.  The  lactalbumin  resembles 
the  serum-albumin  of  the  blood.  Chemists  are  by  no  means  agreed  in 
regard  to  the  proportion  of  the  different  proteids  present  in  milk.  Lact- 
albumin exists  in  woman's  milk  in  much  larger  amount  than  in  other 
varieties,  and  it  is  more  abundant  than  the  casein,  the  proportion  of  the 
two  being,  according  to  Koenig,  about  as  five  to  four. 

The  total  proteids  of  normal  milk  are  usually  from  one  to  two  per 
cent.  In  abnormal  specimens  the  variations  are  from  0  -7  to  4  -5  per  cent. 
The  proteids  are  highest  in  the  milk  of  the  first  few  days ;  after  the  first 
month  they  vary  but  little  until  toward  the  close  of  lactation,  when 
the  amount  falls  very  markedly. 

Fat. — This  exists  in  the  form  of  minute  globules,  which  are  held  in  a 
state  of  permanent  emulsion  by  the  albuminous  solution  in  which  they 
are  suspended.  The  fat  of  woman's  milk  is  chiefly  made  up  of  the  neu- 
tral fats — palmitine,  stearine,  and  oleine ;  there  are  also  small  quantities 
of  the  fatty  acids,  but  these  are  much  less  than  in  cow's  milk.  Like  the 
proteids,  the  proportion  of  fat  is  subject  to  wide  variations,  4  per  cent 
being  taken  as  the  average.  In  thirty-four  analyses  made  for  me  at  the 
laboratory  of  the  College  of  Physicians  and  Surgeons,  the  fat  varied 
'between  1  -12  and  6  -QQ  per  cent.  In  forty-three  analyses  by  Leeds,  the 
variations  were  between  3  -11  and  6  -89  per  cent.  The  proportion  is  very 
little  affected  by  the  period  of  lactation. 

Sugar. — The  sugar  is  in  complete  solution.  Its  proportion  is  very 
constant,  the  average  being  seven  per  cent.  The  ordinary  variations  are 
usually  within  the  limits  of  6  and  7  per  cent.  The  sugar  being  so  im- 
portant as  a  heat-producing  element.  Nature  has  wisely  provided  that  this 
shall  be  the  most  constant  ingredient  of  the  milk.  The  amount  of  sugar 
is  smallest  in  the  milk  of  the  first  week ;  after  the  first  month,  however, 
the  variations  are  slight. 

Salts. — The  average  proportion  of  inorganic  salts  is  0  -30  per  cent,  or 
a  little  more  than  one  fourth  that  of  cow's  milk. 

With  the  exception  of  calcium  phosphate  nearly  all  the  salts  are  in 
solution.  The  milk  of  the  first  few  da^^s  is  very  rich  in  salts ;  after  the 
first  month  the  variations  are  slight  but  show  a  gradual  fall  in  the  quan- 
tity present.* 

The  Examination  of  Milk. — The  exact  composition  of  human  milk  is 
to  be  determined  only  by  a  complete  chemical  anal3^sis.  There  are,  how- 
ever, many  variations  which  the  physician  may  readily  ascertain  for  him- 
self by  simple  methods  of  examination. 

*  Bunge's  analysis  is  given  on  page  147. 


132 


NUTRITION. 


The  quantity  of  milk  secreted  by  the  breasts  may  be  estimated  by  the 
quantitj^  wliich  ma}'  be  drawn  by  a  breast-pump,  altliough  this  is  not  a 
very  reliable  test.  .  If  the  child  nurses  habitually  forty  or  fifty  minutes, 
the  probabilities  are  very  strong  that  the  quantity  of  milk  is  small.  If 
the  breasts  at  nursing  time  are  full,  hard,  and  tense,  the  supply  is  prob- 
ably abundant.  If  they  are  soft  and  flabby,  and  the  milk  appears  to  run 
in  only  while  the  child  is  nursing,  it  is  almost  certain  that  the  quantity 

is  small.  The  most  reliable 
of  all  tests  is  weighing  the 
infant  before  and  after 
nursing,  upon  an  accurate 
pair  of  scales,  sufficiently 
sensitive  to  indicate  half- 
ounces.  Two  or  three 
weighings  will  suffice  to 
g-^o  i,o2o|-|  show    conclusively    whether 

an  infant  at  three  months, 
for  instance,  is  getting  ha- 
bitually four  or  five,  or  only 
one  or  two  ounces  at  a  nurs- 


1,030 


1,010 


r~^ 


The  reaction  of  milk 
may  be  taken  with  ordinary 
litmus  paper.  When  freshly 
drawn  it  should  be  alkaline 
or  amphoteric,  never  acid. 

The  specific  gravity  may 
be  taken  with  any  small 
hydrometer  graduated  from 
1,010  to  1,010  (Fig.  25,  B). 
The  specific  gravity  is  low- 
ered by  the  fat,  but  in- 
creased by  the  other  solids. 
An  ordinary  urinometer  will 
answer  every  purpose,  the 
only  difficulty  being  the  quantity  which  is  required  to  float  the  in- 
strument. 

Microscopical  examination. — The  microscope  reveals  the  presence  of 
colostrum-corpuscles,  blood,  pus,  epithelium,  and  granular  matter.  Co- 
lostrum-corpuscles are  abnormal  after  the  twelfth  day ;  pus  and  blood  are 
always  abnormal.  All  of  these  conditions  necessitate  the  suspension  of 
nursing,  at  least  temporarily.  But  little  importance  can  be  attached  to 
the  size  and  appearance  of  the  fat-globules  as  affecting  the  nutritive 
properties  of  the  milk. 


A  B  C 

Fig.  25. — Apparatus  for  examination  of  woman's  milk. 

A,  Marchand's  tube;  B,  C,  the  author's  lactometer 
and  cream-gauffe. 


WOMAN'S  MILK.  13^ 

The  determination  of  fat. — The  simplest  method  is  by  the  cream- 
gauge  (Fig.  25,  C).  Although  its  results  are  only  approximate,  they  are 
in  most  cases  sufficiently  accurate  for  clinical  purposes.  The  tube  is 
filled  to  the  zero  mark  with  freshly  drawn  milk,  which  stands  at  a  room 
temperature  for  twenty-four  hours,  when  the  percentage  of  cream  is  read 
off.  The  ratio  of  this  to  the  fat  is  approximately  five  to  three ;  thus  5 
per  cent  cream  indicates  3  per  cent  fat,  etc. 

For  a  more  accurate  determination  the  best  ready  method  is  probably 
the  modification  by  Lewi  *  of  the  Leffman  and  Beam  test  for  cow's  milk. 
This  is  a  centrifugal  test  requiring  special  tubes,t  but  they  can  be  used 
in  the  ordinary  centrifuge  for  urine.  Only  six  cubic  centimetres  of  milk 
are  necessary ;  and  if  carefully  made  the  results  are  almost  as  accurate  as 
by  a  chemical  analysis.  Another  rapid  but  less  accurate  method  is  by 
Marchand's  tube  %  (Fig.  25,  A). 

Sugar. — The  proportion  of  sugar  is  so  nearly  constant  that  it  may  be 
ignored  in  clinical  examinations. 

Proteids. — We  have  no  simple  method  for  determining  clinically  the 
amount  of  proteids.  If  we  regard  the  sugar  and  salts  as  constant,  or 
so  nearly  so  as  not  to  affect  the  specific  gravity,  we  may  form  an  ap- 
proximate idea  of  the  proteids  from  a  knowledge  of  the  specific  gravity 
and  the  percentage  of  fat.  We  may  thus  determine  whether  they  are 
greatly  in  excess  or  very  scanty,  which,  after  all,  is  the  important 
thing.  The  specific  gravity  will  then  vary  directly  with  the  proportion 
of  proteids,  and  inversely  with  the  proportion  of  fat — i.  e.,  high  pro- 
teids, high  specific  gravity;  high   fat,  low  specific   gravity.     The   ap- 


*  Archives  of  Paediatrics,  March,  1898. 

•f  Made  by  Richards  &  Co.,  New  York. 

X  Marchand's  test :  First  put  in  five  cubic  centimetres  of  milk,  up  to  the  line  M ; 
then  four  or  five  drops  of  liquor  soda3 ;  shake ;  add  five  cubic  centimetres  of  ether,  up  to 
the  line  E ;  cork,  and  shake  fifteen  or  twenty  times ;  add  ninety-per-cent  alcohol,  up  to 
the  line  A.  The  tube  is  now  tightly  corked,  shaken  thoroughly,  and  placed  upright  in 
a  tall  bottle  containing  water  at  a  temperature  of  120°  to  150°  F.  The  fat  separates 
and  forms  a  distinct  layer  at  the  top,  and  after  half  an  hour  the  amount  is  read  oflf  in 
degrees.    By  reference  to  the  following  table  the  exact  percentage  of  fat  is  shown : 


Degrees  Percentage 

Marchand.  of  fat. 


Degrees  Percentage 

Marchand.  of  fat. 


1 1-49 

3 1-96 

5 2-43 

7 3-89 

9 3-36 

11 3-83 

Each  additional  degree  on  the  tube  corresponds  to  0-23  per  cent  of  fat.     To  insure 


13 4-39 

15 4-75 

17 5-22 

19 5G8 

21 G-14 


accuracy  the  test  should  be  repeated  two  or  three  times  with  the  same  specimen. 
These  tubes  may  be  obtained  from  E.  Greiner.  51  William  Street.  New  York. 


134 


NUTRITION. 


plication  of  this  principle  will  be  seen  b}^  reference  to  the  accompany- 
ing table.* 

Woman's  Milk. 


Average 

Normal  variations.. . 
Normal  variations.. . 
Abnormal  variations. 
Abnormal  variations. 
Abnormal  variations. 
Abnormal  variations. 


Specific  gravity  70°  F. 


1-031 
1-028 -1-029 

1-032 
Low  (below  1-028). 
Low  (below  1-028). 
High  (above  1-032). 
High  (above  1-032). 


Cream— 24  hours. 


7% 
8%  —  \2,% 

High  (above  1' 
Low  (below  5 
High. 
Low. 


Proteids  (calculated). 


1-5^ 

Normal  (rich  milk). 

Normal  (fair  milk). 

Normal  or  slightly  below. 

Very  low  (very  poor  milk). 

Very  high  (very  rich  milk). 

Normal  (or  nearly  so). 


Any  specimen  taken  for  examination  should  be  either  the  middle  por- 
tion of  the  milk — i.  e.,  after  nursing  two  or  three  minutes — or,  better,  the 
entire  quantity  from  one  breast,  since  the  composition  of  the  milk  will 
differ  very  much  according  to  the  time  when  it  is  drawn.  The  first  milk 
is  slightly  richer  in  proteids  and  much  poorer  in  fat.  The  last  drawn 
from  the  breasts  is  low  in  proteids  and  high  in  fat.  The  following  analy- 
ses from  Forster  illustrate  these  differences  : 


First  portion. 

Second  portion. 

Third  portion. 

Fat 

Per  cent. 

1-71 
1-13 

Per  cent. 

2-77 
0-94 

Per  cent. 

5-51 

Proteids 

0-71 

Conditions  Affecting  the  Composition  of  Woman's  Milk. — TJieage  of  the 
nurse. — This  has  no  constant  influence.  Other  things  being  equal,  the  milk 
of  vei'y  young  women,  and  also  of  those  over  thirty-five  years  of  age,  is  likely 
to  be  lower  in  fat  than  that  of  women  between  twenty  and  thirty-five  years. 

Number  of  pregiiancies. — Adrianee  found  that  the  average  milk  of  23 
primiparse  and  23  multiparae,  both  taken  at  the  third  month,  showed  the 
following  differences :  The  milk  of  the  primiparge  was  higher  in  fat  (4  -06 
against  3  -67)  and  in  proteids  (1  -61  against  1  '35),  but  a  little  lower  in 
sugar  (6-52  against  6-85). 

Acute  illness. — In  the  majority  of  cases  of  acute  illness  of  a  minor 
character  and  of  short  duration  there  is  no  perceptible  effect  upon  the 
milk.  In  the  acute  febrile  diseases  of  a  severe  type  the  quantity  of 
milk  is  reduced,  the  fat  is  low,  and  the  proteids  are  apt  to  be  high.  In 
septic  conditions  bacteria  may  appear  in  the  milk. 

Menstruation. — The  effect  of  this  is  exceedingly  variable,  depending 
much  upon  the  individual  and  the  ease  of  menstruation.  From  observa- 
tions upon  685  eases,  Meyer  noted  disturbances  in  the  child  in  over  one- 
half  the   number.     My  own  experience   accords   rather  with  that   of 


*  The  author's  apparatus  may  be  obtained  from  Eimer  &  Amend,  Eighteenth 
Street  and  Third  Avenue,  New  York.  For  a  fuller  discussion  of  the  subject,  see 
Archives  of  Pediatrics,  March,  1893. 


WOMAN'S  MILK. 


135 


Pfeiffer  and  Schlichter,  who  consider  it  quite  exceptional  for  the  child  to 
be  visibly  affected.  Schlichter  made  observations  upon  infants  during 
233  menstrual  days,  noting  the  condition  of  the  stools  and  digestion  both 
before  and  after  menstruation.  In  ninety  per  cent  of  the  cases  there  was 
no  perceptible  influence.  In  only  eight  per  cent  were  the  stools  bad,  and 
in  only  three  per  cent  was  there  disturbance  of  the  stomach  with  vomiting. 
The  nature  of  the  changes  in  milk  produced  by  menstruation  is  illus- 
trated by  the  following  case  taken  from  Eotch  : 


Second  day  of  men- 
struation.   Bowels  of 
child  loose. 

Seven  days  after 

menstruation. 

Bowels  regular. 

Forty  days  after  men- 
struation.   Child 
gaining  rapidly. 

Fat 

Per  cent. 

1-37 
6-10 
2-78 
0-15 
89-60 

Per  cent. 

2-02 
6-55 
2-12 
0-15 
89-16 

Per  cent. 

2-74 

Sugar 

6-35 

Proteids 

0-98 

Salts 

0-14 

Water 

89-79 

At  the  present  time  sufficient  observations  have  not  been  made  to  show 
"whether  the  differences  noted  in  the  above  case — low  fat  and  high  proteids 
— are  the  rule  where  disturbances  are  produced  during  menstruation. 
Monti's  examinations  lead  him  to  the  conclusion  that  the  fat  is  not  con- 
stantly affected.  It  is  safe  to  say  that  the  changes  are  not  uniform,  and 
that  in  very  many  cases  none  of  importance  are  produced  by  menstruation. 

Diet. — The  fat  and  the  proteids  of  the  milk  are  much  influenced  by 
■diet,  the  sugar  but  very  little.  The  fat  is  increased  by  a  diet  made  up 
largely  of  nitrogenous  food,  meat,  eggs,  animal  broths,  etc. ;  it  is  reduced 
by  stopping  these  articles  and  substituting  vegetables  and  farinaceous 
food.  The  proteids  are  increased  by  overfeeding  and  also  by  too  little 
exercise.  Starvation  lowers  the  fat  and  sometimes  also  the  proteids ; 
they  may,  however,  be  increased  but  altered  in  character.  All  fluids 
tend  to  increase  the  quantity  of  milk.  Alcohol  in  the  form  of  malted 
drinks,  and  malt  extracts  increase  the  quantity  of  milk  and  the  amount 
of  fat.  The  effect  of  alcohol  upon  the  proteids  is  not  constant,  but  they 
are  usually  increased.  The  following  table  gives  the  result  of  analyses 
of  the  milk  of  two  women  in  the  New  York  Infant  Asylum  before,  while 
taking,  and  after  taking  an  alcoholic  extract  of  malt : 


I. 

Without  malt. 

n. 

After  taking  8  oz.  malt 
daily  for  10  days. 

III. 
No  malt  for  7  days. 

Case  I : 

Fat 

Per  cent. 

1-74 
1-93 
7-02 
0-20 

1-12 
1-57 
7-11 
0-19 

Per  cent. 

3-83 
1-58 
7-43 
0-17 

2-75 
2-34 
6-77 
0-17 

P«r  Mnt. 

2-41 

Proteids 

2-95 

Sucrar 

6-59 

Salts 

0-19 

■Case  II : 

Fat 

1-70 

Proteids 

1-26 

Sugar 

6-04 

Salts 

0-18 

136  NUTRITION. 

The  child  of  Case  I  gained  one  ounce  and  a  half  during  the  four  days 
preceding  the  first  analysis ;  that  of  Case  II  did  not  gain  at  all.  During 
the  ten  days  while  taking  the  malt,  the  first  child  gained  twelve  ounces, 
the  second  child  eight  ounces.  During  the  seven  days  after  the  malt  was 
discontinued,  the  first  child  gained  eight  ounces,  the  second  child  one 
ounce.  There  was  a  notable  increase  in  the  quantity  of  milk  in  both 
cases  while  taking  the  malt. 

The  nursing  woman  should  have  a  generons  diet  of  simple  food,  and 
should  drink  largely  of  milk  or  gruels  made  with  milk.  The  diet  should 
be  a  varied  one,  not  excessive  in  nitrogenous  food  nor  in  vegetables.  All 
salads  and  highly  seasoned  dishes  should  be  avoided,  not  so  much  because 
they  upset  the  child,  although  this  may  happen,  as  because  they  are  likely 
to  disturb  the  digestion  of  the  nurse.  All  the  common  vegetables  and 
fruits  in  season  may  be  allowed  in  moderation.  Strong  tea  and  coffee 
should  be  prohibited,  although  weak  tea  or  coffee  may  be  allowed,  each 
but  once  a  day.  Cocoa  is  less  objectionable  than  either  tea  or  coffee.  In 
addition  to  her  regular  meals  the  nurse  should  have  milk  or  gruel  at  bed- 
time. The  diet  should  in  all  cases  be  adapted  to  her  digestion.  The  bow- 
els should  move  daily,  by  the  use  of  laxatives  if  necessary.  Great  harm 
often  results  from  over-feeding  with  its  consequent  indigestion.  The 
regular  use  of  alcoholic  beverages  should  be  forbidden. 

Drugs. — The  elimination  of  drugs  through  the  milk  is  somewhat  un- 
certain and  variable ;  few  of  those  popularly  supposed  to  affect  the  child 
through  the  milk  really  do  so.  During  the  early  colostrum  period,  and 
whenever  the  milk  is  very  poor  in  quality,  so  that  it  partakes  more  of  the 
character  of  an  excretion  than  a  secretion,  the  elimination  of  drugs  is 
likely  to  take  place.  The  most  important  drugs  so  eliminated  are  the 
following :  Given  in  full  doses,  belladonna  regularly  appears  in  the  milk. 
Opium  does  not  do  so  constantly;  but  when  the  milk  is  poor,  enough 
may  be  excreted  to  produce  serious  symptoms,  and,  in  infants  a  few  days 
old,  even  to  cause  death.  The  iodides  and  bromides  when  long  admin- 
istered may  be  eliminated  in  sufficient  quantity  to  produce  their  consti- 
tutional effects  in  the  child.  Mercury  does  not  appear  regularly,  but 
only  after  prolonged  use,  and  then  in  variable  quantity.  Most  of  the 
saline  cathartics,  arsenic,  and  the  salicylates  are  occasionally  found  in 
the  milk.  Alcohol  (especially  amylic  alcohol,  Klingemann)  may  appear 
after  being  taken  in  considerable  quantities  by  nurses,  and  may  seriously 
affect  the  child.  The  ingestion  by  nurses  of  stale  beer  may  be  the  cause 
of  grave  disturbance  (Seibert). 

Pregnancy. — The  milk  of  pregnant  women  is  generally  small  in  quan- 
tity and  poor  in  quality,  especially  in  fat.  (See  chart,  p.  175.)  It  is  not 
known,  however,  that  there  are  any  other  differences. 

Bacteria. — Under  normal  conditions  human  milk  may  contain  a  few 
bacteria.     They  are  chiefly  cocci  derived  from  the  external  milk  ducts 


COW'S  MILK.  137 

and  are  of  no  importance.  Eingel  found  the  milk  sterile  in  onl}-  3  of  25 
cases  examined.  In  17  the  staphylococcus  pyogenes  alhus  was  present. 
In  suppurative  inflammation  of  the  mammary  gland,  numerous  bacteria 
may  be  found  in  the  milk ;  also  in  some  cases  of  puerperal  sepsis.  In  the 
milk  of  women  suffering  from  acute  fevers,  not  septic,  Escherich  found 
no  bacteria.  Tubercle  bacilli  have  been  demonstrated  by  Roger  and 
Garnier  in  the  milk  of  a  woman  with  advanced  tuberculosis,  but  ordi- 
narily they  are  not  present  unless  the  gland  is  the  seat  of  the  disease. 

The  elimination  of  antitoxin  and  other  protective  substances  by  the 
milk. — The  immunity  of  nursing  infants  to  most  of  the  contagious  dis- 
eases has  long  been  noted,  but  until  recently  little  understood.  Roger 
has  published  (Revue  de  Med.,  May,  1900)  a  striking  instance  in  point. 
In  a  single  year  there  were  admitted  to  a  hospital  36  nursing  mothers 
suffering  from  contagious  diseases:  15  had  measles;  19  scarlet  fever; 
1  diphtheria ;  1  mumps.  In  no  case  did  an  infant  contract  the  disease 
of  its  mother,  although  nursing  was  continued.  Animal  experiments 
have  demonstrated  the  constant  presence  of  diphtheria  antitoxin  in  the 
milk  of  immunized  animals.  The  Widal  reaction  has  been  obtained  with 
the  milk  of  mothers  suffering  from  typhoid  and  with  the  blood  of  their 
healthy  nursing  infants.  Clinical  observations  like  that  of  Roger  would 
seem  to  admit  of  no  other  explanation  than  that  these  infants  did  not 
take  the  disease  of  the  mothers  because  something  was  conveyed  to  them 
through  the  milk,  which  rendered  them  immune.  From  other  clinical 
facts  it  would  seem  highly  probable  that  the  presence  of  protective 
substances  in  milk  may  be  jDresent  to  some  degree  at  all  times. 

Nervous  impressions. — These,  when  of  a  marked  character,  have  a 
very  decided  and  immediate  effect  upon  the  milk.  Fatigue,  exhaustion, 
great  excitement,  sudden  fright,  grief,  or  passion  are  likely  to  affect  the 
secretion  in  a  most  marked  manner.  An  infant  who  takes  the  breast 
under  such  circumstances  may  exhibit  only  the  ordinary  signs  of  acute  in- 
digestion, such  as  vomiting  and  undigested  stools,  or  there  may  be  in 
addition  high  temperature,  great  prostration,  toxic  symptoms,  and  some- 
times even  convulsions.  The  nature  of  the  changes  in  milk  from  such 
causes  is  as  yet  but  little  understood.  The  probability  is,  however,  that 
it  is  the  proteids  which  are  at  fault,  as  these  are  very  unstable  and  easily 
affected,  and  that  instead  of  the  normal  proteids  others  are  produced 
which  possess  toxic  properties.  In  certain  cases  the  secretion  of  milk 
may  be  almost  entirely  arrested  by  nervous  influences. 

COW'S  MILK. 

The  only  one  of  the  lower  animals  whose  milk  is  practically  available 
for  infant-feeding  is  the  cow.  Cow's  milk  being  our  main  reliance  in  the 
artificial  feeding  of  infants  and  the  staple  food  of  nearly  all  young  chil- 
dren, it  follows  that  evcrytliing  relating  to  its  production  and  handling  is 


138  NUTRITION. 

important.  The  practising  physician  should  therefore  familiarize  him- 
self with  the  main  facts  regarding  the  production  and  handling  of  milk 
according  to  modern  methods,  since  no  one  can  do  more  than  he  to 
educate  public  opinion  in  these  matters,  and  so  to  improve  the  milk 
supply  of  the  community.  Only  an  outline  of  the  subject  can  be  pre- 
sented here.  For  more  minute  knowledge  the  reader  is  referred  to 
special  works  upon  the  subject.* 

The  essential  conditions  to  be  fulfilled  in  cow's  milk  which  is  to 
be  used  as  a  food  for  infants  and  young  children  are:  (1)  Freshness; 
it  should  not  be  over  twenty-four  hours  old;  (2)  it  should  contain  no 
preservatives;  (3)  it  should  be  from  healthy  animals,  free  from  tuber- 
culosis or  other  taint;  (4)  it  should  be  clean;  (5)  it  should  not  be 
skimmed  or  otherwise  falsified;  (6)  it  should  contain  no  pathogenic 
organisms;  (7)  the  number  of  other  organisms  should  not  be  excessive. 
It  is  also  desirable  for  purposes  of  infant-feeding  that  the  composition 
of  the  milk,  particularly  the  percentage  of  fat,  should  be  known,  and 
that  the  milk  should  be  as  nearly  uniform  as  possible  from  day  to  day 
and  at  different  seasons  of  the  year.  Mixed  or  herd  milk  is  therefore  to 
be  preferred  to  that  from  a  single  animal,  since  it  is  subject  to  fewer 
variations.  The  common  varieties  or  "  grade  cows  "  should  be  chosen 
rather  than  highly  bred  animals,  if  for  no  other  reason,  because  they 
are  more  hardy,  less  subject  to  disease,  and  less  susceptible  to  other 
influences  which  might  affect  the  milk. 

When  handled  with  reasonable  care,  milk  is  safe  if  used  before  it  is 
twenty-four  hours  old ;  after  this  time  fermentative  changes  occur  much 
more  rapidly,  and  such  milk  can  not  safely  be  used  for  young  children. 
It  is  therefore  of  the  greatest  importance,  and  under  most  circumstances 
entirely  feasible,  to  obtain  milk  for  infant-feeding  which  is  less  than 
twenty-four  hours  old.  The  safety  of  older  milk  is  secured  only  by 
special  precautions  regarding  cleanliness  in  producing  and  handling  it, 
and  special  care  in  keeping  it  constantly  at  a  temperature  below  45°  F. 

Preservatives  are  very  often  added  by  unscrupulous  dealers  to  retard 
the  souring  of  milk,  particularly  in  hot  weather.  The  substances  for- 
merly used  contained  as  their  active  agent  boric  or  salicylic  acid.  Ee- 
cently  formaldehyd  has  been  largely  employed  for  this  purpose. 

Micro-organisms  in  Milk. — Most  of  the  common  bacteria  grow  read- 
ily in  milk,  and  the  conditions  under  which  it  is  produced  and  handled 
render  it  liable  to  contamination  in  many  ways. 

1.  Disease  in  the  cow. — From  disease  of  the  udder  streptococci  or 
other  pyogenic  germs  may  enter  the  milk  in  such  numbers  as  to  excite 

*  Convenient  works  for  a  physician's  use  are  Richmond's  Dairy  Chemistry ;  Conn, 
Dairy  Bacteriology,  Bulletin  No.  25  of  the  U.  S.  Dept.  of  Agriculture  ;  Aiknian,  Milk : 
Its  Nature  and  Composition,  Block,  London,  1899;  and  Russell,  Outlines  of  Dairy 
Bacteriology,  1899. 


cows  MILK.  139 

acute  gastro-enteritis  in  a  child.  Other  diseases  which  may  possibly  be 
communicated  from  the  cow  are  anthrax,  the  "  foot-and-mouth  "  disease, 
and  tuberculosis.  Trustworthy  statistics  as  to  the  frequency  of  tuber- 
culosis in  cattle  are  difficult  to  obtain.  In  the  State  of  New  York  it  is 
estimated  that  7  per  cent  of  the  cows  are  tuberculous ;  in  Massachusetts, 
in  the  herds  tested  by  request,  25  per  cent  were  found  to  be  tuberculous 
(Freeman).  Of  cattle  slaughtered  in  London,  25  per  cent  are  stated 
to  be  tuberculous.  Of  course  not  all  such  cows  have  tubercle  bacilli  in 
their  milk.  Unless  the  udder  itself  is  the  seat  of  disease  the  great 
majority  do  not;  but  it  is  now  well  established  that  in  the  milk  of  a 
considerable  number  tubercle  bacilli  may  appear  even  though  the  udder 
is  healthy.  One  recent  English  writer  (Eastes)  found  tubercle  bacilli 
in  11  of  186  miscellaneous  specimens  of  milk  examined.  All  this 
looks  most  alarming;  but  for  reasons  given  elsewhere  (vide  article  on 
Intestinal  Tuberculosis)  I  can  not  believe  the  danger  of  acquiring  tuber- 
culosis through  milk  to  be  as  great  as  has  been  represented.  It  now 
seems  to  be  well  established  that  cows  can  not  be  infected  with  human 
tuberculosis;  but  the  converse  proposition  can  not  be  asserted.  For 
the  present,  milk  must  be  regarded  as  one  of  the  possible  sources  of 
tuberculous  infection  and  all  known  precautions  taken  against  it. 

2.  Specific  pathogenic  organisms  accidentally  gaining  access  to  milk. 
— The  agency  of  milk  in  the  spread  of  contagious  disease  has  only  lately 
been  appreciated.  Its  importance  may  be  judged  by  the  fact  that  in 
1900  Kober  *  collected  records  of  330  outbreaks  which  were  spread  by 
milk.  These  illustrate  very  well  how  the  milk  most  frequently  becomes 
infected.  There  were  195  outbreaks  of  typhoid  fever,  99  of  scarlet 
fever,  36  of  diphtheria.  In  the  typhoid  epidemics  the  disease  prevailed 
at  the  dairy  in  148  instances ;  in  67  the  milk  was  diluted  with  infected 
well-water;  in  7  the  cows  probably  waded  in  polluted  Avater;  iu  24: 
cases  the  employees  acted  as  nurses,  and  in  10  they  continued  at  work, 
although  themselves  suffering  from  the  disease ;  in  one  case  it  was  found 
that  the  milk-pans  were  washed  with  cloths  used  about  patients ;  iu  2 
cases  the  dairy  employees  were  connected  with  the  night-soil  service; 
and  in  1  the  milk  had  been  kept  in  a  closet  in  the  sick-room. 

Of  the  99  epidemics  of  scarlet  fever,  there  was  disease  at  the  farm 
or  dairy  in  68 ;  in  17,  employees  were  themselves  affected,  and  in  10  they 
acted  as  nurses;  in  6,  persons  connected  with  the  dairy  either  lodged  in 
or  had  visited  infected  houses ;  in  2  infection  was  brought  by  cans  or  bot- 
tles from  the  houses  of  patients ;  in  3  the  milk  was  stored  near  or  in  the 
sick-room;  in  one  case  milk-utensils  were  wiped  with  an  infected  cloth. 

Of  the  36  outbreaks  of  diphtheria  studied,  there  was  disease  at  the 
farm  or  dairy  in  13;  in  3,  employees  themselves  were  ill.     The  12  in 

*  American  Journal  of  the  Medical  Sciences,  May,  1901. 


140  NUTRITIOX. 

which  the  cows  were  said  to  be  sufEering  from  inflammations  of  teats 
or  udders,  were  possibly  pseudo-diphtheria.  Besides  these  diseases  men- 
tioned^ cholera,  dysentery,  and  certain  forms  of  diarrhoeal  disease  may 
undoubtedly  be  spread  by  milk. 

3.  Other  bacteria  found  in  mWk. — These  are  chiefly  derived  from  the 
air  of  the  stable,  the  hands  and  clothing  of  the  milker,  and  from  the 
dirt  which  falls  from  the  udder,  belly,  and  tail  of  the  cow  into  the  pail 
during  milking;  very  many  come  from  the  cow's  excreta.  Freeman 
exposed  a  Petri  gelatin-plate  beneath  a  cow's  udder  for  one  minute  dur- 
ing milking  and  obtained  4,450  colonies.  The  varieties  of  bacteria  found 
in  fresh  milk  are  many  and  vary  with  locality.  Toward  the  souring 
point  the  great  majority  are  of  two  or  three  varieties  only;  fully  95 
per  cent  at  that  time  belong  to  the  lactic-acid-producing  group.  They 
cause  the  ordinary  souring  of  milk  by  acting  upon  the  milk  sugar.  Oth- 
ers act  upon  the  milk  proteids,  inducing  various  fermentative  or  putre- 
factive changes;  and  still  others  have  a  peptonizing  power.  Of  15  vari- 
eties frequently  present  which  were  studied  by  Eussell,  3  belonged  to  the 
lactic-acid  group,  5  were  peptonizing  bacteria,  while  7  had  no  recogniz- 
able efEect  upon  milk. 

It  is  not  yet  established  that  any  of  these  bacteria  have  a  beneficial 
effect  when  introduced  into  the  body.  Most  of  them  are  without  doubt 
harmless.  But  there  are  many  others  which,  while  not  strictly  speaking 
pathogenic,  when  present  in  large  numbers  induce  changes  in  milk  that 
so  impair  its  nutritive  properties  as  to  render  it  unfit  for  food,  and  in 
susceptible  infants  may  cause  serious  illness. 

The  numher  of  hacteria  in  milh. — This  depends  upon  three  condi- 
tions: (1)  Cleanliness  in  handling;  (2)  temperature;  (3)  age  of  the 
milk.  Hence  the  bacterial  count  becomes  of  the  greatest  value  in  fur- 
nishing information  as  to  these  matters,  although  of  less  importance  in 
regard  to  the  production  of  disease  than  the  nature  of  the  organisms 
present.  The  influence  of  the  different  factors  may  be  illustrated  by 
the  following  experiments  made  at  the  laboratory  of  the  Xew  York 
Health  Department:  A  sample  of  milk  taken  under  good  conditions 
contained  immediately  after  milking  300  bacteria  in  each  drop.  It  was 
cooled  to  45°  F.,  and  kept  at  this  temperature.  After  twenty-four  hours 
it  contained  in  each  drop  only  200  bacteria ;  after  forty-eight  hours,  900 ; 
and  after  seventy-two  hours,  150,000.  The  milk  curdled  on  the  sixth 
day.  Another  sample,  taken  in  a  dirty  barn,  cooled  and  kept  at  52°  F., 
contained  at  first  2,000  bacteria  in  each  drop;  in  twenty-four  hours, 
6,000 ;  in  forty-eight  hours,  245,000 ;  in  seventy-two  hours,  16,500,000. 
The  milk  curdled  on  the  fourth  day. 

The  ability  of  milk  to  resist  the  growth  of  bacteria  for  a  certain  time 
is  indicated  by  these  and  many  other  experiments.  Exactly  to  what  this 
is  due  is  not  quite  clear.     There  seems,  however,  to  be  little  doubt  that 


COW'S  MILK.  141 

milk,  in  common  with  other  animal  fluids,  possesses  certain  bactericidal 
properties  which  render  it  stable  for  a  limited  time,  which  are  soon  ex- 
hausted if  the  temperature  is  allowed  to  rise,  but  which  assist  materially 
in  its  preservation  during  the  first  twenty-four  hours. 

The  number  of  bacteria  in  cream  is  nearly  always  far  greater  than 
in  milk.  Cream  is  usually  much  older  than  milk  at  the  time  of  delivery. 
Huddleston's  investigations  of  the  cream  supplied  to  New  York  city  led 
him  to  the  conclusion  that  most  of  the  cream  was  seventy-two  hours  old 
when  it  reached  the  consumer.  The  consistency  of  much  of  the  very 
heavy  cream  so  popular  with  many  families  is  obtained  with  age  and  is 
largely  the  result  of  bacterial  growth.  Cream  is  frequently  held  back 
from  the  market  to  produce  this  rich  appearance.  Freeman's  experi- 
ments with  gravity  cream  led  him  to  the  conclusion  that  the  bacteria 
were  300  times  as  numerous  in  the  cream  as  in  the  milk  left  behind,  the 
bacteria  being  apparently  carried  up  with  the  fat  globules.  Both  these 
facts  emphasize  the  necessity  of  the  greatest  care  with  reference  to  cream 
and  indicate  that  centrifugal  cream  is  generally  to  be  preferred  on  ac- 
count of  the  fact  that  it  can  be  marketed  at  least  twenty-four  hours 
earlier  than  gravity  cream. 

A  bacteriological  standard  for  pure  milJc. — Much  discussion  has 
arisen  of  late,  especially  among  different  milk  commissions  of  physi- 
cians, regarding  the  possibility  of  establishing  some  such  standard.  One 
commission  requires  that  the  milk  shall  not  have  more  than  10,000  bac- 
teria in  each  cubic  centimetre ;  another  fixes  the  limit  at  30,000.  Meth- 
ods of  cultivating  and  counting  the  bacteria  of  milk  are  by  no  means 
uniform,  and  it  is  often  quite  impossible  to  compare  the  figures  of  differ- 
ent observers,  because  not  all  the  conditions  were  the  same.  We  are  not 
yet  quite  ready  to  fix  a  standard.  For  milk  sold  in  cans  100,000  to  the 
cubic  centimetre  may  be  considered  good;  for  bottled  milk  anything 
under  30,000  is  good,  and  an  average  under  10,000  is  exceedingly  good; 
the  count  in  all  cases  being  made  at  the  time  the  milk  is  offered  for  sale. 

The  reports  made  by  the  bacteriologist  of  one  of  the  New  York  milk 
commissions  showed  that  by  the  most  careful  handling  the  number  of 
bacteria  from  a  single  dairy  *  was  kept  for  an  entire  year  at  an  average 

*  This  was  from  the  Walker- Gordon  Farm  at  Plainsboro,  N.  J.  The  most  impor- 
tant of  the  special  conditions  were  the  following  :  Cement  floors  to  the  stables  to  admit 
of  ready  flushing  with  a  hose;  no  hay,  straw,  or  fodder  kept  in  the  stables;  shavings 
are  used  for  bedding;  the  cows  are  not  fed  until  after  they  are  milked  ;  they  are  care- 
fully groomed  every  day,  and  a  few  minutes  before  milking  the  loose  dirt  is  removed 
from  the  udders  with  a  dry  cloth.  The  milkers  wear  sterilized  coats  and  caps,  and 
wash  their  hands  before  milking  each  cow ;  all  bottles,  pails,  etc.,  are  sterilized  with 
live  steam,  the  pails  just  before  using.  The  milk  is  immediately  removed  to  the  milk- 
house,  where  it  is  strained,  mixed,  cooled  to  38°  P.,  ttottled  and  scaled — all  in  twenty 
minutes  from  the  time  it  leaves  the  cow.  It  is  transported  by  express  trains,  reaching 
New  York  and  Philadelphia  within  two  hours. 
11 


142  NUTRITION. 

of  a  little  more  than  5,000  bacteria  in  each  cubic  centimetre  at  the  time 
when  it  was  delivered  to  customers,  it  being  then  about  sixteen  hours 
old.  The  bottled  milk  from  single  high-class  dairies  usually  ranges  from 
10,000  to  100,000  under  the  same  conditions.  Milk  from  mixed  dairies 
delivered  in  cans  ranged  from  100,000  to  40,000,000,  the  latter  being 
often  reached  in  very  hot  summer  weather. 

The  means  of  excluding  pathogenic  hacteria,  and  of  checking  the 
spread  of  contagious  diseases  through  milk. — Eules  are  readily  deducible 
from  a  study  of  the  records  of  how  milk  has  usually  been  infected. 

1.  No  person  suffering  from,  or  in  contact  with  a  person  suffering 
from,  a  contagious  disease  should  enter  a  dairy  building  or  in  any  way 
come  in  contact  with  the  milk  or  milk-utensils;  especially  should  this 
rule  be  enforced  in  the  case  of  diphtheria,  scarlet  and  typhoid  fevers. 

2.  Milk  should  not  be  handled  in  or  near  dwellings,  privies,  or  sta- 
bles ;  cans  and  pails  should  be  washed  only  at  the  dairy,  and  after  ordi- 
nary cleansing  they  should  be  washed  in  boiling  water  or  sterilized  with 
live  steam.  Especial  attention  should  be  given  to  milk-bottles  which 
have  been  in  infected  rooms.  The  hands  of  the  milker  should  invariably 
be  carefully  washed  just  before  milking. 

3.  Dairies  should  be  subject  to  regular  city  or  State  inspection.  Milk 
from  tuberculous  cows  should  be  excluded ;  also  that  from  animals  which 
are  in  any  way  sick  or  are  suffering  from  disease  of  the  udder  should  not 
be  used. 

4.  In  all  epidemics  of  contagious  disease,  both  large  and  small,  the 
milk  supply  should  be  carefully  investigated;  and  all  cases  of  such  dis- 
eases in  the  families  of  those  who  produce  or  handle  the  milk  should  be 
immediately  reported  and  closely  followed  up  by  the  authorities. 

Means  of  reducing  the  number  and  lessening  the  growth  of  bac- 
teria in  milk. — A  marked  diminution  in  the  number  of  germs  present  in 
milk,  as  it  is  now  handled,  may  be  brought  about  by  attention  to  two  con- 
ditions— cleanliness  and  temperature — and  the  results  will  be  directly 
in  proportion  to  the  care  bestowed  upon  them. 

Cleanliness  must  have  reference,  in  the  first  place,  to  the  cows  them- 
selves. Since  most  of  the  germs  in  milk  come  from  the  cows,  it  is  impor- 
tant that  the  belly,  udder,  and  tail  should  be  cleansed  before  milking,  to 
prevent  droppings  into  the  pail.  The  parts  should  be  wiped  with  a  dry  or 
damp  cloth.  Milking  should  be  done  out  of  doors  or  in  a  clean,  special 
shed;  if  in  the  stable,  this  should  be  clean.  No  dry  fodder  should  be  fed 
and  no  sweeping  done,  nor  anything  else  to  raise  a  dust,  just  before  milk- 
ing. The  milker's  hands  should  be  carefully  washed  and  dry,  not  moist- 
ened with  milk,  as  is  sometimes  done.  Milk  pails  and  cans  should  be 
washed,  as  stated  above,  and  always  dried  upside  down,  remaining  in  this 
position  until  used.  All  sieves  and  straining  cloths  should  be  sterilized 
before  each  using.    When  possible,  milk  should  be  bottled  at  the  dairy, 


cows  MILK.  143 

and  so  transported.  When  this  is  not  done  the  milk,  after  cooling,  should 
be  put  into  the  vessel  from  which  it  is  delivered;  for  every  time  the 
milk  is  handled,  poured  from  one  vessel  into  another,  or  in  any  way 
manipulated,  the  danger  of  contamination  is  greatly  increased. 

As  to  temperature,  no  point  in  the  care  of  milk  is  more  important 
than  the  rapid  first  cooling;  as  soon  as  possible  after  being  drawn  it 
should  be  cooled  to  at  least  45°  F.  Unless  the  milk  is  taken  at  once  to 
a  milk-house,  and  some  of  the  special  forms  of  cooling  apparatus  em- 
ployed, the  cans  should  be  immersed  in  spring  water  having  a  tempera- 
ture below  50°  F.,  or  in  ice-water,  and  remain  at  least  one  hour.  If  a 
temperature  of  45°  F.  is  maintained  during  transportation,  which  is 
quite  possible  if  cans  and  bottles  are  properly  iced,  and  during  subsequent 
storage,  the  growth  of  bacteria  may  be  so  retarded  that  milk  may  be 
a  safe  food  even  when  forty-eight  hours  old.  If  the  temperature  is  not 
kept  as  low  as  50°  F.  this  result  can  not  be  depended  upon,  and  with 
every  degree  above  that  point  the  increase  in  bacterial  growth  is  very 
marked.  Since  the  number  of  bacteria  increases  so  rapidly  with  the  age 
of  the  milk  after  the  first  twenty-four  hours,  it  is  of  the  utmost  impor- 
tance that  milk  be  shipped  as  quickly  as  possible  after  it  is  collected,  for 
after  it  is  twenty-four  hours  old,  every  hour's  delay  adds  greatly  to  the 
number  of  bacteria. 

The  desirable  results  indicated  above  are  to  be  secured,  in  the  first 
place,  by  educating  the  public  to  appreciate,  and  dealers  to  produce,  a 
better  and  cleaner  milk;  secondly,  by  giving  to  the  health  authorities 
of  city  and  State  greater  power  than  heretofore  in  the  matter  of  milk 
inspection;  thirdly,  by  the  formation  of  milk  commissions,*  through 
which  the  physicians  of  a  town  or  city  may  co-operate  to  secure  adequate 
supervision  of  at  least  a  portion  of  the  milk  supply. 

Composition  of  Cow's  Milk. — Except  in  the  percentage  of  fat,  the 
composition  of  mixed  or  herd  milk  is  remarkably  uniform,  whatever  the 
breed.    The  fat  is  lowest,  about  3  per  cent,  in  the  Holsteins,  and  highest, 

*  The  first  such  commission  in  the  United  States  was  organized  in  Newark.  N.  J., 
largely  through  the  efforts  of  Dr.  H.  L.  Coit.  It  entered  into  a  contract  with  a  dairy- 
man, the  terms  of  which  were  that  the  selection  of  the  cows,  the  details  regarding 
their  food  and  care,  and  the  handling  of  the  milk,  should  be  under  the  supervision  of 
the  Medical  Commission.  All  these  matters  were  to  be  carried  out  according  to  the 
most  improved  methods.  The  animals  were  to  be  subjected  to  a  regular  inspection  by  a 
competent  veterinary  surgeon  ;  a  chemist  and  bacteriologist  to  be  employed  to  see  that 
the  milk  was  kept  up  to  the  standard  both  as  regards  composition  and  purity.  In  re- 
turn, the  milk,  which  was  to  be  delivered  only  in  bottles,  was  stamped  with  the  approval 
of  the  commission  as  "certified  milk,"  and  sold  at  a  slightly  higher  price  than  ordinary 
milk.  This  plan  has  proved  eminently  successful  both  from  a  medical  and  commercial 
standpoint,  and  has,  with  some  minor  modifications,  been  imitated  in  several  other 
cities  with  equally  satisfactory  results.  (See  Archives  of  Piediatrics,  1897,  p.  824 ;  also 
Philadelphia  Medical  Journal,  October  20,  1900.) 


1^4  NUTRITION. 

about  5  per  eent^  in  the  Jerseys.  Good  herd  milk  has,  according  to 
the  recent  analyses  of  Eichmond,  Fleischman,  United  States  Experi- 
ment Station,  Adriance,  and  others,  the  following  average  composition: 

Average  Herd  Milk.  Percent. 

Fat 400 

Sugar 4-50 

Proteids 3-oO 

Salts 0-75 

Water 87-25 

100-00 

The  results  obtained  b}^  these  different  analysts  are  quite  uniform, 
and  place  the  proteids  lower  and  sugar  a  little  higher  than  earlier 
analyses.  It  is  with  milk  of  these  proportions  that  the  average  physi- 
cian has  to  do  in  his  infant-feeding.  In  a  poor  milk  the  only  important 
difference  is  that  the  fat  is  lower,  3  to  3-50  per  cent,  while  in  a  very  rich 
or  Jersey  milk  it  ranges  from  5  to  5  -25  per  cent ;  practically,  therefore, 
all  the  physician  needs  to  know  of  the  composition  of  the  milk  is  the  per- 
centage of  fat.  As  to  the  relative  advantages  of  the  different  breeds  for 
infant-feeding,  the  difference  has  not  seemed  to  me  great,  provided  all  are 
equally  healthy.  Jerseys  and  all  highly  bred  animals  are  more  prone  to 
serious  disease  and  minor  disturbances  than  the  hardier  common  breeds. 

The  Examination  of  Cow's  Milk. — The  normal  reaction  of  cow's  milk 
is  amphoteric  or  slightly  acid;  it  should  never  be  strongly  acid.  If  it  is 
strongly  alkaline  it  is  pretty  certain  that  something  has  been  added  to  it. 

The  specific  gravity  is  from  1,028  to  1,033.  If  the  milk  has  been 
falsified  by  the  removal  of  cream,  the  specific  gravity  is  raised. 

The  best  of  all  ready  methods  of  determining  fat  are  by  the  Leffman 
and  Beam  and  the  Babcock  tests.*  By  both  the  fat  is  brought  to  the 
surface  by  the  centrifuge  after  the  addition  of  sulphuric  acid  and  other 
reagents.  These  tests  are  similar,  but  differ  in  the  reagents  used,  the 
method  first  mentioned  being  usually  preferred.  The  tests  can  be  made  in 
a  few  minutes.  When  carefully  made  they  are  very  accurate,  and  are 
believed  by  many  to  be  even  more  reliable  than  a  dry  analysis.  For 
institutions  such  an  apparatus  is  indispensable ;  several  specimens  can 
be  examined  at  the  same  time,  and  the  composition  of  the  milk  and 
cream  used  can  be  determined  each  day.  The  optical  test  by  means  of 
Feser's  lactoscope  (Fig.  26)  is  a  good  one,  and  with  a  little  experience 
in  the  use  of  the  instrument  is  quite  accurate,  f 

*  The  apparatus  for  these  tests  can  be  obtained  of  any  dairy-supply  house. 

f  The  test  is  applied  as  follows :  Four  cubic  centimetres  of  milk  measured  in  a 
pipette  are  put  into  the  tube  and  water  slowly  added,  shaking  from  time  to  time  until 
the  black  lines  on  the  porcelain  stem  "  A ''  are  faintly  visible  through  the  milky  water. 
The  percentage  of  fat  is  then  read  off  on  the  glass  cylinder  at  the  level  of  the  water 
added.     Thus,  water  up  to  the  mark  "  4  "  indicates  4  per  cent  fat,  etc.    This  test  is 


COW'S  MILK. 


145 


Fat: 

7 


4  CC. 


The  cream-gauge  (Fig.  25,  C)  may  be  used  as  for  woman's  milk, 
but  it  is  not  to  be  relied  upon  unless  the  milk  is  put  into  the  cylinder 
soon  after  it  is  drawn  and  cooled  rapidly  by  being  placed  in  ice-water. 
Under  these  conditions,  if  the  reading  is  made  at  the  end  of  eight  or 
ten  hours  the  percentage  of  cream  to  that  of  fat  is  about  four  to  one. 
If  the  milk  has  been  first  cooled  and  afterward  handled  two  or  three 
times  before  the  test  is  made,  the  cream  does  not 
rise  regularly,  and  the  above  ratio  is  not  main-  ')        (' 

tained. 

A  microscopical  examination  of  milk  is  of  con- 
siderable importance,  and  in  cases  where  the  char- 
acter of  the  supply  is  questionable  it  may  give  val- 
uable information.  Both  the  cream  and  the  sedi- 
ment should  be  examined.  'Not  much  can  be 
learned  from  a  study  of  the  fat  globules,  but 
among  them  may  be  found  colostrum  corpuscles, 
which  are  usually  present  for  nearly  a  week  after 
calving.  The  sediment  is  best  studied  after  cen- 
trifuging.  It  should  be  examined  for  pus-cells 
and  blood,  and  stained  for  bacteria.  A  few 
leucocytes  are  almost  invariably  found  in  normal 
milk.  Stokes  and  Wegefarth  consider  that  an 
average  of  more  than  five  in  each  field  exam- 
ined with  an  oil-immerson  lens  should  be  re- 
garded as  abnormal,  and  such  milk  excluded. 
The  most  frequent  source  of  pus-cells  in  numbers 
is  inflammation  of  the  udder.  Pus-cells  may  be 
associated  with  a  stringy  mucus  as  muco-pus. 
Blood  may  also  be  the  result  of  inflammation  of 
the  udder,  sometimes  from  traumatism. 

Where  pus-cells  are  present  the  specimen 
should  be  examined  for  bacteria.  Any  of  the  ordi- 
nary pyogenic  cocci  may  be  found.  Strepto- 
cocci were  found  by  Eastes  in  75  per  cent  of  186  specimens  examined, 
although  in  most  of  these  the  number  was  so  small  that  no  symptoms 
were  produced.  He  cites  one  instance  where  symptoms  were  caused. 
Woodward  has  reported  a  striking  example  where  a  family  of  five  chil- 
dren were  all  made  seriously  ill  with  vomiting  and  collapse  after  taking 
milk  which  was  found  by  him  to  contain  large  numbers  of  streptococci. 
These  cases  are  probably  not  at  all  rare.     In  staining  milk  for  tubercle 


Fig.  26.— Feser's  lacto- 
scope. 


not  to  be  applied  to  human  milk.  For  cow's  milk  it  is  pretty  satisfactory  if  the  in- 
strument is  carefully  made.  A  little  experience  is  necessary  in  order  to  know  exactly 
at  what  point  of  translucency  the  reading  is  to  be  taken.  The  lactoscope  may  be 
obtained  from  Eiraer  &  Amend,  Eighteenth  Street  and  Third  Avenue,  New  York, 


146  NUTRITION. 

bacilli  it  should  be  remembered  that  the  bacilli  found  are,  as  a  rule, 
shorter  than  those  found  in  human  sputum. 

At  the  present  time  it  is  impossible  to  lay  down  definite  rules  as  to 
what  microscopical  findings  justify  one  in  condemning  a  sample  of  milk ; 
but  whenever  pus-cells,  muco-pus,  blood,  or  streptococci  are  at  all  numer- 
ous, the  milk  should  be  regarded  as  unfit  for  food  and  a  thorough  in- 
spection of  the  herd  should  be  made. 

The  Differences  between  Cow's  Milk  and  Woman's  Milk. — Cow's  milk 
is  more  opac[ue  than  woman's  milk,  although  the  latter  may  contain  the 
larger  proportion  of  fat.  This  opacity  is  due  to  the  large  proportion 
of  calcium  phosphate  with  which  the  casein  is  combined. 

The  reaction  of  cow's  milk,  though  alkaline  or  amphoteric  when 
freshly  drawn,  very  soon  becomes  acid.  It  is  almost  invariably  found 
so  unless  some  alkali  Eas  been  added.  "Woman's  milk  is  alkaline  or  am- 
photeric. 

The  specific  gravity  and  total  solids  in  the  two  milks  are  about  the 
same. 

The  sugar  of  both  cow's  and  woman's  milk  is  identical  in  composi- 
tion; it  is  lactose  in  solution.  The  difference  in  amount  is  considerable. 
Cow's  milk  usually  has  4-5  per  cent,  while  woman's  milk  usually  has 
from  6  to  7  per  cent. 

The  greater  part  of  the  fat  of  cow's  milk  is  neutral  fat,  as  in  woman's 
milk ;  cow's  milk,  however,  contains  in  addition  larger  C|uantities  of  the 
volatile  fatty  acids,  of  which  only  traces  exist  in  woman's  milk. 

The  proteids  of  cow's  milk  are  not  only  present  in  two  and  a  half 
times  the  amount  of  those  of  woman's  milk,  but  they  show  marked  dif- 
ferences in  character. 

Koenig  divides  the  proteids  as  follows : 

Woman's  milk,  lactalbumin,  1'26  per  cent ;  casein,  1'03  per  cent. 
Cow's  "  "  0-o3      "  "       3-03      " 

The  casein  *  of  cow's  milk  is  readily  coagulated  by  rennet,  acids, 
many  metallic  salts,  and  by  the  gastric  juice.  The  curd  formed  is  tough 
and  firm  and  dissolves  slowly  by  the  action  of  the  digestive  fluids. 

The  casein  of  woman's  milk  is  not  regularly  coagulated  by  rennet, 
and  onlv  slightly  and  with  difficulty  by  acids  and  metallic  salts.  The 
curd  formed  by  the  gastric  juice  is  loose  and  flocculent,  and  is  readily  and 
completely  dissolved.  It  is  this  difference  in  the  proteids  which  presents 
the  greatest  difficulty  in  the  use  of  cow's  milk  for  infant-feeding. 

*  By  Haliburton  and  some  other  chemists  the  term  caseinogen  is  given  to  this  pro- 
teid  as  it  exists  in  milk.  When  this  is  acted  upon  by  rennet  it  splits  up  into  two  sub- 
stances :  One,  the  firm,  insoluble  coaguhun  to  which  only  the  term  casein  is  applied ; 
the  other,  a  soluble  proteid  which  is  known  as  whey-proteid  or  lacto-protein ;  this  is 
present  in  but  small  amount.  Those  who  use  the  term  casein  to  designate  the  proteid 
in  milk  sometimes  refer  to  the  curd  -ds  paracasein. 


cows  MILK. 


147 


The  inorganic  salts  in  cow's  milk  are  a  little  more  than  three  times 
as  abundant  as  in  woman's  milk.  The  most  important  differences  in 
the  composition  of  these  salts  are  shown  in  the  following  analyses : 


Ash  in 

100  Parts 

of 

Milk 

{Bunge). 

Woman's. 

Cow's. 

Potassium  oxide 

•0703 
•0257 
•0343 
■0065 
•OOOG 
-0469 
-0445 

•1720 

Sodium  oxide 

•0510 

Calcium  oxide 

•1980 

Magnesium  oxide 

•0200 

Ferric  oxide 

•00035 

Phosphoric  acid 

•1820 

Chlorine - 

•0980 

Total 

-2288 

•72135 

From  a  comparison  of  these  figures  it  will  be  noted  that  cow's  milk 
contains  relatively  a  much  larger  amount  of  calcium  phosphate  and  a 
smaller  amount  of  potassium  salts  and  of  iron  oxide.  The  ash  does 
not  accurately  represent  the  mineral  constituents  of  milk.  About  8 
per  cent  of  the  phosphoric  acid  of  the  ash,  according  to  Eichmond,  is 
derived  from  the  phosphorus  of  the  casein ;  while  the  traces  of  sulphuric 
and  carbonic  acid  found  are  not  true  mineral  constituents  of  milk. 

Cow's  milk  always  contains  a  large  number  of  bacteria,  which  in- 
crease in  proportion  to  the  age  of  the  milk;  woman's  milk  is  either 
sterile  or  contains  but  a  few  cocci  from  the  milk  ducts. 

Cream. — A  great  misapprehension  exists  as  to  its  composition.  It  is 
often  spoken  of  as  if  it  were  entirely  different  from  milk.  It  should 
rather  be  regarded  as  a  milk  which  contains  an  excess  of  fat. 

Cream  is  obtained  either  by  skimming — the  gravity  process — or  by 
the  use  of  a  centrifugal  machine  known  as  a  separator.  The  latter  pro- 
cess has  the  advantage  in  point  of  time,  as  centrifugal  cream  can  be  juit 
upon  the  market  from  twenty-four  to  thirty-six  hours  earlier  than  gravity 
cream.  It  is,  however,  attended  by  a  slight  disadvantage,  as  it  may  break 
up  mechanically  some  of  the  fat-globules,  so  that  after  heating  they  may 
form  a  thin  oily  layer  at  the  top  of  the  bottle.  This  is  more  likely  to 
occur  where  centrifugal  cream  has  been  transported  a  long  distance. 

The  following  table  gives  the  composition  of  an  average  milk  and  of 
centrifugal  cream  of  different  densities  removed  from  the  same  milk: 


Whole  milk. 

Cream. 

I. 

II. 

III. 

IV. 

V. 

Fat 

4^00 
4^50 
3^50 
0^75 

8-00 
4-50 
3-40 
0-70 

12-00 
4^20 
3^30 
0-65 

16^00 
4^05 
3^20 
0-60 

20^00 
3^90 
3^05 
0-55 

40^00 

Sutjar 

3-00 

Proteids 

2-20 

Salts 

0-45 

148 


NUTRITION. 


These  will  be  spoken  of  hereafter  as  8-per-cent  cream,  13-per-cent  cream, 
16-per-cent  cream,  etc.,  as  indicating  the  amount  of  fat  which  they 
contain. 

The  percentages  of  proteids  and  sugar  are  but  little  lower  than  in 
milk,  unless  very  rich  creams  are  considered,  and  in  them  the  reduction 
amounts  to  about  one-third  of  the  original  quantity. 

It  is  unfortunate  that  no  standard  exists  as  to  what  shall  be  sold 
as  cream.  In  New  York,  cream  contains  anywhere  between  8  and  40 
per  cent  fat.  The  very  rich,  centrifugal  cream  has  from  35  to  40  per 
cent  fat;  the  ordinary  centrifugal  cream  has  about  18  to  20  per  cent. 
Most  of  the  gravity  cream  sold  has  from  16  to  20  per  cent  fat. 

ISTone  of  the  methods  for  determining  the  fat  in  milk  is  applicable 
to  cream,  except  the  Babcock  or  Leffman  and  Beam  test. 

Top-Milk. — To  secure  a  milk  for  infant-feeding  which  is  fresh  and 
at  the  same  time  one  which  contains  an  extra  amount  of  fat,  the  prac- 
tice has  come  largely  into  vogue  of  using  the  upper  portion — a  third, 
fourth,  or  fifth — after  it  has  stood  only  a  few  hours.  To  this  the  term 
"  top-milk  "  or  "  upper-milk  "  has  been  given.  Different  percentages  of 
fat  may  be  obtained  by  varying  the  amount  removed  and  the  length  of 
time  the  milk  has  been  allowed  to  stand.  Top-milk  and  thin  cream 
have  therefore  the  same  composition,  although  they  may  differ  in  fresh- 
ness. 

If  cow's  milk  from  a  mixed  herd  is  put  into  bottles  soon  after  it  is 
drawn  and  rapidly  cooled,  it  will  be  found  that  after  four  hours  the 
upper  fourth  will  contain  nearly  all  the  fat  that  will  rise  as  cream,  and 
that  the  upper  layers  will  have  nearly  the  same  percentage  of  fat  whether 
the  milk  has  stood  for  four  hours,  for  eight  hours,  or  over  night.  This 
has  been  demonstrated  in  a  series  of  experiments  made  for  me  by  Messrs. 
Upton  &  Jeffers,  at  the  Walker-Gordon  Farm  at  Plainsboro.  After  the 
milk  had  been  standing  under  the  conditions  mentioned,  fat-tests  were 
made  with  the  Babcock  apparatus  of  the  different  four-ounce  layers  of 
bottled  milk,  which  were  carefully  removed  with  a  siphon,  with  the  fol- 
lowing results : 


Percentage  of  fat  in- 

After  four 
hours. 

After  eight 
hours. 

Over  night. 

Upper  4  oz 

20-50 
6-00 
1-50 
1-20 
1-00 

21-25 
6-50 
1-40 
1-00 
1-00 

22-00 

Second  4  oz 

6-50 

Third  4  oz 

1-00 

Fourth  4  oz 

0-30 

Fifth  4  oz 

0-05 

Each  of  these  percentages  represents  the  averages,  each  test  having 
been  repeated  many  times,  110  different  tests  in  all  having  been  made. 
It  will  be  seen  that  after  four  hours  the  composition  of  the  separate 


COW'S   MILK. 


149 


layers  does  not  change  very  much  with  the  period  of  standing.  With 
this  knowledge,  it  becomes  a  comparatively  simple  matter  to  secure 
almost  any  desired  percentage  of  fat  by  simply  varying  the  number  of 
ounces  removed  from  the  upper  part  of  the  quart.  Thus,  with  the  milk 
in  question  it  will  be  seen  that — 

Removing  16  oz.,  or  the  upper  half,    we  secure  approximately  7  per  cent  fat. 
11   "       "  "       third,   "        "  "  10      " 

"  8  "       "  "       fourth,"        "  «  13       "  " 

6  "       "  "       fifth,     "        "  "  IG      " 

The  above  results  are  what  may  be  expected  when  a  milk  containing- 
4  per  cent  fat  or  good  average  milk  is  used.  If  ver}^  rich  or  Jersey 
milk  (4-5  to  5  -5  per  cent  fat)  is  used  instead,  from  two  to  three  ounces 
more  may  be  taken  of  each  variety;  if  a  poor  milk  (3  to  3-5  per  cent 
fat),  about  two  ounces  less  than  the  amount  specified  should  be  taken 
to  secure  the  correct  percentage  of  fat.*  How  top-milk  is  used  will  be 
considered  in  connection  with  the  Home  Modification  of  Milk  (page  188). 


*  A  similar  plan  on  a  large  scale  may  be  followed  in  institutions  by  using  an  appa- 
ratus known  as  the  "  Cooley  creamer."  This  consists  of  a  wooden  tank  lined  with 
metal,  made  of  different  sizes,  holding  two,  four,  or  more  cans  of  milk.  The  cans  (Fig» 
27)  hold  eighteen  quarts,  and  are 
so  covered  that  they  can  be  sub- 
merged. The  bottom  of  the  can 
is  inclined,  and  at  the  lowest 
point  is  placed  a  faucet.  In  the 
side  is  a  glass  window,  so  that 
the  cream  level  can  be  distinctly 
seen.  The  cans  are  filled  and 
placed  in  a  tank  of  ice  water; 
after  six  or  twelve  hours  the 
lower  portion  is  drawn  off  and 
the  upper  creamy  layer  left  be- 
hind. In  this  way  a  cream  of  7, 
10,  or  16  per  cent  may  be  ob- 
tained. If  the  milk  is  put  in 
before  the  cream  has  risen  once, 
after  six  hours  from  eight  to  ten 
quarts  of  7-per-cent  cream  may 
be  obtained,  from  five  to  seven 

quarts  of  10-per-cent  cream,  and  about  four  ounces  of  IG-per-cent  cream,  the  varia- 
tions being  due  to  the  difference  in  the  milk  employed.  Tlic  exact  amount  can  be 
determined  after  a  few  experiments  with  any  given  milk  by  testing  the  strcnglli  of  iho 
cream  each  day  with  the  Babcock  machine.  Then,  with  the  same  conditions  of  time, 
temperature,  etc.,  the  results  will  be  quite  uniform.  If  the  milk  is  so  old  that  tho 
cream  has  already  risen  once,  different  results  from  those  mentioned  will  be  obtained. 
The  plan  is  a  simple  one,  involves  very  little  trouble,  and  the  milk  during  the  time 
tlie  cream  is  rising  is  kept  at  a  low  temperature. 

The  Cooley  creamer  may  be  obtained  at  Bellows  Falls,  Vt. 


Fig.  27. — Cans  of  the  Cooley  creamer.    A,  e.xternal  view; 
B,  section  view. 


150  NUTRITION. 

Milk  Sterilization. — The  term  sterilization  is  widely  and  rather 
loosely  used  to  signify  the  heating  of  milk  for  the  destruction  of  germs. 
It  should,  however,  be  borne  in  mind  that  none  of  the  methods  commonly 
employed  renders  milk  sterile  in  the  bacteriological  sense  of  the  word, 
although  this  can  be  done  by  heating  on  two  or  three  successive  days, 
as  in  preparing  culture  media.  What  is  accomplished  by  the  means  com- 
monly employed,  is  the  destruction  of  such  pathogenic  germs  as  may  be 
present,  and  a  large  number  of  the  other  bacteria,  so  as  to  retard  for 
several  days  the  ordinary  fermentative  changes.  The  preservation  of 
milk  for  infant-feeding,  by  boiling  it  in  small  bottles,  was  advocated  by 
Jacobi  many  years  ago. 

The  advantages  of  sterilizing  milk  are  obvious.  When  we  consider 
the  enormous  number  of  bacteria  present  in  cow's  milk  under  the  usual 
conditions  of  handling,  and  that  none  of  these,  so  far  as  is  now  known, 
are  advantageous,  but  that  they  are  frequently  the  cause  of  disease, 
it  is  not  strange  that  after  its  introduction  by  Soxhlet  the  practice  of 
heating  milk  used  for  infant-feeding  was  generally  adopted  all  over  the 
world.  Following  him,  the  earlier  experiments  in  sterilization  were 
made  at  212°  F.,  usually  continued  for  an  hour  and  a  half,  and  this  tem- 
perature is  still  chiefly  employed  on  the  Continent  of  Europe.  Even  this 
does  not  render  milk  safe  for  very  long.  Spores  are  not  destroyed,  and 
at  ordinary  room  temperatures  spore-bearing  bacteria  may  soon  develop 
in  such  numbers  as  to  make  the  milk  dangerous.  Since  some  of  the 
bacteria  act  upon  the  milk-proteids  and  not  upon  the  sugar,  such  milk 
does  not  always  sour,  and  hence  its  danger  may  not  be  recognised. 

There  are  disadvantages  in  heating  milk  in  the  manner  indicated. 
The  change  in  taste  and  the  constipating  effects  of  sterilized  milk  were 
soon  noticed ;  other  alterations  were  not  so  evident  and  have  only  lately 
come  to  be  appreciated,  although  many  of  these  are  not  yet  fully  ex- 
plained. The  important  chemical  changes  which  have  been  found  in 
sterilized  milk  are  as  follows :  Some  of  the  lactose  is  converted  into 
caramel,  causing  a  slight  change  in  colour;  the  lactalbumin  is  partially 
coagulated,  this  beginning  at  160°  F.  (70°  C.)  ;  the  casein  is  rendered 
less  coagulable  by  rennet,  and  appears  to  be  acted  upon  more  slowly  both 
by  pepsin  and  trypsin ;  the  organic  phosphorus  is  changed  into  an  inor- 
ganic phosphate;  citric  acid  is  partially  precipitated  as  calcium  citrate, 
and  some  lime  salts,  which  are  usually  soluble,  are  converted  into  insolu- 
ble compounds.  Certain  changes  also  occur  in  the  fat.  Moreover,  cer- 
tain natural  ferments  in  fresh  milk,  believed  to  be  of  value  in  digestion, 
are  destroyed  by  heat. 

Many  of  these  changes  are  but  imperfectly  understood,  and  some  of 
them  are  doubtless  without  any  injurious  effect  upon  nutrition.  There 
is,  however,  one  important  clinical  reason  for  believing  that  the  nutritive 
properties  of  milk  are  impaired  by  heating  to  212°  F. — viz.,  the  occur- 


MILK  STERILIZATION.  151 

rence  of  scurvy  in  infants  who  are  fed  upon  such  milk  for  a  long  time. 
Of  379  cases  of  infantile  scurvy  brought  together  in  the  Report  of  the 
American  PjBdiatric  Society  in  1898,  sterilized  milk  was  the  previous 
diet  in  107.  At  least  a  dozen  such  cases  have  come  under  my  own  notice, 
and  further  evidence  is  constantly  forthcoming.  Again  and  again  cases 
of  scurvy  have  been  cured  by  simply  ceasing  to  sterilize  the  milk. 

Sterilizing  at  Lower  Temperatures. — Pasteurizing  Milk. — To  obviate 
the  disadvantages  above  referred  to,  the  practice  has  come  largely  into 
use  in  America  of  employing  much  lower  temperatures  for  milk  steriliza- 
tion, owing  chiefly  to  the  work  of  Freeman  (New  York)  and  Eussell 
(Wisconsin). 

At  first  167°  F.  (75°  C.)  was  used;  subsequently,  however,  a  lower 
temperature  was  found  sufficient,  and  150°  to  155°  F.  (65°  to  68°  C.) 
are  the  temperatures  which  have  now  the  sanction  of  the  highest  author- 
ities, although  by  some  140°  F.  (60°  C.)  is  deemed  adequate.  These 
temperatures  are  maintained  from  twenty  to  thirty  minutes.  From  his 
very  careful  experiments  Eussell  concludes  that  140°  F.  (60°  C.)  is  suffi- 
cient to  destroy  the  bacilli  of  tuberculosis,  diphtheria,  and  typhoid  fever, 
and  from  98  to  99  -8  per  cent  of  all  the  other  bacteria  in  milk.  Most  of 
the  objectionable  changes  produced  in  sterilized  milk  are  avoided  when 
the  temperature  is  raised  only  to  155°  F.  (68°  C),  while  it  does  actually 
accomplish  the  purpose  for  which  milk  is  heated.  The  advantages  of 
this  form  of  sterilization  are  therefore  obvious.  But  spores  are  not  de- 
stroyed, and  such  milk  requires  special  handling.  After  sterilizing,  it 
should  always  be  rapidly  cooled.  If  the  low  temperature  is  maintained 
it  will  keep  for  several  days;  even  at  ordinary  room  temperatures  it 
usually  shows  little  change  for  twenty-four  hours,  but  no  attempt  should 
be  made  to  keep  it  longer,  except  on  ice. 

Pasteurization  vs.  High-temperature  Sterilization. — From  what  has 
already  been  said  it  would  appear  that  the  argument  is  altogether  in 
favour  of  pasteurization.  The  lowest  temperature  and  the  shortest  time 
that  will  surely  destroy  the  objectionable  bacteria  in  milk  would  seem 
to  merit  general  adoption.  Pasteurization,  however,  requires  consider- 
able care,  intelligence,  and  special  apparatus;  if  not  properly  done  it 
may  be  worse  than  nothing.  Moreover,  pasteurized  milk  can  not,  in  very 
hot  weather,  be  kept  without  ice  as  long  as  it  is  necessary  to  keep 
milk.  Sterilization  at  312°  F.  (100°  C.)  is  much  simpler;  it  may 
be  done  with  many  simple  and  inexpensive  forms  of  apparatus  or  even 
without  any  special  apparatus.  Where  no  ice  is  available,  it  is  certainly 
safer  in  hot  weather  than  pasteurization.  Among  the  poor  of  our 
large  cities,  in  summer,  heating  to  212°  for  an  hour  is  to  be  advised  as 
the  most  satisfactory,  and  indeed  the  only  efficient,  method  of  steriliza- 
tion. It  should  not  be  forgotten  that  the  use  of  such  milk  as  the  sole 
diet  for  a  long  time  is  attended  with  a  certain  amount  of  risk;  and  one 


152 


NUTRITION. 


should  always  be  on  the  watch  for  the  soreness  of  the  legs  and  the 
spongy  gums  that  indicate  the  beginning  of  scurvy^  as  well  as  for  the 
more  general  symptoms  of  malnutrition.  Heating  to  212°  F.  on  two 
or  three  successive  days  is  also  to  be  recommended  where  milk  must  be 
kept  for  one  or  two  weeks,  as  upon  ocean  journeys. 

Methods  of  Sterilization. — Milk  should  be  sterilized  preferably  in 
small  bottles,  each  one  of  which  contains  a  sufficient  quantity  for  one 

feeding.  These  bottles  may  be  plugged 
with  cotton  or  corks,  or  special  rubber 
stoppers  may  be  used.  If  the  latter,  they 
should  be  loosely  inserted  during  the 
process  and  pressed  tightly  home  at  its 
completion.  Soxhlet's  apparatus  may  be 
employed,  or  Arnold's  (Fig.  28),  or  any 
one  of  a  half  dozen  others  sold  in  the 
shops.  All  that  is  really  necessary  is  to 
expose  the  bottles  on  all  sides  to  live 
steam  in  a  closed  vessel.  It  can  be  done 
effectively  in  any  tin  vessel  which  has  a 
closely  fitting  cover  and  a  perforated 
bottom,  and  which  can  be  placed  over  a 
pot  of  boiling  water.  Sterilization  at 
212°  is  usually  continued  for  one  hour. 
The  bottles  should  then  be  cooled  in 
water  as  quickly  as  possible  and  placed 
upon  ice  or  in  the  coolest  place  available. 
A  simple  apparatus  for  pasteurizing 
milk  has  been  devised  by  Freeman  (Fig. 
29).  In  this  the  temperature  is  raised  to  155°  F.  (68°  C.)  by  hot  water, 
while  cold  water  is  used  as  a  conducting  medium.*     Another  useful  form 


Fig.  28. — The  Arnold  sterilizer. 


*  Freeman's  apparatus  is  used  as  follows :  The  pail  is  fllled  to  the  groove  with 
water,  which  is  then  raised  to  the  boiling  point.  The  bottles  of  milk  are  dropped  into 
their  places  in  the  cylindrical  cups,  sufficient  water  being  poured  into  each  cup  to  sur- 
round the  bottle,  this  water  acting  as  the  conductor  of  heat.  The  pail  is  now  removed 
from  the  stove  and  placed  upon  a  board  or  other  non-conductor,  and  the  receptacle 
containing  the  bottles  of  milk  is  set  inside  and  the  cover  replaced.  The  volumes  of 
milk  and  water  have  been  so  calculated  that  in  ten  minutes  they  are  both  at  a  tempera- 
ture of  155°  P.  The  water  contains  heat  enough  to  maintain  this,  with  very  slight 
variations,  for  twenty  minutes.  In  half  an  hour  the  bottles  of  milk  are  removed  and 
cooled  rapidly  by  being  placed  in  a  water- bath,  the  water  being  changed  once  or  twice ; 
or,  better,  by  setting  the  pail  in  a  sink  and  allowing  the  cold  water  to  run  from  a 
faucet  through  a  piece  of  rubber  pipe  into  the  pail,  overflowing  into  the  sink.  This 
rapid  cooling  is  very  important.  The  bottles  are  then  put  in  tlie  refrigerator.  This 
apparatus  may  be  obtained  from  James  Dougherty,  411  West  Fifty-ninth  Street,  New 
York.     (See  Archives  of  Paediatrics,  August,  1896.) 


MILK  STERILIZATION. 


153 


or  apparatus  is  that  of  the  Walker-Gordon  Laboratory  Company,  which 
contains  a  thermometer  so  that  any  desired  temperature  can  be  secured. 
An  essential  step  in  pasteurizing  milk  is  rapid  cooling.  After  forty- 
five  minutes  the  bottles  should  be  removed  from  the  pasteurizer  and 
placed  in  tepid  water  and  afterward  in  ice-water,  where  they  should 
remain  half  an  hour  before  being  placed  in  the  cold  room  or  ice  chest. 

Limitations  of  Milk  Sterilization. — Heating  milk  destroys  only  living 
organisms ;  it  does  not  kill  spores,  nor  does  it  remove  toxins.  Before 
sterilization  milk  may  already  contain  the  products  of  bacterial  growth 
in  such  quantity  and  of  such  a  character  as  to  render  it  wholly  unfit  for 
food.  Even  though  just  sterilized,  it  may  be  poisonous  to  an  infant. 
It  is  therefore  very  important  that  sterilization  be  done  at  the  earliest 
possible  moment.  It  is  most  effective  when  done  at  the  dairy  when  the 
milk  is  but  a  few  hours  old. 

Again,  the  fewer  spores  and  spore-bearing  bacteria  which  the  milk 
contains,  the  more  effective  the  sterilization.  Both  these  have  a  very 
close  relation  to  the  amount  of  dirt  contained  in  the  milk.  Hence  the 
cleaner  the  milk  the  better  will  be  the  result. 

It  should  be  distinctly  understood  that  sterilized  milk  requires  the 
same  modifications  for  infant-feeding  as  plain  milk.  There  is  no  evi- 
dence to  show  that  its  digestibility  is  in  any  way  enhanced  by  the  process 
of  heating,  but  rather  the  contrary.  A  great  misapprehension  seems  to 
exist  in  the  minds  of  many  physicians  with  reference  to  this  point.  The 
opinion  has  gained  a  certain  amount  of  currency  that,  if  milk  has  only 


Fig.  29. — Freeman's   pasteurizer.      A,  bottles  in  position  for  Iieatiiij^;   B,  method  of  cooling. 


been  "  slorilized,'"  it  may  bo  fed  to  a  young  infant  without  any  I'urtlier 
modification. 

Sterilized  milk  can  not  be  said  to  have  any  special  therapeutic  value 
in  the  gastro-enteric  diseases  of  infancy.  It  is  capable  of  causing  just 
about  as  much  disturbance  as  plain  milk  given  in  the  same  circumstances. 
Its  chief  value — and  I  think  I  may  say  almost  its  only  value — is  in  pre- 


154  NUTRITION. 

venting  disease,  first,  by  enabling  us  to  feed  infants  upon  milk  in  which, 
although  it  may  be  forty-eight  hours  old,  no  considerable  fermentative 
changes  have  taken  place ;  and  second,  by  destroying  pathogenic  germs- 
with  which  the  milk  may  have  become  accidentally  contaminated. 

Shall  all  Milk  used  for  Infant-feeding  be  Sterilized? — So  long  as 
milk  is  produced  and  handled  as  the  bulk  of  it  is  at  present,  not  being 
delivered  in  large  cities  until  it  is  considerably  over  twenty-four  hours 
old,  and  not  consumed  until  over  forty-eight  hours  old,  heating  is  cer- 
tainly an  added  safeguard.  In  hot  weather  it  should  invariably  be  em- 
ployed where  such  milk  is  used;  also,  where  there  is  any  doubt  about 
the  dairy  hygiene  or  the  health  of  the  cows;  and  during  epidemics  of 
typhoid  fever,  diphtheria,  and  scarlet  fever. 

It  is  quite  possible  to  produce  milk  for  cities  which  does  not  need 
sterilization;  the  conditions  to  be  fulfilled  have  been  detailed  on  page 
138.  There  are  special  dairies  supplying  such  milk  to  many  of  our 
large  cities,  and  their  number  may  be  very  greatly  increased  if  the 
medical  profession  will  use  its  influence  in  this  direction.  It  is  toward 
this  end  that  we  should  work,  to  secure  for  every  town  and  city  a  milk 
sufficiently  clean,  pure,  and  fresh  to  render  heating  unnecessary.  My 
personal  preference  is  strongly  for  such  milk,  believing,  as  I  do,  that  all 
heating  of  milk  sufficient  to  kill  bacteria  does  impair  to  some  extent 
its  nutritive  properties,  and  to  a  degree  directly  proportionate  to  the 
height  of  the  temperature  employed  and  the  length  of  time  it  is  contin- 
ued. In  the  country  where  milk  is  obtained  fresh  from  the  cow  and  used 
before  it  is  twenty-four  hours  old,  sterilizing  is  unnecessary,  provided 
the  cows  are  healthy  and  the  milk  is  handled  with  reasonable  care — the 
most  important  feature  of  which  is  that  it  be  quickly  and  properly  cooled 
as  soon  as  it  is  drawn. 

Peptonized  Milk. — Milk  is  peptonized  through  the  agency  of  a  sub- 
stance derived  from  the  pancreas,  usually  that  of  the  pig.  This  is  known 
in  the  market  as  "  extraetum  pancreatis,"  the  active  ferment  being  the 
trypsin.  As  this  acts  only  in  an  alkaline  medium,  bicarbonate  of  soda 
should  first  be  added  to  the  milk.  The  purpose  of  peptonizing  is  to 
secure  a  partial  or  complete  digestion  of  the  casein  of  milk  before  feeding. 

Partially  Peptonized  Milk. — The  process  is  as  follows :  *  One  pint  of 
fresh  cow's  milk  and  four  ounces  of  water  are  put  into  a  bottle,  and  a 
powder  added  containing  five  grains  of  extraetum  pancreatis  and  fifteen 
grains  of  bicarbonate  of  soda.  This  is  kept  at  a  temperature  of  105°  to 
115°  F.,  or  about  as  warm  as  the  hand  can  bear  comfortably,  best  by  pla- 
cing the  bottle  in  water.  It  should  be  shaken  from  time  to  time.  For 
partial  peptonization,  the  process  is  continued  for  from  six  to  twenty 
minutes.     The  peptonizing  powder  is  sold  in  glass  tubes  and  in  tab- 


*  Fairchild's  process. 


COXDEXSED   MILK.  I55 

lets.  The  tubes  are  to  be  preferred,  as  being  less  liable  to  deteriorate 
with  age.  Milk  which  has  been  peptonized  ten  minutes  is  not  altered 
in  taste;  if,  however,  the  process  is  continued  for  twenty  minutes,  a 
slightly  bitter  taste  is  noticed  from  the  formation  of  peptones.  This  in- 
creases with  the  duration  of  the  process  of  artificial  digestion.  If  it  is 
desired  to  arrest  this  after  ten  minutes,  the  milk  may  be  raised  to  the 
boiling  point,  which  destroys  the  ferment,  or  its  activity  may  be  stopped 
by  placing  the  milk  upon  ice.  If  the  milk  is  to  be  fed  at  once,  neither 
of  these  procedures  is  necessary.  If  it  is  to  be  kept  for  several  hours, 
scalding  is  more  certain  to  arrest  the  change  than  lowering  the  tem- 
perature. 

Completely  Peptonized  Milk. — The  process  is  exactly  the  same  as  the 
above,  except  that  it  is  continued  for  two  hours,  which  is  generally  re- 
quired for  the  conversion  of  all  the  proteids  into  peptones.  The  addi- 
tion of  acetic  acid  to  such  milk  produces  no  coagulation.  Although  com- 
pletely peptonized  milk  is  quite  bitter,  this  is  not  an  obstacle  to  its  use 
for  young  infants,  who  after  the  first  or  second  bottle  do  not  usually 
object  to  its  taste.  For  those  who  are  a  little  older,  the  bitter  taste  may 
be  covered  by  lemon-juice  and  sugar — one  even  teaspoonful  of  cane  sugar 
and  two  teaspoonfuls  of  lemon-juice  being  added  to  each  four  ounces  of 
the  milk. 

Peptonized  milk  is  to  be  diluted  according  to  the  age  of  the  child. 
It  is  usually  better  to  peptonize  a  milk-and-cream  mixture  which  has 
previously  been  diluted  with  the  proper  amount  of  water.  Peptonized 
milk  is  a  valuable  resource  in  chronic  cases  where  there  is  feeble  casein- 
digestion,  and  during  attacks  of  acute  indigestion  in  infancy.  In  acute 
attacks,  completely  peptonized  milk  is  usually  preferable  to  that  which 
has  been  partially  peptonized.  It  is  not  advisable  to  continue  its  use  in- 
definitely, for  in  this  case  the  stomach  gradually  becomes  less  and  less 
able  to  do  its  work.  At  most,  peptonization  should  be  used  only  for  a 
month  or  two  at  a  time ;  as  the  case  improves  the  amount  of  the  powder 
used  is  gradually  diminished  and  the  time  of  peptonizing  shortened. 

Condensed  Milk. — This  is  prepared  by  heating  fresh  cow's  milk  to 
212°  F.  to  destroy  the  bacteria  and  then  evaporating  in  vacuo  at  a  low 
temperature  to  a  little  less  than  one  fourth  its  volume.*  It  is  preserved 
in  tin  cans,  usually  with  the  addition  of  cane  sugar  in  the  proportion  of 
about  six  ounces  to  a  ])int.  The  changes,  therefore,  to  which  the  milk 
has  been  subjected  are :  evaporation  of  a  part  of  the  water,  partial  or 
complete  sterilization,  and  the  addition  of  cane  sugar.  Fresh  condensed 
milk  to  which  no  sugar  had  been  added  is  delivered  daily  in  iSTew  York 
and  in  other  large  cities. 

The  composition  of  condensed  milk  is  shown  in  the  following  table; 

*  Process  followed  by  the  Borden  Condensed  Milk  Company. 


156 


NUTRITION. 


also  the  results  obtained  when  it  is  diluted  with  six,  twelve,  and  eighteen 
parts  of  water,  as  usually  fed : 


Fat 

Proteids 

a  (Cane,  40-44) 

S^^^^'i  Milk;  10-25  j- 

Salts 

Water 


Condensed 
milk.* 


Per  cent. 

6-94 
8-43 

50-69 

1-39 
31-30 


With  6  parts 
of  water 
added. 


Per  cent. 

0-99 
1-20 

7-23 

0-17 
90-49 


With  12 
parts  of 
water. 


Per  cent. 

0-53 
0-65 

3-90 

0-10 
94-82 


With  18 
parts  of 
water. 


Per  c«nt. 

0-36 
0-44 

2-67 

0-07 
96-46 


The  dilution  with  twelve  parts  of  water  is  that  most  frequently  em- 
ployed, although  eighteen  is  often  used  for  very  young  infants. 

The  reasons  both  for  the  success  and  for  the  failure  of  condensed 
milk  as  an  infant-food,  are  apparent  from  a  study  of  its  composition  as 
it  is  ordinarily  used.  As  a  temporary  food  it  is  often  useful,  first  be- 
cause it  has  been  sterilized,  but  chiefly  because  the  casein  of  the  cow^s 
milk  has  been  reduced  by  the  usual  dilution  to  such  a  point  (about  0-6 
per  cent)  that  an  infant  with  a  very  weak  digestion  can  manage  it,  while 
it  furnishes  an  abundance  of  sugar,  the  easiest  thing  for  an  infant  to 
digest.  During  the  first  few  months  of  life  it  is  often  apparently  very 
successful  for  these  reasons,  but  it  can  not'  be  continued  indefinitely 
without  hazard.  I  have  seen  many  infants  reared  exclusively  upon  it, 
but  rarely  one  who  did  not  show,  on  careful  examination,  more  or  less 
evidence  of  rickets.  Condensed  milk  fails  as  a  permanent  food,  partly 
because  it  consists  too  largely  of  carbohydrates,  but  chiefly  because  it  is 
lacking  in  fat.  It  is  admissible  only  for  temporary  use  during  attacks 
of  indigestion,  for  very  young  infants  during  the  first  two  or  three 
months,  or  among  the  very  poor,  where  the  cow's  milk  which  is  available 
is  still  more  objectionable.  It  should  never  be  continued  as  a  perma- 
nent food  where  good,  fresh  cow's  milk  can  be  obtained,  nor  without 
the  addition  of  fat — fresh  cream  when  possible ;  otherwise  cod-liver  oil, 
five  to  twenty  drops  to  a  feeding.  In  travelling  it  is  often  the  most 
convenient  as  well  as  the  safest  food  to  use.  It  should  be  diluted  twelve 
times  for  an  infant  under  one  month,  and  from  six  to  ten  times  for  those 
who  are  older. 

The  fresh  condensed  milk  has  not  the  disadvantage  of  the  addition  of 
a  large  amount  of  cane  sugar,  and  requires  essentially  the  same  modifi- 
cation as  ordinary  cow's  milk.  For  the  poor  in  cities  it  is  sometimes  the 
best  infant-food  available.  For  routine  use  it  should  be  diluted  with 
from  eight  to  twelve  parts  of  water,  sugar  added,  and  fat  as  above. 


*  Analysis  made  for  the  author  by  E.  E.  Smith,  Ph.  D.,  of  Borden's  Eagle-brand 
condensed  milk. 


KUMYSS. 


157 


KuMYSS. — The  original  kumyss  was  fermented  mare's  milk,  and  has 
been  extensively  nsed  by  the  Tartars  for  centuries  both  as  a  food  and  a 
beverage.  In  this  country  kumyss  is  made  from  cow's  milk.  The  fer- 
ment used  by  the  Tartars  was  kefir  grains,  consisting  of  two  forms  of  the 
ordinary  yeast  plant  and  great  numbers  of  lactic-acid  bacilli.  The  first 
kumyss  made  in  the  country  was  fermented  by  these  grains,  but  they 
have  now  been  discarded  by  most  manufacturers  of  kumyss,  as  it  is 
true  that  the  bacteria  which  they  contain  are  of  no  advantage  and 
their  effect  may  possibly  be  deleterious.  Kumyss  was  formerly  made 
chiefly  from  skimmed  milk,  but  at  present  many  manufacturers  use 
the  whole  milk,  with  the  addition  of  cane  sugar  and  a  small  propor- 
tion (about  one  sixteenth)  of  water.  The  process  now  most  commonly 
employed  is  started  with  ordinary  yeast,  causing  a  vinous  fermentation. 
This  is  carried  on  at  a  temperature  of  from  60°  to  70°  F.  in  corked 
bottles.  At  a  little  higher  temperature  the  fermentation  proceeds 
more  rapidly,  and  may  be  completed  in  two  or  three  days;  but  better 
results  are  obtained  with  the  slower  process,  which  requires  a  week  or 
ten  days.* 

As  thus  manufactured,  kumyss  contains  alcohol,  carbon  dioxide,  lac- 
tic acid,  and  traces  of  butyric  and  acetic  acids.  The  casein  is  first  coagu- 
lated, and  then  broken  up  into  minute  particles  by  the  agitation  to  which 
the  kumyss  is  subjected  during  manufacture.  Some  of  the  casein  is 
■probably  converted  into  albumoses  or  similar  compounds. 

Kumyss  has  an  acid  reaction  and  a  peculiar  taste  somewhat  resem- 
bling buttermilk ;  at  first  it  is  often  disagreeable,  but  a  fondness  for  it 
is  soon  acquired  by  the  majority  of  those  who  take  it.  Its  composition 
is  as  follows : 


Kumyss. 


Made  from 

mare's  milk 

(Koenig). 

Made  from 
cow's  milk 
(Koenig). 

Made  from 

skimmed  milk 

(Koenig). 

Bnish'.s  kumyss 
(Doremus). 

Fat 

Proteids 

1-46 
2-24 
1-47 
1-91 
0-91 

6-42 
91-29 

1-88 
2-66 
4-09 
1-14 
0-55 

6-43 
89-80 

0-88 
2-89 
3-95 
1-38 
0-82 

6-53 
89-55 

1-91 
2-04 

Sugar 

Alcohol 

Lactic  acid 

3-26 
0-62 

Acid 

Carbon  dioxide 

Salts 

Water 

0-30 

0-44 

0-44 

90-99 

*  The  following  is  perhaps  the  best  formula  for  tlie  domestic  manufacture  of 
kumyss  :  One  quart  of  fresh  milk,  half  an  ounce  of  sugar,  two  ounces  of  water,  a  {uece 
of  fresh  yeast  cake  half  an  inch  square;  put  into  wired  bottles,  keep  at  a  temperature 
between  60°  and  70°  F.  for  one  week,  shaking  five  or  six  times  a  day,  and  then  put 
upon  ice. 

13 


158  NUTRITION. 

The  advantages  of  kumyss  are  due  to  the  alcohol,  carbon  dioxide,  and 
lactic  acid  which  it  contains,  and  to  the  changes  which  have  taken  place 
in  the  casein  of  the  milk  by  which  its  digestibility  is  very  much  increased. 
It  is  more  useful  for  older  children  than  for  young  infants.  It  is  a 
very  valuable  resource  in  many  forms  of  acute  and  chronic  indigestion. 
Kumyss  is  often  retained  when  milk  in  any  other  form  is  vomited.  In 
chronic  cases  it  frequently  stimulates  the  appetite  and  improves  diges- 
tion. 

Eor  infants,  kumyss  should  be  diluted,  generally  with  an  equal  quan- 
tity of  water.  Many  take  it  better  if  the  gas  has  been  allowed  to  escape 
by  standing  a  few  minutes.  When  the  stomach  is  very  irritable  it  should 
be  given,  preferably  cold,  in  small  quantities  and  frequentlv — e.  g.,  a 
tablespoonful  every  twenty  or  thirty  minutes.  It  is  important  to  secure 
a  reliable  article  and  one  that  is  reasonably  fresh. 

Matzoon. — Matzoon,  or  zoolak,  is  a  form  of  fermented  milk  first 
used  in  Asia  Minor.  The  process  of  manufacture  is  given  by  Dadirrian 
as  follows:  Cow's  milk  is  employed,  with  the  addition  only  of  an  im- 
ported ferment  which  consists  probably  of  a  form  of  yeast.  The  milk  is  ' 
first  boiled  half  an  hour  for  sterilization.  The  fermentation  is  begun  at 
a  temperature  of  about  105°  F.  and  continued  in  an  open  vessel  for 
twelve  hours,  the  temperature  being  gradually  reduced  to  about  70°  F., 
after  which  it  is  cooled,  bottled,  and  kept  on  ice.  It  is  ready  for  use  in 
twenty-four  hours.  A  very  slow  fermentation  continues  after  bottling, 
so  that  the  older  matzoon  is  more  sour  than  that  freshly  made;  older 
specimens  contain  also  a  little  carbon  dioxide.  Matzoon  keeps  on  ice 
for  two  or  three  weeks.  It  is  a  thick,  curdy  fluid  with  a  taste  some- 
what resembling  sour  cream.  For  infant-feeding  it  should  be  diluted 
with  water  and  fed  with  a  spoon,  as  it  is  too  thick  to  be  drawn  from  a 
bottle. 

The  composition  of  Dadirrian's  matzoon  is  as  follows  (Leeds)  : 

Matzoon,  or  ZoolaJc. 

Proteids 3-48 

Fat 3-49 

Milk  sugar 3-68 

Lactic  acid 0-90 

Alcohol  and  other  products  of  fermentation 0'  13 

Mineral  salts 0-69 

Water 87-63 

100-00 

By  the  process  to  which  the  milk  is  subjected  there  is,  as  in  the  manu- 
facture of  kumyss,  a  decomposition  of  the  milk  sugar  into  alcohol,  lactic 
and  carbonic  acids.  The  changes  in  the  proteids  are  quite  similar  to 
those  in  kumyss.    In  kumyss  the  carbonic  acid  is  retained,  while  in  mat- 


BEEF   PREPARATIONS. 


159 


zoon  the  greater  part  of  the  gas  escapes.  The  indications  for  the  use  of 
matzoon  are  the  same  as  for  kumyss. 

Junket,  Curds  axd  Whey. — Junket  is  made  as  follows:  To  one 
pint  of  fresh  lukewarm  cow's  milk  are  added  two  teaspoonfuls  of  essence 
of  pepsin  or  liquid  rennet.  It  is  stirred  for  a  moment  and  then  allowed 
to  stand  until  firmly  coagulated.  It  may  be  flavoured  with  wine,  which 
should  be  added  to  it  before  coagulation.  It  is  given  cold.  The  only 
change  which  has  taken  place  is  the  coagulation  of  the  casein — such  as 
occurs  in  the  stomach  as  the  first  step  in  digestion.  Junket  is  useful  in 
the  feeding  of  older  children,  but  should  not  be  given  to  infants. 

Whey. — -The  milk  is  coagulated  with  rennet  as  above,  the  curd  is 
then  broken  up,  and  the  whey  strained  off  through  muslin.  The  compo- 
sition of  whey  varies  somewhat,  depending  upon  the  way  it  is  prepared. 
If  it  is  desired  to  have  as  little  fat  as  possible,  milk  from  which  the  cream 
has  been  removed,  preferably  by  a  separator,  should  be  used,  and  it 
should  be  strained  through  fine  muslin  and  absorbent  cotton  without 
pressure.  If  it  is  desired  to  retain  some  of  the  fat,  whole  milk  should  be 
used,  coarser  muslin,  and  more  pressure.  The  proteids  of  whey  are 
chiefly  lactalbumin  with  a  smaller  amount  of  lactoprotein. 

Whey. 


Average, 

46  analyses 

(Koenig). 

From 
whole  milk 
(Adriance). 

From 
fat-free  milk 
(Adriance). 

Proteids 

0-86 
0-32 
4-79 
0-65 
93-38 

0-94 
0-96 
5-49 
0-48 
92-13 

1*17 

Fat 

0-04 

Sugar 

5-36 

Salts 

0-52 

Water 

92-91 

Total 

100-00 

100-00 

100-00 

Whey  is  especially  valuable  for  infants  in  cases  of  acute  indiges- 
tion; it  may  often  be  used  in  chronic  cases  with  great  benefit  where 
there  is  much  difficulty  in  the  digestion  of  casein,  it  may  then  be  made 
the  basis  of  a  milk  modification.  Wine  whey  is  made  by  adding  sherry, 
usually  in  the  proportion  of  one  part  to  sixteen. 


BEEP   PREPARATIONS. 

The  nutrient  properties  of  these  preparations  are  to  be  measured  by 
the  amount  of  albumin  they  contain,  their  stimulant  properties  by  the 
pro])oi-tinii  of  extractives. 

Beef  Juice. — Expressed  beef  juice  is  made  as  follows  :  A  piece  of  lean 
steak  is  slightly  broilod,  and  tlic  juice  pressed  out  by  a  meat-press  or  a 
lemon-squeezer.     Two  or  three  ounces  can  ordinarily  be  obtained  from 


160 


NUTRITION. 


one  pound  of  steak.  This  is  seasoned  with  salt  and  given  cold  or  warm, 
but  not  heated  sufficiently  to  coagulate  the  albumin  in  solution. 

Another  excellent  method  of  making  beef  juice  without  cooking,  is 
by  taking  one  pound  of  finel3'-chopped  lean  beef  and  eight  ounces  of 
water  and  allowing  this  to  stand  in  a  covered  jar  upon  ice  from  six  to 
twelve  hours.  The  juice  is  then  squeezed  out  by  twisting  the  meat  in 
coarse  muslin.  It  is  seasoned  with  salt  and  given  as  above.  This  is 
not  quite  so  palatable  as  that  obtained  by  the  first  method,  because  it 
contains  a  smaller  proportion  of  extractives.  It  can  be  made  so,  how- 
ever, by  the  addition  of  sherry  wine  or  celery  salt.  If  the  raw  juice  is 
added  to  milk  in  the  proportion  of  two  or  three  teaspoonfuls  to  each 
feeding,  the  taste  will  not  be  noticed.  The  milk  should  not  be  warmed 
above  100°  F.  before  the  addition  of  the  juice. 

The  composition  of  the  two  products  is  shown  in  the  following  table ; 


Beef  Juice* 

I. 

Expressed  juice 
from  1  lb.,  warm 
process:  quan- 
tity, 2X  oz. 

n. 

Cold  process, 
1  lb.  beef,  8  oz. 
water  ;  quan- 
tity, 83<  oz. 

Proteids 

2-90 
0-60 
3-40 
0-20 
92-90 

3-00 

Fat 

Extractives 

1-90 

Salts 

0-20 

Water 

94-90 

100-00 

100-00 

The  only  difference  in  the  two  preparations  is  that  the  first  contains 
about  twice  as  much  of  the  extractives.  The  second  process  is  much 
more  economical,  as  more  than  three  times  as  much  juice  can  be  ob- 
tained from  a  given  quantity  of  beef.  If  a  stronger  juice  is  desired,  the 
amount  of  proteids  may  be  doubled  by  using  only  four  ounces  of  water. 
This  is  preferable  for  all  except  young  infants. 

Beef  extracts  are  not  to  be  considered  in  any  sense  as  foods.  Kem- 
merich  has  shown  that  animals  receiving  nothing  else  died  of  starvation, 
and  sooner  even  than  when  everything  was  withheld.  According  to  Chit- 
tenden, they  contain  no  nitrogen  in  the  form  of  proteids,  but  only  in 
combination  with  the  soluble  extractives.  They  are  stimulants,  and  as 
such  are  often  useful. 

Of  the  other  preparations  of  beef  in  the  market  probably  the  best  are 
Mosquera's  beef  jelly,  bovinine,  the  liquid  peptonoids  of  the  Arlington 
Company,  panopepton,  and  Murdock's  liquid  food.  These  contain  from 
ten  to  thirty-five  per  cent  of  proteids  available  for  nutrition.    They  are 


*  Analysis  made  for  the  author  by  E.  E.  Smith,  Ph.  D. 


CEREALS.  1P,1 

valuable  additions  to  milk  in  the  artificial  feeding  of  infants.  The,y 
also  furnish  a  proteid  which  can  be  used  in  many  cases  of  indigestion 
where  milk  is  not  admissible.  For  infants  they  must  be  well  diluted. 
They  are  valuable  in  older  children  in  many  cases  of  general  malnu- 
trition. 

Eaw  scraped  beef,  or  that  which  has  been  slightly  cooked,  is  easily 
digested  by  most  young  children.  There  are  many  conditions  in  which 
other  forms  of  proteid,  particularly  casein,  are  not  well  borne,  and  in- 
deed can  not  be  taken  at  all,  where  children  even  as  young  as  twelve 
months  appear  to  digest  this  beef-pulp  without  any  difficulty.  It  should 
be  made  from  very  rare  or  raw  steak,  finely  scraped  and  well  salted.  A 
tablespoonful  may  be  given  at  one  feeding  to  a  child  of  eighteen  months. 
In  nutrient  properties  this  far  exceeds  most  of  the  beef  preparations  in 
the  market.  The  alleged  danger  of  tapeworm  from  the  use  of  raw  meat, 
is  in  this  country  so  slight  that  it  may  be  disregarded. 

Broths. — Animal  broths  may  be  made  from  mutton,  veal,  chicken,  or 
beef.  A  good  formula  for  general  use  is  the  following :  One  pound  of 
lean  meat,  one  pint  of  water;  stand  for  four  or  five  hours,  then  cook  over 
a  slow  fire  for  one  hour  down  to  half  a  pint.  After  it  has  cooled,  skim 
off  the  fat  and  strain  through  a  cloth.  The  composition  of  a  broth  so 
made  is  given  by  Cheadle  as  follows : 

Beef  Broth. 

Proteids 1-02 

Extractives 1-82 

Pat 

Salts 0-88 

Water 96-28 

100-00 

From  its  composition  it  will  be  seen  that  broths  are  not  very  nutri- 
tious ;  they  are,  however,  quite  stimulating,  and  are  at  times  useful,  par- 
ticularly where  milk  is  to  be  temporarily  withheld;  but  they  are  not 
adapted  to  prolonged  use.  Broths  which  have  been  thickened  with  either 
barlev  or  rice  flour  are  useful  for  children  in  the  second  and  third  vears. 


CEREALS. 

Barley  Water. — This  may  be  made  either  from  tlie  grains  or  from  the 
barley  flour.  When  the  grains  are  used,  the  following  is  the  formula 
wbieh  I  have  been  accustomed  to  employ:  To  two  tablespoonfuls  of  bar- 
ley, add  one  quart  of  water,  and  boil  continuously  for  six  hours,  keeping 
the  quantity  up  to  a  quart  by  the  addition  of  water;  strain  through 
coarse  muslin.  It  is  an  advantage  to  soak  the  barley  for  a  few  hours,  or 
even  over-night,  before  using.     The  water  in  which  it  is  soaked  is  not 


162  NUTRITION. 

used.    When  cold  this  makes  a  rather  thin  barley  jelly.    Its  composition 
by  analysis  is  as  follows : 

Barley  Water. 

Starch 1-63 

Fat 0-05 

Proteids 0-09 

Inorganic  salts 0'03 

Water 98-20 

100-00 

Almost  an  identical  product  may  be  obtained  in  an  easier  way  by 
using  either  the  prepared  barley  flour  of  the  Health  Food  Compan}^,  Xew 
York,  or  Robinson's  barley,  two  drachms — one  even  tablespoonful — to 
each  twelve  ounces  of  water,  and  cooking  for  fifteen  minutes. 

nice  Water,  Oatmeal  Water,  etc. — These  may  be  made  in  the  same 
manner  as  the  barley  water,  using  the  same  proportions  either  of  the 
flour  or  the  grains.  These  are  useful  as  additions  to  milk  for  healthy 
infants  who  have  reached  the  age  of  seven  or  eight  months;  they  may 
also  be  given  in  many  cases  of  acute  or  chronic  indigestion  where  milk 
must  be  omitted  or  given  in  small  C[uantities.  When  there  is  a  tendency 
to  constipation  oatmeal  is  preferred;  when  to  looseness,  barley  or  rice 
water.  The  digestibility  of  cereals  is  greatly  increased  by  the  addition 
of  diastase;  dextrinization  may  be  effected  by  such  preparations  as 
Forbes's  diastase,  elixir  of  taka-diastase,  c-ereo,  etc. 

INFANT-FOODS. 

It  is  not  possible,  nor  even  desirable,  for  a  physician  to  know  all  about 
the  infant-foods  with  which  the  market  is  flooded.  He  should,  however, 
know  at  least  that  they  are  not  perfect  substitutes  for  breast-milk,  that 
as  permanent  foods  they  are  greatly  inferior  to  properly  modified  cow's 
milk,  and  that  as  often  used  by  the  laity,  and  even  by  the  medical  pro- 
fession, they  are  capable  of  doing  and  have  done  much  positive  harm. 
Eickets  and  scurvy  have  so  frequently  followed  their  prolonged  use,  espe- 
cially when  given  without  the  addition  of  fresh  milk,  that  there  can  be 
no  escaping  the  conclusion  that  they  were  the  active  cause.  The  almost 
unanimous  verdict  of  intelligent  physicians  is  against  their  use  as  perma- 
nent foods.  On  the  other  hand,  there  are  times  when  some  of  these 
preparations  may  be  of  considerable  value,  but  chiefly  for  temporary  use 
in  pathological  conditions.  Here  they  are  to  be  prescribed  like  drugs, 
but  only  with  a  very  definite  knowledge  of  exactly  what  they  do  and  what 
they  do  not  contain.  The  most  commonly  used  infant-foods  may  be 
grouped  as  follows : 

1.  The  Milk  Foods. — Xestle's  food  is  perhaps  the  most  widely  known. 
The  others  closely  resembling  it  in  composition  are  the  Anglo-Swiss,  the 


PLATE     III. 


WOMAN'S   MILK. 


COW'S   MILK. 


Proteids. 

Fat 

Soluble  Carbohydrates  (s^gar  - 

Salts. 

Insoluble  Carbohydrates  Utarch 


CANNED   CONDENSED   MILK. 


MELLIN'S   FOOD. 


MALTED   MILK. 


NESTLE'S   FOOD. 


CARNRICK'S  SOLUBLE    FOOD. 


H 


IMPERIAL  GRANUM. 


Chart  showing  the  solid  ingredients  of  various  infant  foods 
as  compared  with  those  of  woman's  milk. 


INFANT-FOODS. 


163 


Franco-Swiss,  the  American-Swiss,  and  Gerber's  food.  These  foods  are 
essentially  sweetened  condensed  milk  evaporated  to  dryness,  with  the 
addition  of  some  form  of  flour  which  has  been  partially  dextrinized ;  they 
all  contain  a  large  proportion  of  nnchanged  starch. 

2.  The  Liebig  or  Malted  Foods. — Mellin's  food  may  be  taken  as  a  type 
of  the  class.  Others  which  resemble  it  more  or  less  closely  are  Liebig's, 
Horlick's  food,  Hawley's  food,  malted  milk,  and  cereal  milk.  Mellin's 
food  is  composed  principally  (80  per  cent)  of  soluble  carbohydrates. 
They  are  derived  from  malted  wheat  and  barley  flour,  and  are  composed 
chiefly  of  a  mixture  of  dextrins,  dextrose,  and  maltose. 

3.  The  Farinaceous  Foods. — These  are  imperial  granum,  Ridge's 
food,  Hubbell's  prepared  wheat,  and  Robinson's  patent  barley.  The  first 
consists  of  wheat  flour  previously  prepared  by  baking,  by  which  a  small 
proportion  of  the  starch — from  one  to  six  per  cent — has  been  converted 
into  sugar.  In  chemical  composition  these  four  foods  are  very  similar  to 
each  other,  consisting  mainly  of  unchanged  starch  which  forms  from 
seventy-five  to  eighty  per  cent  of  their  solid  constituents. 

4.  Miscellaneous  Foods. — Under  this  head  may  be  mentioned  (1) 
Carnriek's  soluble  food,  which  is  composed  mainly  of  carbohydrates, 
more  than  one  half  being  unchanged  starch;  (2)  lacto-preparata,  which 
differs  from  the  above  chiefly  in  the  fact  that  the  starch  has  been  re- 
placed by  milk  sugar;  (3)  lactated  food,  which  is  composed  of  about 
seventy-five  per  cent  carbohydrates,  nearly  one  half  of  which  is  un- 
changed starch. 


The  Composition 

of  Infant-Foods* 

NesUfi's 
fopd. 

Mellin's 
food. 

Eskay's 
food. 

Malted 
mUk. 

Ridge's 
food. 

Imperial 
granum. 

Lacto- 
preparata. 

Camrick'» 
food. 

Fat 

Per  cent. 

4-45 
11-47 
29-22 

6-22 

[-15-95 

si -39 

28  43 

1-73 

2-53 

Per  cent. 
0-24 
11-50 

i9-26 
eo-so 

80-00 

'3-59 
4-73 

Per  cent. 
1-16 

5-82 

i4-.35 
{-53-46t 

67-81 

21-21 

1-30 

2-70 

Per  cent. 
8-78 
16-35 

18-86 

|-49-1.5t 
67-95 

"3-86 
3-06 

Per  cent. 
Ill 

11-81 

'i-28 
0-52 

'i-86 

76-21 
0-49 
8-58 

Per  cent. 
104 
14-00 

"i'38 
0-42 

'i-so 

73-54 
0-39 
9-23 

Per  cent. 
12-35 
14-51 

63-68 

63-68 

3-66 
5-80 

Per  cent. 
7-45 

10-25 

Cane  sugar 

Dextrins 

Dextrose 

Total  soluble  carbohydrates 

Insoluble  carbohydrates  (starch) 
Inorganic  salts 

27-08 
37-37 
4-42 

3-42 

A  better  idea  of  the  composition  of  these  foods  can  be  obtained  by 
a  study  of  the  accompanying  chart  (Plate  III),  which  shows  their  solid 
constituents  as  compared  with  those  of  woman's  milk.  The  essential 
features  of  the  foods  are  seen  at  a  glance — i.  e.,  they  are  all  composed 
principally  of  carbohydrates  and  are  lacking  in  fat.     Some  of  them  con- 

*  With  the  exception  of  lacto-preparata  and  Carnrick's  soluble  food,  which  are 
taken  from  Leeds,  all  these  analyses  were  made  for  the  author  by  E.  E.  Smith,  PIi.  D., 
of  samples  purchased  in  the  open  market,  1901. 

t  Chiefly  lactose.  t  Lai'gely  maltose. 


164  NUTRITION. 

tain  a  large  proportion  of  nnclianged  starch.  Furthermore,  their  pro- 
teids,  though  often  sufficient  in  amount,  are  chiefly  vegetable,  not  ani- 
mal proteids.  Xo  one  of  them  can  be  regarded  in  any  sense  as  a  proper 
substitute  for  breast-milk. 

Some  of  these  foods — Xestle's  and  other  milk  foods,  malted  milk, 
cereal  milk,  and  Camrick's  food,  and  even  some  of  the  farinaceous 
foods,  like  imperial  granum — are  advertised  as  substitutes  for  breast- 
feeding and  recommended  for  use  alone.  Others,  such  as  Mellin's,  Lie- 
big's,  and  Eskay"s  foods,  are  intended  to  be  prepared  with  milk.  The 
use  of  any  of  the  commercial  foods  alone  is  admissible  only  for  short 
periods  during  derangements  of  digestion,  when  we  wish  to  withhold 
for  the  time  all  fat  and  milk  proteids.  Their  prolonged  use  almost 
invariably  produces  some  grave  disorder  of  nutrition,  most  frequently 
scurvy.  Those  foods  which  require  in  their  preparation  the  addition 
of  milk  are  open  to  less  serious  objections.  They  should  not  be  used 
with  condensed  milk.  When  added  to  fresh  milk  they  may  serve  a  use- 
ful purpose  in  furnishing  the  additional  carbohydrates  required  by  an 
infant  fed  upon  a  diluted  cow's  milk.  In  such  a  case  they  would  take 
the  place  of  milk  sugar  or  cane  sugar  in  the  milk  modification.  That 
they  themselves  exert  an  important  modifying  influence  upon  cow's  milk 
so  as  to  increase  its  digestibility  is  certainly  to  be  doubted.  The  group 
classed  as  farinaceous  foods,  since  they  furnish  starch  in  a  convenient 
and  palatable  form,  may  often  be  advantageously  used  as  an  addition 
to  milk  after  the  seventh  or  eighth  month  and  during  the  second  year. 


CHAPTER    III. 

IXFANT-FEEDING. 
CHOICE   OF   METHODS   OF   FEEDING. 

The  different  methods  of  feeding  which  are  available  are : 

1.  Breast-feeding,  either  by  the  mother  or  by  a  wet-nurse. 

3.  Mixed  feeding,  or  a  combination  of  nursing  and  artificial  feeding. 

3.  Artificial  feeding  exclusively. 

In  deciding  by  which  one  of  these  methods  a  child  shall  be  fed,  many 
circumstances  must  be  taken  into  consideration :  the  vigour  of  the  child, 
the  health  of  the  mother,  and  especially  the  surroundings,  since  these 
determine  very  largely  the  success  or  failure  of  any  method  employed. 

Maternal  Nursing. — This  is  the  natural  and  the  ideal  method  of 
infant-feeding.  Every  mother  should  nurse  her  infant  unless  there  are 
some  very  weighty  reasons  to  the  contrary.     The  physician  should  do  all 


MATERNAL  NURSING.  165 

in  his  power  to  encourage  maternal  nursing  and  to  promote  its  success. 
This  may  be  furthered  by  proper  care  of  the  nipples  before  delivery,  so 
that  they  may  be  prepared  for  their  work ;  by  attention  to  them  during 
the  early  days  of  nursing  to  prevent  fissures  and  mastitis,  which  so  often 
interrupt  otherwise  successful  nursing ;  by  careful  regulation  of  the  diet 
and  habits  of  the  nursing  mother  to  secure  the  simple,  natural  life  in 
which  lactation  is  easiest. 

In  spite  of  all  efforts  to  the  contrary,  it  is  nevertheless  a  fact  that 
the  capacity  for  maternal  nursing  is  steadily  diminishing  in  this  coun- 
try, chiefly  in  the  cities,  but  to  a  considerable  degree  in  the  rural  dis- 
tricts as  well.  Among  the  well-to-do  classes  in  Xew  York  and  its  sub- 
urbs, of  those  who  have  earnestly  and  intelligently  attempted  to  nurse, 
not  more  than  25  per  cent,  in  my  experience,  have  been  able  to  con- 
tinue satisfactorily  for  as  long  as  three  months.  An  intellectual  city 
mother  who  is  able  to  nurse  her  child  successfully  for  the  entire  first 
3'ear  is  almost  a  phenomenon.  Among  the  poorer  classes  in  our  cities 
a  marked  decline  in  nursing  ability  is  also  seen,  although  not  yet  to  the 
same  degree  as  in  the  higher  social  scale.  These  are  facts  that  must 
be  taken  into  account  in  deciding  the  question  of  feeding.  While  noth- 
ing is  so  good  as  good  maternal  nursing,  no  method  of  feeding  gives 
much  worse  results  than  poor  nursing.  Among  the  higher  classes  of 
society,  where  most  of  the  maternal  nursing  is  of  an  inferior  qual- 
ity, but  where  every  facility  can  be  afforded  for  the  best  artificial  feed- 
ing, one  should  not  be  slow  to  adopt  the  latter  in  cases  of  doubt. 
Among  the  poor  and  ignorant,  however,  where  artificial  feeding  can 
not  be  carried  on  with  anything  like  the  same  chances  of  success,  one 
should  persist  in  maternal  nursing  so  long  as  there  is  any  possibility  of 
success. 

When  maternal  nursing  should  not  he  attempted. — (1)  No  mother 
who  is  the  subject  of  tuberculosis  in  any  form,  whether  latent  or  active, 
should  nurse  her  infant ;  it  can  only  hasten  the  progress  of  the  disease 
in  herself,  while  at  the  same  time  it  exposes  the  infant  to  the  danger  of 
infection.  (2)  Xursing  should  not  be  allowed  where  serious  compli- 
cations have  been  connected  with  parturition,  such  as  severe  haemor- 
rhage, puerperal  convulsions,  nephritis,  or  puerperal  septicaemia.  (3) 
If  the  mother  is  choreic  or  epileptic.  (4)  If  the  mother  is  suffering 
from  any  serious  chronic  disease  or  is  very  delicate,  since  great  harm  may 
be  done  to  her,  without  any  corresponding  benefit  to  the  child.  (5) 
Where  experience  on  two  previous  occasions  under  favourable  conditions 
has  shown  her  inability  to  nurse  her  child.  (6)  When  no  milk  is  secreted. 
Witli  reference  to  the  fourth  and  fifth  conditions,  an  absolute  opinion 
can  not  always  bo  given  at  the  outset.  My  own  inclination  as  a  result 
of  increasing  experience  is  not  to  allow  nursing  in  either  of  these  condi- 
tions, provided  the  means  for  proper  artificial  feeding  can  be  com- 


166 


NUTRITION. 


manded.  The  chances  of  success  are  so  small  and  the  difficulties  are  so 
increased  by  even  a  few  weeks  of  bad  nursing  that  I  prefer  not  to  put 
the  child  to  the  breast  at  all,  even  for  the  first  two  or  three  days.  The 
breasts  are  bound  up  at  once  and  kept  bandaged.  The  theoretical  objec- 
tion that  uterine  contractions  are  not  likely  to  be  sufficient  under  these 
circumstances  does  not  hold  in  practice.  When  one  begins  with  healthy 
digestive  organs,  artificial  feeding  is  very  simple  and  almost  invariably 
successful ;  how  simple  and  how  successful,  one  who  is  in  the  habit  of 
allowing  all  children  to  nurse  until  they  are  manifestly  upset  by  it,  can 
hardly  appreciate.     (See  Fig.  30.) 


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Fig.  30. — Weight  curve  of  nursing  and  artificial  feeding  compared. 

Both  infants  were  strong,  well  nourished,  and  in  good  surroundings.  The  bottle-fed  infant 
was  never  once  put  to  the  breast ;  fed  from  the  milk  laboratory.  First  formula  :  Fat  1  per  cent, 
sugar  5  per  cent,  proteids  0-5  per  cent.  At  six  weeks  taking ;  Fat  3  per  cent,  sugar  7  per  cent, 
proteids  1'25  per  cent.  It  will  be  observed  that  the  nursing  infant  made  more  rapid  progress 
during  the  first  few  weeks,  while  the  bottle-fed  infant  more  than  made  up  for  this  oetween  the 
fifth  and  ninth  month,  for  weaning  became  necessary  in  the  other  child  owing  to  the  gradual 
failui-e  of  the  mother's  milk.  The  stutiouary  weight  was  the  result  of  this  condition,  and  the 
irregular  subsequent  gain  was  incident  to  the  change  of  food. 


Artificial  Feeding  vs.  "Wet-Nursing. — When  maternal  nursing  is  im- 
possible or  undesirable,  the  milk  of  another  woman  would  seem  to  be 
the  most  natural  and  best  substitute.  While  this  is  theoretically  true, 
the  practical  obstacles  are  so  many  as  to  put  wet-nursing  out  of  the 


BREAST-FEEDING.  167 

question  as  a  general  method  of  feeding.  We  have  in  America  no 
peasant  class  like  that  of  Europe  to  draw  upon;  and  in  the  class  which 
furnishes  most  of  our  wet-nurses  the  capacity  to  nurse  has  steadily 
diminished.  The  expense  of  a  wet-nurse — twenty  to  thirty-iive  dollars 
a  mouth  in  'New  York — the  danger  of  transmitting  contagious  disease, 
and  the  difficulty  of  obtaining  proper  care  for  her  own  infant,  are  all  very 
serious  objections  to  wet-nursing.  The  recent  advances  in  artificial  feed- 
ing have  placed  it  now  on  quite  a  different  footing  from  that  which  it 
formerly  occupied.  While  it  is  true  that  good  breast-milk  is  unques- 
tionably the  best  food,  it  is  equally  true  that  properly  modified  cow's 
milk  is  a  far  better  food  than  the  milk  of  many  wet-nurses  who  are 
employed.  These  facts  added  to  the  constantly  increasing  difficulty  of 
obtaining  good  ones  have  caused  wet-nurses  to  be  pretty  generally  dis- 
carded, even  in  our  large  cities,  where  formerly  no  other  substitute  for 
maternal  nursing  was  considered. 

There  are,  however,  some  conditions  in  which  they  are  necessar)', 
even  indispensable.  Some  young  infants,  usually  those  who  have  been 
badly  started,  can  not  be  made  to  thrive  upon  any  form  of  artificial  feed- 
ing. There  are  also  many  premature  infants  and  some  very  delicate 
ones  whose  powers  of  assimilation  are  so  feeble  that  they  are  reared 
under  any  circumstances  only  with  the  greatest  difficulty,  but  whose 
.chances  of  life  are  much  increased  by  a  good  wet-nurse.  Again,  in 
young  infants  who  have  been  suffering  for  some  time  from  chronic  indi- 
gestion and  failing  nutrition,  the  symptoms  of  acute  inanition  some- 
times develop  with  great  rapidity  and  severity.  From  such  a  condi- 
tion, apparently  hopeless,  infants  may  sometimes  be  rescued  by  the 
timely  assistance  of  a  good  wet-nurse. 

The  difficulties  in  the  way  of  successful  infant-feeding  in  foundling 
asylums  and  other  institutions  for  young  infants  are  such  tliat  in  them 
wet-nursing  should  be  employed  whenever  possible. 

Mixed  Feeding. — Mixed  feeding,  or  a  combination  of  nursing  and 
artificial  feeding,  may  be  employed  whenever  the  supply  of  the  nurse  is 
insufficient,  also  to  relieve  the  mother  from  the  strain  of  nursing  entirely, 
and,  during  the  later  months,  for  the  purpose  of  gradual  weaning. 

BREAST-FEEDING. 

Care  of  the  Breasts  during  Lactation. — For  the  safety  of  both  mother 
and  child  it  is  essential  that  the  most  scrupulous  attention  be  given  to 
cleanliness.  The  nipples,  and  the  breasts  as  well,  should  always  be  care- 
fully washed  after  each  nursing.  Usually  plain  water  is  sufficient,  or  a 
weak  boric-acid  solution  may  be  employed. 

Nursing  during  the  First  Days  of  Life.— This  is  necessary,  to  accus- 
tom the  child  and  the  mother  to  the  procedure,  and  to  empty  the  breasts 


168  NUTRITION. 

of  the  colostrum;  it  also  promotes  uterine  contractions.  All  these  re- 
sults can  be  attained  by  putting  the  child  to  the  breast  on  the  first  day 
once  in  six  hours,  on  the  second  day  once  in  four  hours.  It  is  unneces- 
sary to  repeat  the  nursing  more  frequently.  The  child  gets  from  the 
breast  only  from  four  to  six  ounces  a  day  during  the  first  two  days.  Did 
it  require  more  nourishment  before  the  milk-flow  is  usually  established, 
we  may  be  sure  that  Kature  would  not  have  been  so  late  with  her  supply. 
Considering  how  great  are  the  changes  taking  place  during  these  first 
days  in  the  circulatory  and  respiratory  systems,  we  are  hardly  surprised 
that  two  days  pass  before  the  organs  of  digestion  are  given  much  work 
to  do.  The  common  practice  of  administering  to  an  infant  a  few  hours 
old  all  sorts  of  decoctions,  with  the  idea  that  because  it  cries  it  is  suf- 
fering from  colic,  can  not  be  too  strongly  condemned.  A  certain 
amount  of  crying  is  proper  and  necessary.  In  exceptional  circumstances, 
when  an  infant  is  unusually  strong  and  robust  and  screams  excessively, 
and  especially  when  the  temperature  is  elevated  (see  page  120),  it  may 
be  necessary  to  give  food  even  on  the  first  day ;  but  this  is  not  to  be  the 
rule.  A  little  warm  water,  or  a  five-per-cent  solution  of  milk  sugar, 
should  first  be  given ;  from  two  to  four  teaspoonfuls  at  a  time  are  suffi- 
cient. This  often  satisfies  the  child;  when  it  does  not  do  so,  regular 
feeding  should  be  begun  on  the  second  day.  Should  the  milk  be  delayed 
beyond  the  second  day,  feeding  should  then  be  begun  at  regular  inter- 
vals, as  in  the  cases  which  are  to  have  no  breast-milk. 

Nursing  Habits. — Good  habits  of  nursing  and  sleep  are  almost  as  eas- 
ily formed  as  bad  ones,  provided  one  begins  at  the  outset.  A  vast  deal 
of  the  wear  and  tear  incident  to  the  nursing  period  may  be  avoided  if 
the  child  is  trained  to  regular  habits.  Attention  to  these  minor  points 
often  makes  all  the  difference  between  successful  and  unsuccessful  nurs- 
ing. The  physician  must  have  a  very  clear  notion  of  how  often  nursing 
is  necessary,  must  give  very  explicit  directions,  and  see  that  they  are  car- 
ried out.  After  the  third  day,  for  the  first  month,  ten  nursings  in  the 
twenty-four  hours  are  quite  sufficient,  and  no  more  should  be  allowed. 
An  infant  at  this  age  can  usually  be  depended  upon  to  take  at  least 
one  long  nap  of  from  four  to  five  hours  in  the  course  of  the  twenty-four. 
For  the  rest  of  the  day  the  child  should  be  awakened,  if  necessary,  at 
the  regular  nursing  time,  and  put  to  the  breast;  this  plan  being  con- 
tinued until  nine  o'clock  at  night.  It  should  then  be  allowed  to  sleep  as 
long  as  it  will,  and  but  two  nursings  given  between  this  hour  and  seven 
in  the  morning.  In  the  course  of  two  or  three  weeks  a  healthy  infant 
can  usually  be  trained  to  nurse  and  sleep  with  almost  perfect  regularity, 
frequently,  when  a  month  old,  going  six  hours  regularly  at  night  without 
feeding.  A  trained  nurse  of  my  acquaintance  states  that  out  of  thirty- 
three  infants  of  which  she  had  the  care  from  birth,  thirty-one  were' 
trained  without  difficulty  in  the  manner  described.    In  only  one  case  was 


BREAST-FEEDING. 


169 


the  training  a  failure — that  of  a  delicate,  highly  nervous  child.  Of 
course,  success  in  training  must  rest  almost  entirely  with  the  nurse ;  but 
the  physician  should  at  least  appreciate  its  importance  and  lend  it  his 
support.  The  great  gain  to  the  mother  is,  that  she  is  enabled  to  have  a 
quiet,  undisturbed  night.  This  is  of  the  utmost  importance,  and  has 
more  to  do  with  a  good  milk  supply  than  any  other  single  thing  in  con- 
nection with  the  mothers  habits.  So  far  as  the  child  is  concerned,  regu- 
lar habits  of  feeding  and  sleep,  and  regular  evacuations  from  the  bowels, 
which  nearly  always  go  with  them,  are  important  factors  in  infant 
hygiene,  especially  in  the  prevention  of  gastro-enteric  diseases. 

Schedule  for  Breast- Feeding. 


Age. 

Number  of  nurs- 
ings in  24  hours 

Interval  during 
the  day. 

Night  nursings 

between  9  p.  m. 

and  7  a.  m. 

First  day 

4 
6 

10 
8 
7 
6 

Hours 
6 
4 
2 
2A 
3' 
3 

1 

Second  day 

1 

Third  to  twenty-eighth  day 

2 

Fourth  to  thirteenth  week 

1 

Third  to  fifth  month 

1 

Fifth  to  twelfth  month 

0 

These  rules  can  be  carried  into  effect  with  but  little  difficulty,  and 
with  great  benefit  to  both  mother  and  child.  It  is  to  be  remembered  that 
we  are  here  speaking  only  of  healthy  children.  The  possibility  of  train- 
ing children  to  eat  and  sleep  in  the  manner  described  will  be  doubted  only 
by  one  who  has  not  made  a  careful  trial  of  it.  Relieving  the  mother  of 
night-nursing  after  the  child  is  five  months  old  is  of  the  greatest  value, 
and  will  often  enable  her  to  continue  lactation,  when  otherwise  it  would 
be  brought  to  an  abrupt  termination.  On  no  account  should  the  child 
be  allowed  to  sleep  upon  the  mother's  breast,  nor  in  the  same  bed  with 
the  mother.  The  temptation  to  frequent  nursing  is  thus  largely  re- 
moved. Xo  mere  sentiment  in  regard  to  these  matters  should  l)c  allowed 
to  interfere  with  the  plain  dictates  of  reason  and  experience. 

Symptoms  of  Inadequate  Nursing. — Attempts  at  maternal  nursing  so 
often  result  in  failure,  jeopardizing  the  health,  and  even  endangering  the 
life  of  the  child,  that  it  becomes  a  matter  of  the  greatest  importance  to 
decide  this  question  aright,  and  as  early  as  possible.  On  the  one  hand, 
one  should  not  hastily  wean  a  child  on  account  of  symptoms  which  may 
have  no  connection  with  the  food,  nor  should  weaning  be  advised  when 
the  indigestion  from  which  the  infant  is  suffering  is  due  to  causes  which 
are  temporary  and  remediable.  On  the  other  hand,  nursing  should  not 
be  allowed  to  continue  simply  because  a  conscientious  mother  desires  it, 
when  every  indication  points  to  failure.  These  cases  must  all  be  closely 
watched  during  the  first  month  or  two  that  valuable  time  may  not  bo 


170  NUTRITION. 

wasted.  If  artificial  feeding  is  to  be  employed  the  difficulties  are  fewer 
when  it  is  begun  early  than  after  the  digestive  organs  have  been  deranged 
by  several  weeks  of  very  poor  nursing.  The  physician  should  be  as 
familiar  with  the  symptoms  of  inadequate  nursing  as  with  those  of  any 
disease  of  infancy. 

During  the  first  days  of  life  a  most  important  sign  is  the  tempera- 
ture. As  a  rule,  a  child  who  gets  a  proper  amount  from  the  breasts  has 
a  normal  temperature.  Very  many  who  get  little  or  nothing  during  this 
time  have  a  temperature  of  101°  or  102°  F.,  and,  in  extreme  cases,  104° 
or  even  106°  F.  If  no  obvious  symptoms  of  illness  are  present,  such  a 
temperature  from  the  second  to  the  fourth  day  may  be  considered  evi- 
dence of  insufficient  nourishment,  or  even  of  starvation.  (See  page 
120.) 

The  child  is  habitually  uncomfortable  and  does  not  thrive.  This  dis- 
comfort is  shown  in  that  sleep  is  restless,  easily  disturbed,  and  much  less 
than  normal;  and  when  awake  the  child  is  fretful,  irritable,  and  cries 
much  of  the  time.  Nothing  so  well  indicates  that  a  child  is  thriving 
as  an  increase  in  weight.  All  infants,  and  particularly  those  whose 
nutrition  is  the  subject  of  special  difficulty,  should  be  weighed  twice  a 
week  during  the  early  months.  A  child  need  not  gain  rapidly,  but  should 
always  gain  steadily  unless  obvious  signs  of  disease  are  present.  One 
should  not  be  satisfied  unless  the  weekly  gain  is  at  least  four  ounces.  In 
the  great  majority  of  cases  a  failure  to  gain  in  weight  during  the  first 
six  months  depends  upon  the  nourishment,  and  upon  that  alone. 

In  addition,  there  may  be  symptoms  indicating  serious  indigestion. 
Sometimes  these  relate  chiefiy  to  the  stomach,  in  most  such  cases  there 
being  habitual  vomiting.  More  often  the  derangement  is  intestinal. 
There  is  habitual  colic,  with  constipation  and  dry,  hard,  white  stools; 
or  there  is  diarrhoea,  with  thin  green  discharges  usually  containing  curds ; 
if  continued,  after  a  time  mucus  in  considerable  quantities  is  present. 

Often  when  the  milk  is  very  scanty  something  may  be  learned  from 
the  manner  in  which  the  child  takes  the  breast.  Where  the  milk  is 
abundant,  five  or  six  minutes  are  often  sufficient.  If  the  milk  is  very 
scanty,  an  infant  will  frequently  nurse  half  or  three-quarters  of  an  hour 
and  then  stop,  more  because  it  is  exhausted  than  because  it  is  satisfied. 
Sometimes  a  scanty  supply  is  indicated  by  exactly  the  opposite  symp- 
tom— viz.,  the  child  seizing  the  nipple  and  nursing  vigorously  for  a 
few  moments,  then  dropping  it  in  apparent  disgust  and  refusing  to  make 
any  further  efforts.  This  is  often  seen  where  the  breasts  are  practically 
empty. 

When  we  see  a  combination  of  the  above  symptoms — viz.,  a  fret- 
ful, colicky,  sleepless  infant  with  either  no  gain  in  weight  or  a  loss  of 
a  few  ounces  a  week,  and  with  stools  which  never  approach  the  normal 
in  colour,  odour,  or  consistency,  and  these  conditions  persisting  beyond 


BREAST-FEEDING. 


lYl 


the  mother's  three  or  four  weeks  of  convalescence — we  are  justified  in 
taking  the  child  from  the  breast  at  once  (Fig.  31).  When  the  symptoms 
are  less  numerous  and  less  severe,  and  especially  when,  in  spite  of  all 
discomfort  and  indigestion,  the  infant  is  steadily  gaining  in  weight,  the 


OF  AGE  2   4   6   8   10   12  14  16   18  20   22  24  26 

19 
IB 

17 
16 
15 

14 

CO 
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z 

D 
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CL 
1  1 

10 
9 
8 

7 
6 

1 

1 

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1 

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Fig.  31.  — Weight  curve  showing  the  effect  uf  bad  nursing  and  good  feeding.  Maternal  nursings 
for  seven  weeks;  continued  symptoms  of  indigestion  ;  colic,  frequent  green  passages,  con- 
stant discomfort,  etc. ;  other  treatment  without  avail.  Immediate  improvement  when 
weaned  and  put  on  modified  milk  from  the  laboratory.  Formula:  Fat  1"5  per  cent,  sugar  6 
per  cent,  proteids  0-75  per  cent.  All  symptoms  of  indigestion  rapidly  disappeared,  the  per- 
centages were  gradually  increased,  and  steady  gain  in  weight  followed. 

case  should  receive  further  study  before  weaning  is  ordered.  Consider- 
able assistance  may  often  be  obtained  from  examination  of  the  milk. 

The  Management  of  Woman's  Milk  where  Nursing  Infants  are  not 
Thriving. — Tlio  milk  examination  usually  discloses  one  of  three  condi- 
tions :  ( 1 )  an  over-rich  milk,  quantity  usually  abundant ;  (2)  milk  poor 
in  quality  and  scanty;  (3)  quantity  abundant,  quality  poor. 

Excessively  rich  milk. — This  is  usually  found  under  the  following 
conditions :  The  woman  is  in  good  health,  has  large,  well-developed 
breasts,  which  are  full  and  tense  at  nursing  time.  In  most  cases  she  is 
upon  a  very  abundant  diet,  largely  of  nitrogenous  food,  getting  little  or 
no  exercise,  and  frequently  taking  some  alcoholic  beverage  witli  the  no- 
tion that  because  the  child  is  not  thriving  the  milk  is  poor.  This  is  often 
seen  in  the  wet-nurse  after  making  a  change  from  the  simple  life  and 
habits  of  home  to  the  more  luxurious  life  and  diet  of  the  family  to  which 


172 


NUTRITION. 


she  goes.  The  following  analyses  from  Rotch  are  a  good  illustration  of 
the  exact  composition  of  milk  under  such  circumstances :  Analysis  I 
shows  milk  of  a  healthy  but  under-fed  wet-nurse  two  days  before  change 
of  food;  II,  the  milk  of  the  same  nurse  after  one  month  of  rich  food 
with  very  little  exercise ;  III,  milk  of  the  same  nurse,  the  food  and  exer- 
cise being  regulated : 


I. 

n. 

III. 

Fat 

Per  cent. 

0-72 
6-75 
2-53 
0-22 

Per  ceot. 

5-44 
6-25 
4-61 
0-20 

Per  cent. 

5-50 

Sugar     

6-60 

Proteids 

2-90 

Salts 

0-14 

The  effect  of  the  diet  and  life  is  seen  to  be,  high  fat  and  high  pro- 
teids. As  a  result  of  the  exercise,  there  is  seen  a  very  marked  reduction 
in  the  proteids. 

The  clinical  examination  of  very  rich  milk  shows  the  cream  to  be 
from  eight  to  twelve  per  cent,  and  the  specific  gravity  from  1,033  to 
1,034.  Instead  of  weaning  the  baby,  or  dismissing  the  wet-nurse  be- 
cause the  child  has  indigestion  or  loses  in  weight,  certain  changes  should 
be  instituted.  Alcohol  should  be  entirely  prohibited.  The  diet,  espe- 
cially the  meat,  should  be  reduced,  and  the  nurse  required  to  take  daily 
exercise  in  the  open  air,  particularly  by  walking.  The  improvement 
following  such  a  regimen  is  often  immediate,  the  child's  symptoms  dis- 
appearing in  the  course  of  a  few  days  and  a  regular  gain  in  weight 
beginning. 

Scanty  milk  of  a  poor  quality. — This  is  most  often  seen  in  a  delicate 
or  anaemic  mother — one,  perhaps,  who  has  had  a  difficult  or  complicated 
labour,  who  is  emotional,  anxious,  and  careworn.  In  such  cases  it  is 
often  with  the  greatest  difficulty  that  we  can  secure  the  necessary  half 
ounce  required  for  examination.  The  milk  is  sometimes  so  poor  that  we 
can  decide  positively  after  two  examinations  that  it  is  useless  to  continue 
lactation.  In  such  cases  we  often  find  the  specific  gravity  from  1,024  to 
1,027,  and  the  cream  only  two  or  three  per  cent.  In  other  cases,  where 
the  variations  from  the  normal  are  not  so  great — i.  e.,  specific  gravity 
1,030,  cream  four  per  cent,  and  the  quantity  fairly  abundant — we  may  be 
able  so  to  improve  the  milk  that  lactation  may  be  easily  and  advanta- 
geously continued.  In  the  management  of  such  cases  the  first  thing  is  to 
secure  to  the  mother  undisturbed  rest  at  night.  If  possible,  she  should  be 
entirely  relieved  of  the  care  of  the  infant  at  this  time,  and  if  feeding  is 
necessary  the  bottle  should  be  given.  She  should  have  a  certain  amount 
of  fresh  air  every  day,  driving  if  possible,  or  walking  as  soon  as  she  is 
able  to  take  more  active  exercise.  One  of  the  most  powerful  stimulants 
to  the  secretion  of  milk  is  massage  of  the  breasts.     A.  M.  Thomas  (New 


BREAST-FEEDING.  I73 

York)  places  it  above  all  others.  It  should  be  done  with  great  care  and 
gentleness,  and  most  of  all  with  every  precaution  against  infection.  The 
entire  breast,  including  the  nipple,  should  be  rendered  aseptic,  as  should 
the  hands  of  the  masseuse.  Some  mild  antiseptic  ointment  may  be  used 
with  the  massage.  It  should  be  done  two  or  three  times  a  day  for  ten 
minutes.  The  diet  should  be  abundant,  with  a  large  allowance  of  milk 
and  meat,  especially  beef.  If  there  is  anaemia,  iron  should  be  given. 
Some  of  the  alcoholic  extracts  of  malt  are  useful.  Every  means  should 
be  taken  to  improve  the  general  nutrition,  for  whatever  benefits  this 
improves  the  milk.  If  the  conditions  present  are  incident  to  the  con- 
finement or  the  convalescence,  the  prognosis  is  good;  and  in  the  course 
of  a  week  or  two  very  marked  improvement  may  be  evident,  and  lacta- 
tion may  be  successfully  continued.  If,  however,  the  conditions  depend 
upon  constitutional  debility,  or  if  the  mother  has  an  exceedingly  nervous 
temperament,  the  prognosis  is  much  worse.  Temporary  improvement 
may  take  place,  but  it  soon  becomes  evident  that  the  experiment  is  a 
failure,  both  as  regards  mother  and  child. 

Quantity  ahundant,  quality  very  poor. — This  condition  is  occasion- 
ally seen  in  women  who,  to  improve  the  milk,  have  been  taking  large 
quantities  of  fluids,  often  with  alcohol  in  some  form.  In  such  cases,  in- 
stead of  being  formed  by  the  epithelium  of  the  glands,  the  milk  is  largely 
a  mere  transudation  from  the  blood-vessels.  Where  the  patient  is  very 
anaemic  and  the  general  condition  poor,  the  glands  act  as  little  more  than 
a  filter.  In  such  circumstances  the  breasts  may  be  so  full  as  to  be  pain- 
ful, and  the  milk  may  often  come  away  spontaneously.  An  examination 
usually  shows  low  specific  gravity  and  very  low  fat.  Where  these  condi- 
tions exist  nursing  should  be  discontinued. 

Summary. — Poor  milk  is  usually  low  in  fat  and  scanty  in  quantity, 
while  the  proteids  may  be  either  high  or  low.  Very  rich  milk  is  usually 
high  both  in  fat  and  proteids.  While  the  examination  of  the  milk  often 
gives  a  clue  as  to  the  nature  of  the  variations  from  the  normal,  the 
<3auses  of  such  variations  are  to  be  sought  in  the  nurse's  condition  and 
habits,  and  removed  by  correcting  these.  Very  poor  milk  can  seldom  be 
permanently  improved  unless  the  causes  are  very  definite  and  of  a  tem- 
porary character.  Over-rich  milk  can  often  be  improved  if  the  true  ex- 
planation for  it  can  be  reached.  Eesults  are  to  be  judged  not  so  much 
by  the  change  in  the  composition  of  the  milk  as  by  improvement  in  the 
infant's  symptoms.  The  question  is  always  whether  the  individual  milk 
can  be  made  to  agree  with  the  individual  child.  On  the  whole,  since 
artificial  feeding,  when  it  can  be  properly  done,  gives  so  much  better 
results  than  poor  or  doubtful  nursing,  I  am  inclined,  as  a  result  of  in- 
creasing experience,  to  stop  nursing  after  a  fair  trial — e.  g.,  of  two  weeks 
— has  been  made,  and  begin  feeding,  rather  than  waste  time  in  prolonged 
•efforts  to  improve  the  breast-milk. 
13 


174  NUTRITION. 

Wet-Nursing. — In  the  selection  of  a  wet-nurse,  it  is  by  no  means 
so  essential  as  has  generally  been  supposed,  that  her  child  shall  be  of 
about  the  same  age  as  the  child  she  is  to  nurse,  for,  after  the  first 
month,  the  changes  in  the  composition  of  breast  milk  are  insignificant. 
It  is  always  desirable  that  the  wet-nurse  shall  have  nursed  her  own  infant 
long  enough  to  demonstrate  the  fact  that  she  has  an  abundance  of  good 
milk ;  hence,  taking  a  wet-nurse  at  the  end  of  the  first  or  second  week  is 
always  fraught  with  considerable  uncertainty.  For  an  infant  six  weeks 
old,  a  wet-nurse  whose  milk  is  anywhere  between  one  and  five  months  old 
will  usually  answer  perfectly  well.  For  an  infant  only  two  or  three  weeks 
old,  the  milk  should  not  be  more  than  six  weeks  old. 

A  good  nurse  must,  first  of  all,  be  a  healthy  woman,  free  from  syphi- 
litic or  tuberculous  taint,  and  her  throat,  teeth,  skin,  glands,  hair,  and 
legs  should  be  carefully  inspected.  She  must  have  good  mammary  glan- 
dular development.  ISTot  much  is  to  be  expected  of  small  flat  breasts. 
The  breasts  should  be  full  and  hard  three  hours  after  nursing.  They  may 
be  very  large  and  yet  supply  very  little  milk,  being  then  composed  almost. 
entirely  of  fat.  On  the  other  hand,  some  smaller  breasts  may  be  almost 
all  glandular  tissue.  The  difl^erence  in  the  size  of  a  breast  before  and 
after  nursing,  is  one  of  the  best  guides  as  to  the  amount  of  milk  it  is  se- 
creting. The  nipples  should  be  free  from  erosions  or  fissures,  and  long 
enough  for  the  needs  of  the  child.  The  nurse  should  not  be  anaemic, 
since  it  is  impossible  for  a  pale,  anemic  woman  to  furnish  good  milk. 
Preferably  she  should  be  of  a  phlegmatic  temperament,  and  of  a  good 
moral  character.  This  is  desirable  for  personal  reasons,  although  there 
is  no  evidence  of  moral  qualities  being  transmitted  through  the  milk. 
It  is  desirable  that  a  nurse  should  be  between  twenty  and  thirty  years  of 
age,  although  much  more  depends  upon  the  individual  than  upon  the  age. 
Other  things  being  equal,  a  primipara  should  be  chosen.  An  examina- 
tion of  the  milk  may  be  of  some  assistance  in  selecting  a  nurse ;  but  the 
best  evidence  to  be  obtained  of  the  character  of  a  woman's  milk  is  the 
condition  of  her  own  child,  which  should  always  be  seen  before  she  is 
accepted.  It  often  happens  that  a  woman  who  has  had  an  abundant 
supply  of  milk  for  her  own  infant,  has  very  little  for  another  infant  for 
the  first  few  days  in  her  new  surroundings.  This  is  usually  the  result 
of  the  nervous  influences  connected  with  parting  from  her  own  child, 
going  to  a  new  place,  being  carefully  watched,  etc.  In  such  a  case  it 
should  not  be  too  readily  decided  that  she  is  incompetent  as  a  nurse,  for, 
under  most  circumstances,  with  proper  treatment  her  normal  flow  of 
milk  will  be  re-established. 

Weaning. — Weaning  should  always  be  done  gradually,  when  pos- 
sible, for  the  sake  of  both  mother  and  child.  Sudden  weaning  is  apt 
to  be  followed  by  an  attack  of  acute  indigestion  in  the  infant.  This,  how- 
ever, is  not  a  necessary  result,  and  usually  depends  upon  the  fact  that 


WEANING. 


175 


the  child  is  given  eow^s  milk  without  sufficient  dilution.  Weaning  in  hot 
weather  is  usually  to  be  avoided,  but  the  harm  from  this  is  not  nearly  so 
great  as  sometimes  results  where  lactation  is  unduly  prolonged  because 
of  a  prejudice  against  a  change  of  food  at  this  time.  While  there  are 
many  women  of  the  lower  classes  who  are  able  to  nurse  their  children  to 
advantage  for  the  entire  first  year,  the  number  of  such  among  the  bet- 
ter classes  is  certainly  very  small.  By  the  latter,  nursing  can  rarely  be 
continued  beyond  the  ninth,  and  often  not  beyond  the  sixth  month,  with- 
out unduly  draining  the  vitality  of  the  mother  and  at  the  same  time 
harming  the  child.  The  late  months  of  lactation,  like  the  early  months, 
require  close  watching.  It  is  a  common  mistake  to  continue  both  mater- 
nal and  wet-nursing  too  long,  owing  to  a  dislike  of  making  a  change 
when  things  are  going  tolerably.  It  is  a  safe  rule  to  make  the  ninth 
month  the  time  to  supplement  the  breast-feeding  by  other  food.  But 
here,  as  in  the  early  months,  the  child's  weight  is  the  best  guide.  In  the 
absence  of  evident  signs  of  disease,  a  stationary  weight  for  several  weeks 
makes  weaning  advisable ;  a  steady  loss  makes  it  imperative. 

The  accompanying  weight-chart  (Fig.  32)  illustrates  this  point.    The 
Infant  was  nursed  by  the  mother,  and  did  unusually  well  until  the  sixth 


Name 

Date 

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MONTH  OF  AGE.                                                           I 

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32. — C'luirt  shovviiiLT  the  eft'cct  of  pregnancy  upon  the  weight  of  a  nureing  infant.     The 
upper  line  ia  that  of  the  patient;  the  lower  one  is  the  average  line  lor  the  iirst  year. 


month.  As  it  did  not  seem  ill,  the  parents  were  not  disturbed  by  the 
gradual  loss  in  weight,  and  I  was  not  consulted  until  tbe  loss  had  reached 
three  pounds.  Feeding  was  at  once  begun,  and  in  a  week  all  nursing  was 
stopped  and  the  child  gradually  regained  its  lost  weight.    It  was  subse- 


176 


NUTRITION. 


quently  discovered  that  the  mother  was  pregnant  at  the  time  the  loss 
was  going  on. 

When  a  nursing  infant  has  been  accustomed  from  birth  to  take  one 
feeding  a  day  from  the  bottle,  always  a  great  convenience  to  a  nursing 
mother,  gradual  weaning  is  generally  an  easy  matter;  otherwise  it  is 
sometimes  an  impossibility,  the  child  refusing  all  food  except  the  breast 
so  long  as  this  is  given,  and  nothing  but  starvation  inducing  it  to  take 
food  either  from  a  bottle  or  a  spoon.  Infants  will  sometimes  refuse 
food  until  so  weak  as  to  make  their  condition  serious. 

Sudden  weaning  may  be  required  at  any  time  from  the  development 
in  the  mother  of  acute  disease  of  a  serious  nature,  such  as  typhoid  fever 
or  pneumonia,  of  grave  chronic  disease,  such  as  tuberculosis  or  nephritis, 
from  the  intercurrence  of  pregnancy,  or  from  disease  of  the  mammary 
gland.  On  no  account  should  an  infant  be  suckled  at  a  breast  which  is 
the  seat  of  acute  inflammation.  Through  many  of  the  minor  ills — mild 
attacks  of  bronchitis,  pharyngitis,  indigestion,  and  even  malarial  fever — 
mothers  will  frequently  nurse  their  children  without  any  seeming  detri- 
ment to  them  or  to  themselves.    In  acute  illness  of  short  duration,  even 


WEEK 

OF  AGE  28      30     32      34     36      38     40     42     44     46      48      50     52 

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Fig.  33. — Weight  curve  of  a  child  properly  weaned.  Abrupt  weaning  at  eight  months;  loss  ot 
weight  for  the  first  week  due  to  the  child's  being  put  upon  cow's  milk  with  low  percent- 
ages. Formula :  Fat  1*6  per  cent,  sugar  6  per  cent,'proteid3  0-80  per  cent.  Percentages  were 
rapidly  increased,  with  subsequent  steady  and  regular  gain  in  weight.  Weaning  accom- 
plished without  the  slightest  symptom  of  indigestion.     The  lower  is  the  average  line. 

if  severe,  it  is  usually  better,  unless  we  decide  to  wean  altogether,  to 

maintain  the  flow  of  milk  by  the  use  of  the  breast-pump  rather  than 

allow  it  to  dry  up.    The  breasts  may  be  pumped  three  or  four  times  a  day. 

In  cases  of  sudden  weaning,  the  food  must  in  the  beginning  be  very 


MIXED  FEEDING.  I77 

much  weaker  than  for  an  artificially-fed  child  of  the  same  age.  If 
weaned  at  six  months,  the  child  should  be  put  upon  a  food  appropriate 
for  a  healthy  child  of  one  month ;  if  at  nine  or  ten  months,  upon  a  food 
appropriate  for  one  of  three  or  four  months.  If  this  is  done,  the  change 
can  be  made  without  causing  much  disturbance  (Fig.  33).  When  the 
infant  has  become  somewhat  accustomed  to  cow's  milk  the  strength  of 
the  food  may  be  gradually  increased,  and  regular  gain  in  weight  will 
follow. 

MIXED  FEEDING. 

By  mixed  feeding  is  meant  a  combination  of  nursing  and  artificial 
feeding.  This  may  be  resorted  to  in  any  case  in  which  the  milk-supply 
of  the  mother  is  insufficient,  or  when  the  drain  upon  her  health  is  unduly 
great.  In  most  cases  it  is  better  than  entire  artificial  feeding,  and  there 
is  no  objection  to  combining  the  two;  but  before  allowing  a  mother 
partly  to  nurse  and  partly  to  feed  her  infant,  one  must  be  sure  that  the 
quality  of  the  milk  is  good.  This  is  to  be  determined  by  the  principles 
given  in  the  preceding  pages. 

It  is  well  from  the  very  outset  to  accustom  the  infant  to  take  one 
of  its  feedings,  or  at  least  to  take  water,  from  a  bottle  each  day.  In 
maternal  nursing,  the  occasional  feeding  which  is  usually  necessary,  be- 
comes then  an  easy  matter.  If  circumstances  make  it  desirable  to  relieve 
the  mother  of  night-nursing,  or  of  one  or  more  feedings  during  the  day, 
this  also  can  be  accomplished  without  difficulty.  If  the  child  is  being 
wet-nursed,  the  same  plan  is  advisable,  for  it  then  becomes  easy  to  put  an 
infant  upon  the  bottle  entirely  in  the  event  of  the  wet-nurse  leaving  sud- 
denly— a  not  uncommon  occurrence.  If  at  any  time  the  mother's  health 
begins  to  suffer,  she  should  be  relieved  of  two  or  more  nursings  a  day,  and 
the  bottle  substituted.  In  this  way  she  may  be  able  to  continue  lactation 
for  some  time  longer.  When,  however,  the  nursings  have  been  reduced 
to  only  two  or  three  daily,  the  milk  should  be  examined  frequentl}^  as  it 
is  apt  to  deteriorate  rapidly  in  quality.  Mixed  feeding  is  also  necessary 
in  many  cases  during  the  first  few  weeks,  while  the  mother's  milk  is  insuf- 
ficient in  consequence  of  anything  which  has  retarded  convalescence  after 
parturition.  It  often  happens  that  the  milk  becomes  abundant  and  of 
good  quality  when  the  mother  is  well  enough  to  be  up  and  out  of  doors, 
although  it  was  previously  scanty  and  of  inferior  quality.  Two  or  three 
feedings  a  day  from  the  bottle  help  to  bridge  over  this  period  and  pre- 
vent the  child's  nutrition  from  suffering.  In  all  cases  of  mixed  feeding, 
the  food  should  be  the  same  as  when  the  child  is  fed  exclusively. 

ARTIFICIAL  FEEDING. 

There  are  several  fundamental  principles  regarding  which  nearly  the 
whole  scientific  world  is  agreed. 

1.  Woman's  milk  is  not  only  the  best,  it  is  the  ideal  infant-food. 


178  NUTRITION. 

2.  Any  substitute  should  furnish  the  same  constituents — fat,  sugar, 
proteids,  salts,  and  water;  furthermore,  they  should  be  in  about  the 
same  proportion  as  they  exist  in  a  good  sample  of  woman's  milk. 

3.  As  nearly  as  possible  the  different  constituents  should  resemble 
those  of  woman's  milk  both  in  their  chemical  composition  and  in  their 
behaviour  toward  the  digestive  fluids. 

4.  These  conditions  are  fulfilled  only  by  fresh  milk  from  some  other 
animal. 

In  the  artificial  feeding  of  infants,  cow's  milk  is  selected  as  being 
the  only  milk  available  for  general  use.  Although  it  furnishes  all  the 
constituents  required,  they  are  not  present  in  the  proportions  suited  to 
young  infants,  and  the  constituents  are  not  identical  with  those  in  wom- 
an's milk.  Cow's  milk,  therefore,  can  not  be  fed  to  most  infants  without 
some  changes.  These  changes  are  technically  known  as  the  Modifica- 
tion of  Coiu's  Milk. 

Although  there  is  practical  agreement  among  writers  and  teachers 
regarding  the  foregoing  points,  there  still  exists  considerable  difference 
of  opinion  respecting  methods  of  adapting  cow's  milk  to  the  infant's 
digestion.  To  make  these  changes  properly  it  is  necessary  to  know 
in  the  first  place  what  are  the  exact  differences  between  cow's  milk  and 
woman's  milk;  and,  secondl}^,  to  devise  the  simplest  method  of  over- 
coming them. 

The  earliest  milk  modification  was  simply  dilution  with  water  and 
the  addition  of  enough  cane-sugar  to  make  it  taste  like  breast-milk.  The 
only  change  made  with  the  age  of  the  child  was  simply  to  vary  the  amount 
of  water.  Instead  of  water  as  a  diluent  many  have  preferred  to  use 
gruels  made  from  different  cereals — oatmeal,  barley,  arrowroot,  etc. — 
believing  that  thereby  the  casein  was  rendered  more  digestible.  Upon  such 
simple  modifications  as  these  many  children  have  done,  and  many  still  do, 
very  well,  when  the  matter  of  dilution  is  judiciously  managed.  But  it  is 
equally  true  that  very  many  do  not  do  well,  and  that  present  knowledge 
enables  us  to  do  something  better.  There  are,  however,  circumstances 
where  anything  more  complex  is  impossible  in  the  way  of  milk  modifica- 
tion ;  then  only  should  the  old  methods  of  simple  dilution  be  employed. 

Later,  when  the  composition  of  woman's  milk  came  to  be  better  un- 
derstood, it  was  thought  that  all  that  was  necessary  in  modified  milk 
was  to  secure  the  exact  percentages  of  fat,  proteids,  sugar,  and  salts 
which  exist  in  a  good  sample  of  woman's  milk,  and  that  this  would 
be  the  best  possible  substitute  for  it.  Out  of  this  came  the  various  mix- 
tures of  milk,  cream,  sugar,  etc.,  which  aimed  to  reproduce,  according  to 
the  views  of  different  writers,  the  exact  proportions  of  woman's  milk. 

This  was  a  great  step  in  advance,  in  that  some  proper  relation  be- 
tween the  different  food  constituents  was  maintained.  While  frequently 
successful,  such  formulas  often  failed  for  lack  of  flexibility.     The  food 


ARTIFICIAL  FEEDING.  179 

was  the  same,  but  the  child  was  not  always  the  same.  Furthermore,  the 
diiference  in  the  digestibility  of  some  of  the  elements,  particularly  the 
proteids,  was  not  sufficiently  taken  into  account.  Experience  has  shown 
that  no  single  milk-formula  can  be  made  to  serve  as  a  substitute  for 
woman's  milk;  and  intelligent  students  of  the  problem  have  ceased  to 
search  for  one. 

The  central  thought  of  the  newer  method  of  modification — which 
may  very  properly  be  called  the  "  American  method  " — is  to  consider  the 
different  elements  of  the  food  separately  and  to  adapt  their  proportions 
to  the  child's  digestion.  Like  the  method  just  described,  it  is  based 
upon  the  percentage  composition  of  woman's  milk,  and  also  recognises 
that  there  is  a  difference  in  the  digestibility  of  cow's  milk  and  woman's 
milk,  particularly  of  the  proteids.  It  aims  to  discover  the  proper  propor- 
tions of  fat,  sugar,  and  proteids,  and  the  best  methods  of  gradational  in- 
crease for  healthy  infants  with  normal  digestion;  and  also  to  discover 
for  those  with  abnormal  or  feeble  digestion,  the  combinations  best  suited 
to  the  individual  conditions.  Where  difficulty  exists  in  the  digestion  of 
milk,  it  is  usually  with  some  one  of  its  elements,  or  at  least  chiefly  with 
one.  In  such  a  condition,  instead  of  stopping  milk  entirely,  or  reducing 
the  proportion  of  all  the  elements  by  simply  diluting  the  food  still  fur- 
ther, that  one  alone  which  is  causing  the  disturbance  is  reduced. 

In  practice  there  is  necessary  an  easy  method  of  securing  the  usual 
percentages  which  experience  has  shown  to  be  best  for  healthy  infants, 
following  in  a  general  way  those  existing  in  woman's  milk — a  method, 
moreover,  which  can  readily  be  adapted  to  special  and  peculiar  condi- 
tions. In  brief,  the  American,  or,  as  it  is  sometimes  called,  the  "  per- 
centage method  "  of  milk  modification  for  infant-feeding,  aims  at  some- 
thing which  is  definite,  exact,  and  at  the  same  time  flexible.  It  is  some- 
what more  complex  possibly  than  the  older  methods,  but  not  nearly  so 
difficult  as  may  at  first  appear.  In  practical  results,  however,  it  is  in 
my  judgment,  and  in  the  opinion  of  nearly  every  one  who  has  taken  the 
trouble  to  master  it,  a  very  great  step  in  advance.  By  this  method 
infant-feeding  has  been  placed  for  the  first  time  upon  a  scientific  basis. 
Percentages  are  simply  a  method  of  stating  definitely  just  what  we  are 
giving,  and  furnish  the  only  means  by  which  our  observations  can  be 
recorded  and  compared  with  those  of  others. 

For  the  fundamental  work  along  this  line  the  world  is  indebted  to 
Prof.  T.  M.  Eotch,  of  Harvard,  and  Mr.  G.  E.  Gordon,  of  the  Walker- 
Gordon  Laboratory  Company. 

The  Modification  of  Cow's  Milk  for  Healthy  Infants  during 
THE  First  Year. — By  the  modification  of  cow's  milk  is  meant  its  adap- 
tation to  the  purpose  of  infant-feeding.  It  is  desirable  to  consider  sepa- 
rately the  changes  required  by  healthy  infants  with  normal  digestion,  and 
those  required  by  infants  with  feeble  digestion,  or  those  suffering  from 


180 


NUTRITION. 


more  or  less  indigestion.  From  a  failure  to  make  this  distinction,  nmch 
confusion  has  arisen  and  many  errors  have  crept  into  the  subject  of 
infant-feeding.  The  digestion  of  all  healthy  infants  is  very  much  alike, 
and  they  can  all  be  fed  in  much  the  same  way;  while,  on  the  contrary, 
the  variations  afforded  by  unhealthy  infants  are  almost  endless,  and 
each  case  must  be  considered  by  itself.  If  it  is  only  healthy  infants 
that  can  be  fed  by  rule,  it  is  equally  true  that  if  fed  from  the  beginning 
by  proper  rules  most  infants  will  remain  healthy. 

When  cow's  milk  is  substituted  for  woman's  milk  the  differences  in 
chemical  composition  must  first  be  taken  into  account.  The  averages, 
based  upon  the  latest  and  most  reliable  analyses,  are  as  follows : 


Woman''s  milk, 
average. 

Cow's  milk,  aver- 
age. 

Fat      

Per  cent. 

4-00 
7-00 
1-50 
0-20 

87-30 

Per  ceDt. 

400 

Sugar    

4-50 

Proteids 

3-50 

Salts  

0-75 

Water 

87-25 

100-00 

100-00 

We  have,  therefore,  in  cow's  milk,  an  excess  of  proteids  and  salts,  too  lit- 
tle sugar,  and  about  the  quantity  of  fat  required.  Other  conditions 
which  must  be  considered  are  the  presence  of  bacteria  in  cow's  milk,  its 
acid  reaction,  and  the  fact  that  its  proteids,  and  possibly  the  fat,  are 
more  difficult  of  digestion. 

Fat. — Except  for  the  first  few  days  of  life,  the  average  amount  of  the 
fat  of  cow's  milk  which  a  healthy  infant  can  digest  varies  from  2  to  4 
per  cent.  Beginning  with  1  per  cent  on  the  second  day,  it  may  visually 
be  increased  to  2  per  cent  at  one  week;  to  3  per  cent  at  three  or  four 
weeks ;  and  to  4  per  cent  at  four  or  five  months.  I  have  never  found  it 
necessary  and  seldom  advantageous  to  increase  the  fat  above  4  per 
cent,  while  I  constantly  see  derangements  of  digestion  produced  by  the 
use  of  higher  percentages.  There  are  some  healthy  infants  who  can  not 
digest  even  4  per  cent  of  fat  at  any  time,  and  there  are  many  who  dur- 
ing hot  weather  do  much  better  when  a  reduction  to  3  or  3  -5  per  cent 
is  made.  No  modification  of  the  fat  of  cow's  milk  is  possible  except  in 
the  amount.  Much  has  been  written  of  late  regarding  the  effect  of  the 
centrifuge,  as  used  in  the  separator,  upon  the  emulsion  of  the  fat  in 
cow's  milk.  For  myself,  I  have  been  able  to  see  no  appreciable  differ- 
ence in  the  digestibility  of  gravity  and  centrifugal  cream.  Freshness  is 
a  very  important  consideration  in  all  extra  fat  added  to  milk;  since 
undoubtedly  the  fermentative  changes,  some  of  which  may  take  place 
in  the  fat  quite  early,  seriously  affect  its  digestibilty. 


ARTIFICIAL   FEEDING.  181 

Sugar. — In  woman's  milk  the  percentage  of  sugar  is  remarkably 
constant  under  all  conditions — between  6  and  7  per  cent.  In  feeding 
cow's  milk  it  is  seldom  required  to  have  the  sugar  less  than  5  and 
never  more  than  7  per  cent.  This  is  the  simplest  part  of  the  modifi- 
cation. As  the  sugar  in  milk  is  simply  lactose  in  solution,  it  is  only 
necessary  to  calculate  the  amount  required  to  be  added  to  bring  this 
up  to  the  5,  6,  or  7  per  cent  desired.  The  milk  sugar  should  first  be 
dissolved  in  boiling  water,  and,  when  it  contains  impurities,  filtered 
through  absorbent  cotton.  It  should  be  prepared  at  least  every  second 
day,  and  in  summer  daily.  It  is  more  rational  in  theory,  and  certainly 
better  in  practice,  to  use  milk  sugar  rather  than  cane  sugar,  since  the 
former  supplies  what  exists  in  woman's  milk.  It  should  be  distinctly 
understood  that  the  purpose  of  adding  sugar  to  milk  is  not  to  sweeten 
the  food,  but  to  furnish  the  proper  proportion  of  soluble  carbohy- 
drates necessary  for  the  infant's  nutrition.  When,  however,  good  milk 
sugar  can  not  be  obtained,  cane  sugar  may  be  substituted;  the  amount 
added  must  be  but  little  more  than  half  that  of  milk  sugar  on  account  of 
its  sweeter  taste,  and  greater  liability  to  undergo  fermentation  in  the 
stomach. 

Proteids. — The  modification  of  the  proteids  is  the  most  important 
change  necessary  in  cow's  milk,  for  it  is  the  proteids  which  give  most 
of  the  trouble  to  the  infant's  digestion.  Of  the  other  elements,  only 
the  amount  has  required  consideration;  but  in  the  proteids  there  are 
other  differences.  Woman's  milk  contains  more  lactalbumin  than  casein, 
while  cow's  milk  contains  about  five  times  as  much  casein  as  lactalbumin. 
Besides  this  difference  in  quantity  is  that  of  coagulability  in  the  infant's 
stomach.  The  firm  dense  coagulum  which  forms  with  cow's  milk  is 
greatly  lessened  by  diluting  the  milk,  but  does  not  disappear  altogether 
even  when  the  total  proteids  are  made  the  same  as  in  woman's  milk. 

Four  different  methods  have  been  proposed  for  modifying  the  pro- 
teids of  cow's  milk:  (1)  Eeducing  the  proportion;  (2)  partially  pre- 
digesting  them  by  peptonizing;  (3)  separating  them,  by  removing  the 
casein  by  coagulation  with  rennet;  (4)  using  as  a  diluent,  instead  of 
water,  gruels  made  of  different  cereals — oatmeal,  barley,  arrowroot,  etc. 
— for  their  mechanical  effect  upon  the  coagulation  of  the  casein. 

For  healthy  infants  with  average  digestion,  reduction  in  the  quantity 
of  the  proteids  is  all  that  is  necessary ;  the  other  measures  will  be  con- 
sidered in  connection  with  Difficult  Cases  of  Feeding  (page  20G). 
On  account  of  the  differences  mentioned,  it  is  not  enough  to  reduce  the 
proteids  to  the  average  present  in  woman's  milk — i.  e.,  1  -5  per  cent. 
During  the  early  months  the  percentage  should  be  much  less  than  this. 
I  have  obtained  the  best  results  by  making  the  proteids  for  the  first 
few  days  only  0  -33  or  0  -50  per  cent ;  then,  as  the  stomach  becomes  some- 
what accustomed  to  cow's  milk,  gradually  raising  the  proportion  until 


182 


NUTRITION. 


before  the  end  of  one  month  the  child  is  -usuall}'  taking  1  per  cent;  by 
the  end  of  the  second  or  third  month,  1  -5  per  cent;  and  by  the  end  of 
the  fourth  or  fifth  month,  2  per  cent  proteids.  It  is  seldom  that  the 
total  quantity  of  proteids  present  in  cow's  milk  can  be  given  before  a 
child  is  a  year  old.  I  believe  the  secret  of  success  in  feeding  cow's  milk 
is  to  begin  with  the  proteids  so  low  as  not  to  disturb  the  infant's  diges- 
tion, and  then  slowly  but  steadily  to  raise  the  quantity.  While  the 
infant's  stomach  was  not  intended  to  digest  cow's  milk,  but  woman's 
milk,  it  is  perfectly  certain  that  by  this  method  it  can  gradually  be 
trained  to  digest  cow's  milk  of  the  percentages  mentioned. 

Except  to  start  with  too  high  proteids  no  more  common  mistake  is 
made  than  to  continue  long  with  too  low  proteids.  Anemia,  malnu- 
trition, and,  I  believe,  not  infrequently  scurvy  are  seen  as  a  consequence 
of  this  practice.  The  gradual  increase  is  therefore  just  as  important 
as  the  low  beginning. 

Inorganic  Salts. — These  are  excessive  in  cow's  milk,  and  nearly  to 
the  same  degree  as  the  proteids.  They  may  generally  be  calculated  as 
one-fifth  the  total  proteids.  Xo  separate  modification  of  the  salts  has 
thus  far  been  attempted.  When  the  proper  dilution  is  made  for  the 
proteids,  the  proportion  of  the  salts  will  be  nearly  correct,  except  during 
the  first  days  of  life. 

Eeduction  in  the  proteids  and  inorganic  salts  of  cow's  milk  is  effected 
by  dilution.  The  amount  of  reduction  obtained  by  the  different  dilu- 
tions is  shown  in  the  following  table : 


Cow's 
milk. 

Diluted 
once. 

Diluted 
twice. 

Diluted 
3  times. 

Diluted 
4  times. 

Diluted 
6  times. 

Diluted 
9  times. 

Proteids 

3  50 
0-75 

l-7o 
0-37 

116 
0-25 

0-87 
■   0-18 

0-70 
0-15 

0-50 

0-10 

0-35 

Inorganic  salts 

0-07 

Reaction. — The  acidity  of  cow's  milk  may  be  overcome  by  the  addi- 
tion either  of  lime-water  or  bicarbonate  of  soda.  Of  the  former,  there  is 
required  about  one  ounce  to  each  twenty  ounces  of  the  food;  of  the 
latter,  about  one  grain  to  each  ounce  of  the  food.  For  very  young  in- 
fants it  is  often  desirable  to  use  twice  as  much  of  each  one  of  these. 

Bacteria. — These  are  always  present  in  cow's  milk.  They  have  been 
already  considered  on  page  138. 

Milk  Laboratories. — The  first  milk  laboratory  was  established  in 
Boston  by  the  AValker-Gordon  Company  in  1892 ;  one  in  New  York  in 
1893,  and  since  that  time  others  in  many  American  cities.  They  under- 
take to  furnish  "  modified  milk  "  of  any  desired  proportions,  upon  the 
prescription  of  physicians,  exactly  as  drugs  are  dispensed  by  an  apothe- 
cary. The  elements  chiefly  used  by  the  Walker-Gordon  laboratories 
are:  (1)  Cream  containing  16  per  cent  fat;   (2)  separated  milk,  from 


ARTIFICIAL  FEEDING. 


183 


which  the  fat  has  been  removed  by  the  centrifugal  machine;  (3)  a 
standard  solution  of  milk  sugar,  20  per  cent  strength.  These  contain 
fat,  sugar,  and  proteids  in  the  following  proportions : 


Cream. 

Separated  milk. 

Sugar  solution. 

Fat 

Per  cent. 

16-00 

4-00 

3-20 

Per  cent. 
013 
4-40 
4-00 

Per  cent. 

Sugar 

20  00 

Proteids      

By  combining  these  it  is  possible  to  vary  the  percentages  of  fat,  sugar, 
.and  proteids  in  the  milk  to  almost  any  degree  desired,  and  to  do  this 
with  very  great  accuracy.  Lately,  by  using  whey,  a  separate  modifica- 
tion of  the  proteids  has  been  accomplished ;  so  that  within  certain  limits 
a  larger  proportion  of  lactalbumin  can  be  given.  The  highest  propor- 
tion of  lactalbumin  with  the  lowest  proportion  of  casein  can  be  given 
when  the  total  proteids  do  not  exceed  1 -15  per  cent;  of  this,  '90  per 
cent  may  be  lactalbumin  and  "25  per  cent  casein.  The  alkalinity  is  usu- 
ally obtained  by  adding  lime-water  in  any  desired  amount.  The  labora- 
tory uses  either  gravity  or  centrifugal  cream,  as  preferred  by  physicians ; 
it  also  adds,  when  requested,  gruels  of  wheat,  oats,  or  barley  of  any 
■desired  strength;  and,  finally,  it  delivers  the  milk  raw,  or  heats  it  for 
sterilization  to  any  temperature  ordered  by  the  physician. 

The  food-supply  for  the  entire  day  is  delivered  each  morning  in  the 
bottles  from  which  it  is  to  be  fed.  The  empty  bottles  returned  are 
washed  and  sterilized  at  the  laboratory.  In  ordering  the  food  the  physi- 
cian simply  writes  for  the  percentages  of  fat,  sugar,  and  proteids  which 
he  desires,  together  with  the  number  of  feedings  for  twenty-four  hours 
and  the  quantity  in  each  feeding.  The  following  is  the  form  in  which 
prescriptions  are  written : 

5     Fat 3  per  cent. 

Sugar 6       " 

Proteids 1       " 

Alkalinity,  lime-water 5  per  cent. 

Number  of  feedings 8 

Amount  for  each  feeding 4  ounces. 

Heat  to  155°  F.,  30  minutes. 

The  establishment  of  the  milk  laboratory  and  the  adoption  of  the 
percentage  method  of  milk  modification  have  been  a  great  step  in 
advance.  The  laboratory  does  not  feed  babies  directly  nor  does  it  pre- 
pare "  a  food  " ;  it  works  only  with  physicians,  and  simply  carries  out 
their  directions  regarding  the  preparation  of  the  milk.  Infant-feeding 
is  thus  put  upon  a  somewhat  different  footing  than  heretofore.  It  is 
now  assumed  to  be  the  physician's  prerogative  to  direct,  taking  the 
matter  out  of  the  hands  of  the  mother  or  nurse,  who  have  done  most 


184  NUTRITION. 

of  it  in  the  past.  This,  of  course,  necessitates  that  the  physician  have 
a  certain  amount  of  familiarity  with  the  subject  of  feeding,  and  fur- 
thermore that  he  keep  in  touch  with  the  progress  of  the  case;  which, 
moreover,  is  just  as  necessary  with  am'  other  form  of  feeding.  For  the 
first  few  weeks  it  is  essential  that  the  physician  see  the  infant  every  few 
days,  inspect  the  stools,  hear  the  nurse's  report,  and  see  how  his  direc- 
tions are  being  carried  out.  When  the  child  is  well  started  and  has 
begun  to  gain  regularly  in  weight,  a  weekly  visit  will  be  sufficient.  Still 
later  a  regular  weekly  report  in  writing,  to  be  continued  up  to  the  sev- 
enth or  eighth  month,  may  be  all  that  is  required;  after  that  time 
monthly  reports  are  usually  sufficient.  My  plan  is  to  have  the  weekly 
report  include  only  answers  to  certain  questions— viz. : 

1.  Weight : gain  or  loss  since  last  report. 

2.  Stools :  frequency  and  general  character. 

3.  Vomiting  or  regurgitation — when  ?  and  how  much  ? 

4.  Flatulence  or  colic? 

5.  Appetite;  is  the  child  satisfied?    Does  he  leave  any  of  his  food? 

6.  Is  he  comfortable  and  good-natured? 

7.  How  much  does  he  sleep  ? 

8.  Date. 

9.  Date  of  last  report. 

An  excellent  plan  is  to  furnish  the  patient  with  printed  forms  con- 
taining these  questions  to  be  filled  out  and  returned.  This  is  a  simple 
matter,  and  there  are  very  few  intelligent  mothers  who  will  be  unwilling 
to  co-operate  with  the  physician  to  this  extent.  With  information  re- 
garding the  points  indicated,  it  is  possible  for  the  physician  to  know 
pretty  accurately  how  the  case  is  doing,  what  changes,  if  any,  are  de- 
sirable in  the  food,  and  whether  he  ought  to  see  the  patient.  It  is  only 
by  some  systematic  method  of  observation  that  one  can  secure  the  best 
results  in  this  or  any  other  form  of  infant-feeding.  The  plan  just  de- 
scribed is  equally  useful  in  all  methods. 

Those  whose  knowledge  of  laboratory-feeding  consists  only  in  the 
acquisition  of  a  few  formulas,  which  are  supposed  to  be  proper  for  the 
earl}'',  middle,  or  late  period  of  infancy,  are  in  little  better  position  than 
one  who  feeds  all  children  under  his  care  on  Dr.  A.'s  or  Dr.  B.'s  "  mix- 
ture," or  upon  any  of  the  commercial  infant  foods.  The  results  will 
probably  be  about  the  same.  An  equally  improper  way  of  using  the 
laboratory  is  that  of  those  physicians  who  know  nothing  of  milk  per- 
centages, and  care  less,  and  who  simply  write,  as  I  have  known  many 
to  do,  such  directions  as  the  following :  "  Send  milk  suitable  for  a 
three-months-old  baby."  In  these  ways  all  the  advantages  of  labora- 
tory-feeding are  missed  and  its  fundamental  principle  violated,  which 
is  for  the  physician  to  prescribe  a  food  adapted  to  the  child's  digestion 
at  the  time.     Properly  used,  laboratory-feeding  has  some  very  obvious 


ARTIFICIAL  FEEDING.  185 

and  very  important  advantages.  The  ability  to  vary  the  different  con- 
stituents of  the  milk  separately,  and  at  will,  even  to  a  fraction  of  a  per 
cent,  has  already  been  mentioned ;  but  what  is  still  more  important,  the 
physician  can  be  sure  that  the  child  is  actually  getting  what  he  has 
ordered;  so  that  he  is  independent  of  the  ignorance,  carelessness,  or 
caprice  of  the  nurse,  who  otherwise  would  prepare  the  food.  Where 
milk  is  prepared  at  a  central  station  much  greater  care,  intelligence,  and 
accuracy  can  be  secured  than  are  obtainable  in  the  average  home.  As  the 
laboratory  company  has  direct  oversight  of  the  health,  care,  and  feed- 
ing of  the  cows,  and  the  handling  of  the  milk  from  the  time  it  leaves 
the  cow  till  it  reaches  the  nursery,  greater  cleanliness,  freshness,  and 
purity  are  secured  than  would  otherwise  be  possible. 

While  physicians  in  active  practice  are  able  to  calculate  percentages 
with  tolerable  accuracy  from  the  ordinary  materials  at  hand  for  the 
home  modification  of  milk,  this  is  a  subject  in  which  nearly  every  one 
experiences  at  first  considerable  difficulty,  and  the  laboratory  becomes  a 
great  saving  of  time  and  trouble. 

The  practical  advantages  of  laboratory-feeding  are  sufficiently  at- 
tested by  the  fact  that  laboratories  have  been  established  in  sixteen  of 
the  larger  cities  of  the  United  States  and  Canada,  and  have  received 
the  indorsement  of  the  great  body  of  the  most  intelligent  physicians  of 
the  country. 

The  objections  to  laboratory-feeding  are  mainly  three :  The  expense, 
from  forty  to  sixty  cents  a  day,  is  such  as  to  place  it  out  of  the  reach 
of  many  who  need  it  most.  This  must  ever  stand  in  the  way  of  its 
general  adoption.  The  second  objection  is,  I  think,  a  theoretical  one — 
viz.,  that  the  process  now  followed  of  separating  and  recombining  the 
milk  elements,  impairs  its  nutritive  properties  in  some  unexplained  way. 
This  is  supposed  to  take  place  in  the  emulsion  of  the  fat  as  a  result 
of  the  use  of  the  centrifuge  as  a  cream  separator.  Whatever  may  be  said 
against  the  use  of  laboratory  milk  on  this  ground,  may  be  urged  with 
equal  propriety  against  the  use  of  all  centrifugal  cream,  which  comprises 
most  of  the  cream  now  sold  in  our  cities.  Personally,  I  do  not  think 
this  objection  has  much  weight.  In  cases  with  difficult  fat  digestion  I 
have  repeatedly  tried  the  experiment  of  changing  from  centrifugal  to 
gravity  cream,  and  have  been  unable  to  see  any  appreciable  difference 
in  their  digestibility.  Others  have  had  the  same  experience.  The  third 
objection  to  laboratory-feeding  is  that  a  mother  or  nurse  can  not  use  it 
without  the  advice  and  direction  of  the  physician.  One  of  the  chief  rea- 
sons why  we  see  so  many  disastrous  results  with  artificial  feeding  is  that 
so  much  of  it  is  done  by  mothers  aud  nurses  on  their  own  responsibility, 
their  advisers  being  their  friends  or  the  circulars  issued  by  manufac- 
turers of  the  commercial  infant-foods.  Successful  artificial  feeding  by 
any  method  requires,  for  the  first  few  months  at  least,  close  attention. 


186 


NUTRITION. 


As  already  stated,  it  is  to  my  mind  one  of  the  great  advantages  of  the 
laboratory  method,  that  the  entire  control  of  the  quantity  and  quality 
of  the  food  is  kept  in  the  physician's  hands,  for  in  no  other  way  can  he 
be  held  responsible. 

The  milk  laboratory  is  only  an  instrument  or  agency  in  the  physi- 
cian's hands  for  carrying  out  his  own  ideas  in  infant-feeding,  and  the 
results  will  be  good  or  bad,  according  to  the  use  he  makes  of  it.  Failures 
occur  at  times  with  this  as  with  all  other  methods  of  feeding.  My  own 
results  have  steadily  improved  each  year  as  I  have  come  to  understand 
more  clearly  the  indications  for  using  the  different  changes  in  the  milk 
which  the  laboratory  has  made  possible.  Many  of  the  finest  specimens 
of  physical  development  under  my  care  have  been  those  who  have  had 
for  the  first  j'ear  practically  nothing  but  modified  milk  from  the  labora- 
tory; and  after  over  eight  years"  experience  with  laboratory- feeding  I 
am  more  than  ever  convinced  of  its  scientific  value  and  its  practical 
utility,  and  have,  therefore,  no  hesitation  in  placing  it,  when  intelli- 
gently used,  next  to  maternal  nursing.  As  a  general  guide  to  the  modi- 
fication of  milk  for  an  average  healthy  infant  the  following  table  is  in- 
troduced, showing  the  manner  in  which  the  changes  required  by  the  age 
and  development  of  the  child  are  made :  * 

Schedule  for  an  Average  Healthy  Infant,  shoiving  Percentages  of 
Fat,  Sugar,  and  Proteids,  and  the  Quantities. 


Age. 


Premature  infants  .  .  . 
First  to  fourth  day.  . . 
Fifth  to  seventh  day .  . 

Second  week 

Third  weeli 

Fourth  to  eighth  week 

Third  month  

Fourth  month 

Fifth  month 

Sixth  to  tenth  month. 

Eleventh  month 

Twelfth  month 

Thirteenth  month.    .  . 


PERCENTAGES  OF 


Sugar 


Pro- 
teids. 


•00 

4  00 

•00 

500 

•50 

500 

•00 

6  00 

•50 

6-00 

00 

600 

•00 

6-00 

•50 

700 

•50 

TOO 

•00 

700 

■00 

5-00 

-00 

5-00 

•00 

4-50 

0  25 
0-30 
0-50 
0  60 
0-80 


QUANTITY  FOR  ONE 
FEEDING. 


Ounces.      Grammes. 


1   -  U 

1  -  2 

2  -  2i 
2-3+ 
2i-  4 
3-5 
3^-  5* 
4-6 
5-8 
6-9 
7-9 
7  -10 


7-22 

30-45 

30-60 

60-75 

60-110 

75-125 

90-155 

110-170 

125-185 

155-250 

185-280 

220-280 

220-310 


No.  feed- 
ings in  24 
hours. 


Interval 
bj-  day. 


12-18 
6-10 
10 
10 
10 

9 

8 

7 

7 

6 

5 

5 

5 


1-H  hours.. 
2-4 

2 

2 

2 

2i 

2+ 

3" 

3 

3 

4 

4 

4 


Home  Modification  of  Milk. — Inasmuch  as  milk  laboratories  are  as 
yet  inaccessible  to  the  great  body  of  the  profession,  the  problem  pre- 
sented is  how  the  advantages  of  the  laboratory  method  may  be  utilized 
where  milk  is  prepared  at  home.  'No  plan  of  home  modification  3'et 
proposed  secures  more  than  approximate  accuracy  in  the  percentages  of 


*  For  details  regarding  the  milk  laboratory,  see  Rotch,  Archives  of  Ptediatrics, 
February,  1893. 


ARTIFICIAL   FEEDING.  187 

fat,  sugar,  proteids,  etc.  Yet,  if  the  directions  given  below  are  carefully 
carried  out,  a  degree  of  accuracy  sufficient  for  all  practical  purposes  can 
be  secured.  The  physician  thus  can  not  only  know  the  percentages  he 
is  giving,  but  he  can  himself  readily  vary  them  within  the  range  usually 
required,  according  to  the  indications  presented.  The  thing  desired  is 
a  method  simple  enough  to  be  readily  grasped  by  the  average  mother 
or  nurse  who  is  to  carry  out  the  physician's  directions.  The  method 
here  given  is  one  which  in  principle  I  have  followed  for  many  years ;  and 
I  have  found  little  difficulty  in  making  patients  understand  how  to  use 
it.  Several  other  methods  have  been  proposed,  which  have  their  merits ; 
all  require  a  little  study  to  enable  one  to  use  them  freely. 

The  requisites  for  success  in  the  home  modification  of  milk  are : 

1.  Good  raw  materials — the  freshest  and  cleanest  milk  obtainable. 

2.  Knowledge  on  the  part  of  the  physician  of  at  least  the  approxi- 
mate composition  of  the  milk  and  cream  used  in  the  home. 

3.  Directions  which  are  clear,  explicit,  and  in  writing,  that  they  may 
be  understood. 

4.  The  co-operation  of  an  intelligent  mother  or  nurse,  that  they  may 
be  properly  carried  out. 

The  formulas  given  in  the  table  (page  186)  may  be  roughly  grouped 
into  three  series:  (1)  Those  in  which  the  fat  is  three  times  the  pro- 
teids;  (2)  those  in  which  the  fat  is  twice  the  proteids;  (3) those  in 
which  the  two  are  nearly  equal.  In  practice  I  have  found  that  these 
include  all  that  are  ordinarily  required.  In  general,  the  first  series  is 
suited  to  normal  cases  during  the  first  period  of  infancy — i.  e.,  from 
birth  to  the  third  or  fourth  month;  the  second  series,  to  the  middle 
period  of  infancy — i.  e.,  from  the  third  or  fourth  to  the  ninth  or  tenth 
month ;  the  third  series,  to  the  later  period — i.  e.,  from  the  tenth  to  the 
twelfth  or  fourteenth  month. 

For  the  early  months. — For  this  period  it  is  desirable  that  the  fat 
Bhould  be  three  times  the  proteids,  or  the  usual  ratio  existing  in  good 
breast-milk.  The  easiest  way  to  arrive  at  this  would  seem  to  be,  first, 
to  secure  some  milk  or  milk  combination  containing  three  times  as  much 
fat  as  proteids,  and  then  dilute  this  according  to  the  infant's  age  and 
digestion.  After  such  dilution  it  will  be  necessary  only  to  add  sugar 
and  lime-water  to  complete  the  modification.  This,  in  brief,  is  the  whole 
process. 

The  most  convenient  combination  for  dilution  in  the  early  months 
is  one  containing  10  per  cent  fat  and  3  -3  per  cent  proteids.  I  shall  call 
it  a  10-per-cent  milk,  and  refer  to  it  subsequently  as  the  primary  for- 
mula of  the  First  Series.  The  10-per-cent  milk  may  be  obtained  by 
removing  the  upper  third  (see  Fig,  34)  from  a  (|uart  bottle  of  milk,  as 
described  on  page  148.  This  method  will  answer  for  persons  who  can 
obtain  milk  fresh  from  the  cow,  or  for  those  who  use  bottled  milk,  pro- 


188 


NUTRITION. 


vided  the  bottling  is  done  at  the  dairy  before  the  cream  rises.  The  upper 
milk  may  be  taken  off  with  a  siphon,  spoon,  or  small  dipper  (Fig.  35)  ; 
pouring  off  is  not  so  accurate.     For  those  who  do  not  get  their  milk  as 


Fig.  34. — The  percentage  of  fat  in  different  layers  of  milk. 

above  described,  the  additional  fat  can  be  secured  only  by  adding  cream 

to  the  milk.    To  secure  a  combination  containing  10  per  cent  fat,  equal 

parts  of  plain  milk  and  the  ordinary  (16-per-cent)  cream  should  be  used. 
The  next  step  is  the  manner  and  degree  of  dilution  of  the  primary 

formula.     It  is  convenient  in  our  calculation  to  make  up  20  ounces  of 

the  food  at  a  time.  For  such  a  20-ounce 
mixture  it  is  seldom  necessary  to  use  less 
than  2  ounces  of  our  10-per-cent  milk; 
this  is  weak  enough  for  a  newly  born  in- 
fant. When  one  wishes  to  strengthen  the 
food  he  gradually  increases  the  amount  of 
the  10-per  cent  milk,  1  ounce  at  a  time, 
making  it  successively  3  ounces,  4  ounces, 
5  ounces,  6  ounces,  etc.,  in  a  20-ounce 
mixture,  the  water,  of  course,  being  re- 
duced by  the  same  amount. 

These  mixtures  may  readily  be  trans- 
lated into  percentages  by  remembering 
that  the  percentage  of  fat  is  always  exact- 
ly one  half  the  number  of  ounces  of  the 
10-per-cent  milk  used  in  a  20-ounce  mix- 
ture.    Thus  using  3  ounces  will  give  us 

1  -5  per  cent  fat ;  4  ounces,  2  per  cent  fat ;  6  ounces,  3  per  cent  fat,  etc. 

The  proteids  will  continue  to  be  in  every  instance  exactly  one-third  the 

fat,  as  in  the  primary  formula. 


Fig.  S5.— Chapin's  dipper,  for  remov 
ing  the  upper  layers  of  milk. 


ARTIFICIAL  FEEDING. 


189 


The  amount  of  milk  sugar  needed  to  bring  this  up  to  the  percentage 
usually  required  (5  -5  to  6  -5)  is  1  ounce  in  each  20-ounee  mixture.  One 
may  obtain  from  a  druggist  a  box  holding  exactly  1  ounce  of  sugar,  or 
may  measure  in  a  tablespoon,  calculating  2|  even  tablespoonfuls  as  1 
ounce.    This  sugar  is  dissolved  in  the  water  used  for  diluting  the  milk. 

The  usual  proportion  of  lime-water  needed  is  5  per  cent,  or  1  ounce 
in  a  20-ounce  mixture ;  this  may  be  easily  increased  to  any  desired  quan- 
tity.   The  foregoing  directions  may  be  expressed  in  the  following  table : 

First  Series  of  Formulas. — Fat  to  proteids,  3:1, 

Primary  Formula. — Ten-per-cent  milk — or  fat  10  per  cent,  sugar  4"3  per  cent,  pro- 
teids 3-3  per  cent.  Obtained  (1)  as  upper  one-third  of  bottled  milk  (Fig.  34),  or  (2) 
equal  parts  milk  and  (16-per-cent)  cream. 


Derived  Formulas,  giving  Quantities  for  Tiventy -ounce  Mixtures. 
[  Milk  sugar. . .     1  oz. 
<  Lime-water  . .     1  oz. 
(  Water,  q.  s.  to  20  oz. 


Per  cent.         Per  cent.  Per  cent. 

with  2  oz.  of  10^  milk  =  fat  1-00,  sugar  5-50,  proteids  0-33. 


IL 
III. 
IV. 

V. 
VI. 


3oz. 

4oz. 

5  oz. 

6  oz. 
7oz. 


1-50, 

'      5-50, 

2-00, 

'      6-00, 

2-50, 

'      6-00, 

3-00, 

'      6-00, 

3-50, 

'      6-50, 

0-50. 
0-66. 
0-83. 
1-00. 
1-16. 


Making  more  than  a  20-ounce  mixture  will  be  found  very  simple  if 
we  calculate  for  25,  30,  35  ounces,  etc.  Thus  for  25  ounces  we  add  one- 
fourth  more  of  each  ingredient ;  for  30  ounces  one-half  more,  etc.  For 
25  ounces  of  II,  therefore,  the  exact  formula  would  be :  10-per-eent  milk, 
3f  ounces;  milk  sugar,  1^  ounces;  lime-water,  1^  ounces;  water  q.  s.  to 
make  25  ounces — i.  e.,  20  ounces. 

Table  giving  in   a   Condensed  Form  the   Quantities  usually  required 
for  obtaining  the  different  Fat  Percentages. 


A 

•50 

B 

1 

C 
1-5 

D 
2 

E 
2 

F 
2-5 

G 
2^ 

H 
2-75 

I 
3 

J 
3 

K 
3 

L 
3-25 

M 
3^ 

N 
3-7 

0 

To  obtain  fat,  per  cent. . . 

4 

For  total  food,  ounces 

20 

20 

20 

20 

25 

25 

28 

28 

30 

33 

36 

36 

37 

38 

40 

Take  10^  milk,  ounces  . . . 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

16 

Proteids. — The  percentage  in  each  case  will  be  one-third  the  fat. 

Sugar. — One  ounce  in  20,  or  one  even  tablcspoonful  in  8  ounces,  gives  5*5  per  cent 
for  the  lower  and  6'5  for  the  higher  formulas. 

Lime-water. — One  part  to  20  of  the  food,  the  average  required. 

Water. — Enough  to  be  added  to  the  above  ingredients  to  bring  the  total  to  the 
number  of  ounces  specified  ;  in  part  of  this  water  the  milk  sugar  is  dissolved.  Barley 
water  or  any  other  diluent  may  be  added  in  the  same  manner. 

For  example,  suppose  one  wishes  10  feedings  of  2|  ounces,  in  which 
the  fat  is  2  per  cent;  the  proteids,  ])eing  always  one-third  the  fat,  will  be 
necessarily  0  -QtQ  per  cent.    Eeferring  to  the  table,  column  E,  it  will  be 
14 


190  NUTRITION. 

seen  that  to  make  25  ounces  of  food,  5  ounces  of  the  10-per-cent  milk  will 
be  needed.  Further,  there  will  be  required  1|  ounces,  or  3  even  table- 
spoonfuls,  sugar,  and  1^  ounces  lime-water.  The  full  formula  will  be : 
fat  2,  sugar  6,  proteids  0  -66,  lime-water  5  per  cent.  Or,  to  take  a  higher 
formula,  to  make  up  8  feedings  of  4  ounces,  containing  3  per  cent  fat; 
the  proteids,  being  always  one-third  the  fat,  will  be  necessarily  1  per 
cent.  Eeferring  to  the  table,  column  J,  one  finds  that  to  make  33 
ounces,  containing  3  per  cent  fat,  10  ounces  of  the  10-per-cent  milk  will 
be  required,  using  which  we  will  have  1  ounce  of  food  to  spare ;  the  sugar 
will  be  4  tablespoonfuls,  or  If  ounces;  the  lime-water.  If  ounces.  The 
full  formula  will  be  :  fat  3 ;  sugar  6 ;  proteids  1 ;  lime-water  5  per  cent. 

With  this  First  Series  of  formulas  a  healthy  infant  can  usually  be 
carried  along  from  birth  until  three  or  four  months  old,  the  increase  in 
the  strength  of  the  food  being  made  from  time  to  time  as  required. 
When  this  age  is  reached  and  the  fat  has  been  raised  to  3  or  3  -5  per 
cent,  the  further  increase  should  be  made  chiefly  in  the  proteids,  since 
the  fat  is  now  nearly  at  the  normal  limit.  To  secure  this  change  we 
require  a  different  primary  formula. 

For  the  middle  period  of  infancy. — This  extends  from  the  end  of 
the  third  or  fourth  to  the  end  of  the  ninth  or  tenth  month.  For  healthy 
children  it  is  desirable  during  this  period  that  the  fat  should  still  be 
higher  than  the  proteids,  though  not  to  the  same  degree  as  in  the  early 
months.  The  best  results  are,  I  think,  obtained  when  the  fat  is  about 
twice  the  proteids.  This  corresponds  to  a  rich  breast-milk.  Here,  as 
for  the  early  months,  we  first  obtain  a  combination,  or  primary  formula, 
in  which  the  fat  and  proteids  stand  in  the  relation  of  two  to  one,  and 
dilute  it  as  before,  adding  milk  sugar  and  limewater  to  complete  the 
modification. 

The  primary  formula  most  conveniently  obtained  for  this  purpose  is 
one  containing  7  per  cent  fat  and  3  -5  per  cent  proteids,  or  a  7-per-cent 
milk.  This  we  may  get  by  removing  the  upper  half  (Fig.  34)  from  a 
quart  bottle  of  milk,  as  described  on  page  148.  Or  in  case  milk  and  cream 
are  used,  instead  of  this  upper  milk,  it  will  be  necessary  to  add  one  part 
ordinary  (16-per-cent)  cream  to  three  parts  milk.  The  dilution  is  ac- 
complished in  the  same  general  way  as  for  the  early  months.  Usually  an 
infant  is  carried  with  the  First  Series  up  to  formula  V  (fat,  3  per  cent; 
sugar,  6  per  cent ;  proteids,  1  per  cent),  obtained  by  using  6  ounces  of  top 
milk  in  a  20-ounce  mixture.  Now  to  raise  the  proteids  we  pass  to  7 
ounces  in  a  20-oiince  mixture.  No.  V  of  the  Second  Series  of  formulas, 
which  can  be  successively  increased  to  8  ounces,  9  ounces,  10  ounces,  etc., 
in  a  20-ounce  mixture.  It  so  happens  in  making  the  change  from  one 
series  of  formulas  to  the  other  that  the  fat  is  at  first  somewhat  re- 
duced when  the  proteids  are  increased ;  this  is  not  essential  nor  impor- 
tant, and  occurs  only  in  the  first  formulas  used. 


ARTIFICIAL   FEEDING. 


191 


These  formulas  may  readily  be  translated  into  percentages  by  remem- 
bering that  the  percentage  of  fat  in  any  formula  is  exactly  seven-twenti- 
eths, or  about  one-third,  the  number  of  ounces  of  the  7-per-cent  milk  in  a 
20-ounce  mixture.  Thus  3  ounces  in  the  mixture  will  give  1  per  cent 
fat ;  *  5  ounces  will  give  1  "6  per  cent ;  9  ounces  about  3  per  cent,  etc. 
In  the  following  table  these  directions  are  expressed: 

Second  Series  of  Formulas. — Fat  to  proteids,  2:1. 

Primary  Formula. — Seven-per-cent  milk — or  fat  7  per  cent,  sugar  4'40  per  cent, 
proteids  3-50  per  cent.  Obtained  (1)  as  upper  half  of  bottled  milk  (Fig.  34),  or  (2)  by- 
using  three  parts  milk  and  one  part  (16-per-cent)  cream. 


Derived  Formulas,  giving  Quantities  for  Twenty-ounce  Mixtures. 
(  Milk  sugar. . .     1  oz. 
.  \  Lime-water. .     1  oz. 


Water,  q.  s.  to  20  oz. 


Per  cent.       Per  cent.  Per  cent, 

with  3  oz.  of  1%  milk  =:  fat  TOO,  sugar  5'50,  proteids  0-50. 


n. 

«               u 

'    4  oz. 

III. 

u 

'    5  oz. 

IV. 

ii                    H                           t( 

'    6  oz. 

V. 

"        "           '< 

'    7oz. 

VL 

U                    «                           (( 

'    8oz. 

VII. 

"        "           " 

'    9  oz. 

VIIL 

Milk  sugar...     f  oz.  ^ 

'  10  oz. 

IX.j 

Lime-water. .     1  oz.  V 
Water,  q.  s.  to  20  oz.  ,' 

'  12  oz. 

1-40, 

'      5-75, 

0-70. 

1-75,     ' 

'      6-00, 

'       0-87. 

2-10, 

'      6-00. 

1-05. 

2-50, 

'      6-50, 

1-25. 

2-80,     ' 

'      6  50, 

1-40. 

3-15,     ' 

'      7-00, 

1-55. 

3-50, 

'      7-00, 

'        1-75. 

=    "   4-00, 


7-00, 


2-00. 


In  the  above  table  are  given  the  formulas  containing  the  very  low 
percentages  of  fat  and  proteids,  although  with  healthy  children  we  sel- 
dom use  any  which  are  lower  than  V.  The  others  are  convenient  in 
disturbances  of  digestion  where  a  lower  fat  than  usual  is  desired.  From 
V  we  may  increase  quite  rapidly  to  VI  and  VII ;  VIII  or  IX  may 
usually  be  continued  for  several  months,  until  the  infant  is  ten  or  eleven 
months  old. 

With  these,  as  with  the  First  Series,  if  more  than  20  ounces  are  re- 
quired, we  may  make  25,  30,  or  40  ounces  by  using  of  each  ingredient 
one-quarter  more,  one-half  more,  or  twice  as  much. 

Table  giving  in  a  Condensed  Foyvn  the   Quantities  usually  required 
for  obtaining  the  diffey^ent  Fat  Percentages. 


To  obtain  fat,  per  cent 
For  total  food,  ounces 
Take  '~i%  milk,  ounces 


A 

B 

c 

D 

E 

F 

G 

H 

1 

J 

K 

L 

1 

1 

1-4 

1-8 

2 

2-33 

2-75 

2-75 

3-1 

3-5 

3-5 

4 

20 

30 

30 

33 

33 

36 

36 

40 

40 

40 

44 

44 

3 

4 

6 

8 

10 

12 

14 

16 

18 

20 

22 

25 

4 

48 


*  To  obtain  the  exact  fat  percentage  take  one-third  the  number  of  ounces  of  top 
milk  in  a  20-ounce  mixture  and  add  0-15  to  the  result.  This  small  error  may  in  prac- 
tice be  disregarded. 


192  NUTRITION. 

Proteids. — The  percentage  in  each  case  will  be  one-half  the  fat. 

Sugar. — One  ounce  in  20,  or  1  even  tablespoonful  in  8  ounces,  until  the  food 
becomes  half  milk ;  after  that  1  ounce  in  25,  or  1  even  tablespoonful  to  each  10 
ounces  of  the  food,  will  give  the  proper  amount. 

Lime-water. —  Usually  in  the  proportion  of  1  part  to  20  of  the  total  food. 

Water  or  other  diluent. — Enough  to  be  added,  after  the  above  ingredients,  to 
bring  the  total  to  the  number  of  ounces  specified ;  in  part  of  this  the  sugar  is  dis- 
solved. 

For  the  latter  part  of  the  first  year. — At  this  time  a  further  increase 
in  the  proteids  may  be  made  until  the  child  is  gradually  brought  to  take 
whole  milk.  For  making  such  changes  we  find  a  third  series  of  modi- 
fications useful,  formulas  in  which  the  fat  and  proteids  are  nearly  equal. 
This  is  accomplished  by  using  plain  milk  and  diluting  it,  adding  lime- 
water  and  milk  sugar.  The  exact  percentages  of  fat  and  proteids  ob- 
tained with  the  various  dilutions  of  milk,  and  the  amount  of  sugar  neces- 
sary to  bring  this  up  to  the  desired  quantity,  are  shown  in  the  table 
below.  The  sugar  during  the  latter  part  of  the  period  is  reduced  for 
the  reason  that  at  this  age  the  child  is  already  taking  a  considerable  part 
of  his  carbohydrates  in  the  form  of  starch. 

Third  Series  of  Formulas. — Fat  to  proteids,  8:7. 

Primary  Formula. — Plain  milk :  Fat  4  per  cent,  sugar  4*5  per  cent,  proteids  3"5 
per  cent. 

Derived  Formulas^  giving  Quantities  for  Tiventy-ounce  Mixtures. 

!  Milk  sugar...      1  oz.  j  Percent.       Percent.  Percent. 

Lime-water . .     1  oz.  |-  with  5  oz.  plain  milk  =  fat  1*00,  sugar  6*00,  proteids  0'87. 
Water,  q.  s.  to  20  oz.  ) 


II. 

"        "    "     " 

"     6  oz.     " 

"      =  " 

1-20,      ' 

'      600, 

1-00. 

III. 

t(             tl      tl         It 

"     8  oz.     " 

((            . 4( 

1-60,      ' 

'      6-50,       ' 

1-40. 

IV. 

1  JMilk  sugar. . .     i  oz.  \ 

"  10  oz.     " 

((        a 

2-00,     ' 

■'      7-00,       ' 

1-75. 

v.- 

<  Lime-water . .     1  oz.  V 
(  Water,  q.  s.  to  20  oz.  ) 

"  12  oz.     " 

H            It 

2-40,      ' 

'      5-00, 

2-10. 

VI. 

"     "      " 

"  14  oz.     " 

tt        t( 

2-80,     ' 

'      5-50, 

2-50. 

VII. 

ti              (1      a         n 

"  16  oz.     " 

tt        tt 

3-20,      ' 

'      5-50,       ' 

2-80. 

From  formula  IX  of  the  Second  Series  a  child  can  generally  pass 
to  V  of  the  Third  Series,  then  successively  to  VI  and  VII,  and  from 
this  to  plain  milk  without  any  modification. 

General  Rules  for  varying  Milk  Percentages. — We  have  already  indi- 
cated the  formulas  most  used  in  laboratory-feeding,  and  subsequently 
have  shown  how  approximately  the  same  formulas  can  be  derived  when 
milk  is  prepared  at  home.  The  next  question  is  how  to  use  the  formulas 
we  have  obtained.  A  theoretical  schedule  for  feeding  a  healthy  infant 
from  birth  by  the  laboratory  method  is  given  on  page  186.  Using  the 
method  of  home  modification  described,  to  follow  the  same  general 


ARTIFICIAL  FEEDING. 


193 


scTiedule  we  would  begin  with  formula  I  of  the  First  Series,  or  fat  1  per 
cent,  sugar  5-50  per  cent,  proteids  0-33  per  cent;  gradually  increase 
to  V  or  VI  of  the  same  series;  pass  then  to  V  or  VI  of  the  Second 
Series,  increasing  gradually  to  IX;  then  passing  to  V  or  VI  of  the  Third 
Series,  from  which  an  increase  is  made  to  VII,  and  then  to  whole  milk". 
The  temporary  lowering  of  the  fat,  which  occurs  when  we  pass  from  one 
series  of  formulas  to  the  next  for  the  purpose  of  raising  the  proteids,  is, 
as  already  stated,  not  essential  nor  important. 

Feeding  by  schedule. — It  is  impossible  to  indicate  in  a  schedule  any- 
thing more  than  the  general  rate  of  increase.     It  does  not  follow  because 


o^^^GE  2        4       6       8       10     12     14     16      10     20     22     24    26 

17 

16 

15 

14 

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6 
5 

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Fig.  36.— Weight  curve  of  bottle-fed  infant  for  first  six  months.  Heavy  line  that  of  patient; 
light  line,  the  normal  average.  Small  child,  not  particularly  vigorous,  never  put  to  the 
breast;  feeding  begun  on  the  second  day  from  the  milk  laboratory.  Formula:  Fat  1  per 
cent,  sugar  5  per  cent,  proteids  0'33  per  cent;  at  five  weeks,  taking  fat  3  per  cent,  sugar 
6  per  cent,  proteids  1  per  cent;  at  five  months,  taking  fat  4  per  cent,  sugar  7  per  cent,  pro- 
teids 2  percent;  not  the  slightest  discomfort  or  any  symptom  of  indigestion  during  the 
entire  period.     Weight  at  twelve  months,  21  pounds,  8  ounces. 


an  infant  is  two  months  old  that  he  should  be  given  certain  percentages, 
and  certain  others  because  he  is  three  months  old.  How  rapidly  the 
strength  of  the  food  is  increased  must  always  depend  upon  the  individ- 
ual child.  One  who  is  large  and  robust  and  has  a  strong  digestion,  may 
at  four  months  be  a  month  or  two  ahead  of  the  average;  and  a  small 
child,  with  rather  feeble  digestion,  may  be  as  much  behind;  but  the  same 
gradational  steps  of  increase  may  be  advantageously  followed  with  all. 
No  schedule,  therefore,  can  be  followed  with  absolute  regularity.     To 


194  NUTRITION. 

follow  any  one  too  closely  is  to  violate  the  central  principle  of  percent- 
age feeding,  which  is  to  adapt  the  milk  to  the  child's  digestion  at  the 
time.  A  schedule  is  intended  rather  as  a  general  guide,  showing  the 
method  according  to  which  the  gradations  of  the  food  may  best  be  made 
in  health.  The  one  given  represents  the  average  proportions  which 
in  my  experience  have  succeeded  best  with  children  of  normal  diges- 
tion. 

The  principles  underlying  the  schedule  given  must  be  understood  if 
it  is  to  be  rightly  applied.  In  the  First  Series  the  ratio  of  fat  and  pro- 
teids  is  three  to  one,  or  about  that  of  breast-milk.  I  think  I  have  ob- 
tained better  results  with  most  cases  by  maintaining  this  ratio  during 
the  early  months,  making  the  proportion  of  the  fat  as  well  as  that  of 
the  proteids  low  during  the  early  weeks.  We  must  start  with  low  per- 
centages, and  I  believe  that  1  per  cent  of  fat  and  0  '33  per  cent  of  pro- 
teids are  not  too  low  for  the  first  two  or  three  days  of  life  (Fig.  36). 
But  it  is  a  serious  mistake  to  continue  with  low  percentages.  We  increase 
the  power  of  digestion  by  gradually  increasing  the  work  the  organs  are 
given  to  do,  not  by  giving  them  very  little  to  do.  In  effect,  the  latter  is 
like  the  continued  use  of  predigested  foods.  Because  of  the  slight  dis- 
comfort or  disturbance  which  is  apt  to  follow  an  increase  in  the  percent- 
ages, the  physician  is  ofttimes  inclined  to  go  back  to  the  weaker  formula ; 
while  if  the  stronger  is  continued  the  child  very  soon  becomes  accus- 
tomed to  the  higher  percentages,  and  quite  equal  to  digesting  them; 
the  only  essential  is  that  the  increase  is  not  made  too  rapidly.  Properly 
managed,  the  organs  of  an  average  infant  can  be  trained  to  digest  3  -5 
per  cent  fat  and  1  -5  per  cent  proteids  at  the  end  of  three  months,  and 
4  per  cent  fat  and  2  per  cent  proteids  at  five  or  six  months. 

Indications  for  increasing  the  food. — With  all  infants  it  is  best  to 
increase  the  food  very  gradually.  Abrupt  increases  are  very  likely  to 
derange  the  organs  of  digestion.  The  successive  formulas  of  the  sched- 
ule indicate  the  steps  by  which  the  strength  of  the  food  is  increased.  In 
increasing  the  quantity,  it  is  seldom  wise  to  do  more  than  add  half  an 
ounce  to  each  feeding,  and  often  a  fourth  of  an  ounce  is  better.  The 
best  general  rule  that  can  be  given  is  to  increase  the  food  when  the  child 
is  unsatisfied  or  not  gaining  in  weight,  but  is  digesting  well.  During 
the  early  weeks  both  the  quantity  and  the  strength  of  the  food  must 
be  increased  every  few  days.  It  may  be  difficult  to  tell  which  of  these 
is  best  to  do.  I  have  found  it  well  to  alternate ;  thus  when  the  infant 
demanded  more  food,  first  increasing  the  quantity;  then,  after  a  few 
days,  if  still  unsatisfied,  increasing  the  strength ;  the  next  time  increas- 
ing the  quantity  again,  etc.  In  this  way  will  be  avoided  the  error  into 
which  mothers  and  nurses  so  often  fall,  who  adopt  a  single  formula 
a,nd  keep  on  simply  increasing  the  quantity  indefinitely  whenever  the 
child  is  unsatisfied.     I  have  repeatedly  seen  infants  of  two  or  three 


ARTIFICIAL  FEEDING. 


195 


months  taking  as  much  as  7  or  8  ounces  every  two  hours,  and  even  then 
crying  from  hunger.  After  a  daily  total  of  35  to  38  ounces  is  reached, 
as  happens  with  most  infants  by  the  fourth  month,  the  increase  in  the 
food  should  be  chiefly  in  strength;  for  the  same  child  at  eight  months 
will  rarely  require  more  than  40  to  48  ounces. 

While  the  child's  weight  is  an  important  guide  in  directing  the  feed- 
ing, it  is  a  mistake  to  be  influenced  by  it  alone  during  the  first  two  or 
three  weeks  in  infants  artificially  fed  from  birth.  Very  low  percentages 
are  necessary  until  a  child  has  become  somewhat  accustomed  to  the 
food.  While  taking  such  low  percentages  no  material  gain  in  weight  is 
to  be  expected.  However,  if  there  is  no  vomiting  or  colic,  if  the  child 
is  entirely  comfortable  and  sleeps  most  of  the  time,  and  if  the  stools  are 
gradually  assuming  a  healthy  colour  and  normal  odour,  conditions  may 


WEEK 

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fiG.  37. — Weight  curve  of  artificially  fed  infant,  showing  the  efl'cct  of  beginning  with  too  hiirh 
percentages.  Kobust  child  ;  digestion  deranged  when  a  few  days  old  by  bosrinning  with 
fat  2  per  cent,  sugar  6  per  cent,  proteids  0"75  per  cent;  food  in  two  or  three  clays  was  in- 
creased to  fat  3  per  cent,  sugar  6  per  cent,  proteids  1  per  cent.  A  good  deal  of  indigestion 
resulted,  and  the  disturbance  was  such  that  it  was  eight  weeks  before  the  digestion  became 
normal  and  the  gain  in  weight  regular;  progress  for  the  rest  of  the  year  satisfactory. 


be  considered  entirely  satisfactory.  The  food  may  bo  steadily  strength- 
ened with  the  demands  of  the  child's  appetite,  and  soon  the  increase  in 
weight  will  begin,  and  when  once  begun  it  will  be  continuous.  But  noth- 
ing is  easier  than  to  derange  the  organs  during  the  first  weeks  by  too 
high  percentages,  and  such  disturljances,  even  though  they  a]ipear  trivial, 
often  continue  for  many  weeks  (Fig.  37).    The  closest  attention  is  re- 


196  NUTRITION. 

quired  for  the  first  few  weeks;  for  if  well  started,  subsequent  progress 
becomes  an  easy  matter ;  but  if  badly  started,  there  will  be  trouble  most 
of  the  time. 

At  weaning,  or  with  a  child  who  has  previously  had  no  cow's  milk, 
one  must  begin,  even  in  the  case  of  one  whose  digestion  seems  quite 
normal,  with  percentages  considerably  lower  than  the  age  and  weight 
would  appear  to  require.  At  three  months  it  is  better  to  begin  with 
the  proportions  ordinarily  taken  by  a  bottle-fed  infant  at  three 
weeks;  or  at  nine  months  with  those  usually  taken  by  one  of  two  or 
three  months,  making  the  increase  in  strength  just  as  rapidly  as  the- 
condition  of  the  digestive  organs  warrants.  A  stationary  weight  for  a. 
week  or  two,  or  even  a  loss  of  a  few  ounces,  is  of  no  importance,  pro- 
vided the  change  in  diet  can  be  effected  without  deranging  digestion^ 
for  as  soon  as  a  child  becomes  somewhat  accustomed  to  cow's  milk 
the  percentages  can  be  raised,  and  progress  is  assured  (Fig-  33,. 
page  176). 

When  a  child  is  taken  from  some  other  diet,  or  some  other  milk 
formula,  and  put  upon  one  of  the  foregoing  series,  the  physician  may 
be  at  a  loss  where  in  the  schedule  to  begin;  especially  since  most  such 
changes  in  diet  are  made  because  the  child  is  not  thriving  or  is  suffering 
from  some  evident  symptoms  of  indigestion.  In  such  cases  we  must 
get  out  of  our  minds  the  notion  that  food  can  be  ordered  by  the  child's- 
age  or  even  by  its  weight,  although  both  must  be  taken  into  account. 
The  essential  thing  is  the  condition  of  the  digestive  organs,  and  unless- 
this  is  carefully  considered,  failure  is  almost  inevitable.  To  decide  as- 
to  proportions  best  to  use  one  must  know,  besides  the  age  and  weight, 
the  previous  gain  or  loss,  character  and  quantity  of  the  food  which  has- 
been  taken,  the  appetite,  the  number  and  nature  of  the  stools,  and  also- 
whether  any  such  symptoms  are  present  as  vomiting  or  regurgitation, 
colic,  constipation,  fretfulness,  discomfort,  or  disturbed  sleep.  Nothing- 
but  personal  experience  will  enable  one  to  judge  aright  as  to  the 
combination  best  suited  to  the  existing  conditions.  In  any  case 
the  first  prescription  must  be  an  experiment.  It  is  always  wise  to 
begin  with  lower  percentages  and  smaller  quantities  than  the  average, 
and  watch  the  effect,  making  subsequent  changes  according  to  symp- 
toms. 

A  caution  is  necessary  against  changing  the  formula  too  frequently. 
It  is  not  possible  to  modify  the  milk  in  such  a  way  as  to  relieve  every 
transient  discomfort  or  disturbance  an  infant  may  have.  Nurses  are 
usually  ready  to  ascribe  every  trivial  symptom  to  the  food,  particularly 
if  they  have  strong  opinions  of  their  own  upon  the  subject  of  feeding, 
and  are  not  in  full  sympathy  with  modern  ideas  of  milk  modification. 
Very  often  the  cause  is  outside  of  the  food  and  even  of  the  organs  of 
digestion.    (See  Fig.  39,  page  204.)    Unless  some  very  definite  symptoms- 


ARTIFICIAL  FEEDING.  197 

of  indigestion,  such  as  severe  colic,  vomiting,  etc.,  are  produced  by  the 
fornuUa  ordered,  it  is  usually  better  to  continue  with  it  at  least  two 
days,  as  it  is  hardly  possible  in  a  shorter  time  to  determine  what  the 
child's  digestive  organs  are  capable  of  doing.  For  slight  disturbances  of 
a  transient  nature  it  is  usually  enough  to  dilute  the  food  for  a  day  or 
more ;  just  before  the  bottle  is  given,  one  ounce  or  more  of  milk  may  be 
poured  off  and  replaced  by  boiled  water. 

Special  Modifications  to  meet  Particular  Symptoms. — There  are  few 
infants  whose  digestion  remains  perfectly  normal  throughout  the  first 
year.  Changes  are  from  time  to  time  necessary,  even  in  the  most 
healthy,  to  meet  special  symptoms  which  may  arise,  or  to  adapt  the  milk 
to  the  peculiarities  of  the  individual  child.  The  exact  indications  accord- 
ing to  which  the  percentages  of  fat,  sugar,  or  proteids,  the  quantity  of 
food,  and  the  frequency  of  feeding,  are  to  be  varied  are  by  no  means  fully 
determined.  This  requires  close  observation  by  the  physician  and  a 
study  of  each  individual  case,  and  constitutes  the  most  difficult  part  of 
the  problem  of  infant-feeding. 

Many  of  these  special  symptoms  are  disturbances  of  a  minor  char- 
acter, not  so  serious  as  to  make  one  regard  the  child  as  ill,  but  often 
persistent,  most  troublesome,  and  quite  enough  to  prevent  regular  and 
steady  progress  in  weight  and  development.  They  are  usually  the  result 
of  some  previous  mistake  in  the  composition  of  the  food.  Most  of  the 
general  rules  here  given  apply  equally  well  to  more  aggravated  condi- 
tions, which  would  be  regarded  as  pathological. 

Vomiting. — If  considerable  quantities  are  ejected  almost  immediate- 
ly after  feeding,  it  is  usually  because  too  much  food  has  been  given. 
Other  causes  must  be  considered  also — i.  e.,  the  food  may  be  too  rapidly 
taken,  the  child  may  be  moved  about  too  much,  the  abdominal  bands 
may  be  too  tight,  etc.  The  frequent  regurgitation,  often  one  or  two 
hours  after  feeding,  of  sour,  curdled  milk  or  a  watery  fluid,  is  usually 
an  indication  that  the  proportion  of  fat  is  too  high.  With  many  in- 
fants this  symptom  becomes  almost  constant,  and  after  a  time  this 
"  spitting  "  is  associated  with  more  active  vomiting,  often  of  considerable 
quantities  of  mucus.  The  first  indication  is,  therefore,  to  reduce  the  fat, 
which  may  be  accomplished  by  changing  from  a  formula  of  the  First 
Series  to  the  one  of  the  Second  Series  in  which  tlie  sugar  and  proteids 
are  the  same,  but  the  fat  lower;  or  if  a  still  lower  fat  is  desired,  to  a 
corresponding  formula  of  the  Third  Series.  Other  modifications  of  the 
milk  which  are  sometimes  helpful  are  to  use  double  the  amount  of  lime- 
water,  making  this  10  per  cent,  or  2  ounces,  in  each  20-ounce  mixture. 
Still  another  is  a  reduction  of  the  sugar.  It  is  also  important  that  the 
food  be  taken  slowly,  that  the  child  be  kept  perfectly  quiet  after  feeding, 
and  usually  that  the  intervals  of  feeding  be  longer  than  in  the  case  of 
good  digestion. 


198  NUTRITION. 

Constipation. — This  probably  gives  physicians  more  trouble  than  any 
other  symptom  in  connection  with  artificial  feeding.  Much  of  this  can 
be  prevented  or  overcome  by  proper  management.  Mothers  and  physi- 
cians often  expect  that  the  bottle-fed  baby  will  have  during  its  first 
month  or  two,  the  two  or  three  large  stools  daily  to  which  they  have 
been  accustomed  in  healthy  breast-fed  infants.  Not  finding  these,  but 
instead  only  one  movement  a  day,  and  that  small  and  sometimes  dry, 
they  at  once  resort  to  laxatives  or  enemata,  and  by  their  use  really  cause 
much  of  the  trouble  they  are  seeking  to  remove.  During  the  first  few 
weeks,  if  the  percentages  are  low,  as  I  believe  they  should  be,  there  is 
often  a  species  of  constipation  present  which  is  simply  the  result  of  the 
small  food-residue  in  the  intestine,  due  to  the  low  total  solids  of  the  milk 
given.  The  bowels  usually  move  naturally  every  day,  sometimes  even 
twice  a  day;  but  the  stools  are  small,  dry,  often  only  detached  masses, 
instead  of  a  smooth,  pasty  discharge.  Unless  there  is  associated  very 
manifest  discomfort  on  the  part  of  the  child,  such  a  condition  should 
be  disregarded,  especially  if  the  odour  and  colour  of  the  discharges  are 
nearly  normal.  After  a  few  days,  as  the  proportions  of  both  the  pro- 
teids  and  the  fat  are  gradually  increased  along  the  general  lines  of  the 
schedule,  this  form  of  constipation  passes  away.  On  the  other  hand,  if 
the  physician  tries  to  remedy  it  by  rapidly  raising  only  the  fat,  as  is  often 
done,  to  4  per  cent  or  even  higher,  the  constipation  is  rarely  over- 
come, but  there  is  frequently  produced  a  serious  disturbance  both  of  the 
stomach  and  the  intestines.  It  is  just  in  this  way  that  many  infants  are 
so  unnecessarily  upset  while  being  fed  from  the  milk  laboratories,  since 
it  is  very  easy  under  such  circumstances  to  raise  the  fat  1  or  2  per  cent. 
In  this  manner  disturbances  of  digestion  are  caused  which,  though  not 
serious,  frequently  continue  for  several  weeks,  and  prevent  a  normal 
gain  in  weight  for  even  a  longer  period.  With  early  constipation,  there- 
fore, it  is  usually  better  gradually  to  increase  both  fat  and  proteids; 
but  the  very  high  fats  often  used  in  the  early  weeks  are  particularly 
likely,  as  already  stated,  to  lead  to  habitual  vomiting.  Personally, 
I  have  found  that  anything  higher  than  3  per  cent  fat  during  the 
first  four  or  five  weeks  almost  always  works  badly;  that  over  -i  per 
cent  at  any  time  during  the  first  year  can  seldom  be  long  continued 
without  disturbing  digestion;  and  that,  if  constipation  persists  with 
these  percentages,  something  else  should  be  done  rather  than  raise 
the  fat. 

Colic. — The  habitual  colic  of  early  infancy  is  almost  invariably  due 
to  too  high  proteids,  and  rarely  occurs  when  percentages  as  low  as  those 
above  advised  are  given. 

Curds  in  the  stools. — The  appearance  of  curds  in  the  stools  is  due 
to  the  same  cause  as  habitual  colic,  and  is  usually  associated  with  it. 
The  curds  generally  appear  as  white  masses  or  lumps;  sometimes  they 


ARTIFICIAL  FEEDING.  I99 

are  gray  or  green,  coated  with  mucus,  and  expelled  with  effort.  Colic, 
curds  in  the  stools,  and  constipation  are  a  frequent  combination,  and 
are  usually  due  to  too  high  proteids  or  to  inability  to  digest  the  pro- 
teids  given,  even  though  the  percentage  is  not  high.  This  subject  is 
more  fully  discussed  in  connection  with  Difficult  Cases  of  Feeding  (page 
206). 

Loose,  green,  or  yellowisli-green  stools  of  a  sour  odour. — These  are 
sometimes  due  to  too  high  a  percentage  of  sugar,  but  more  often,  I  think, 
to  an  excess  of  fat.  The  number  of  stools  is  usually  from  two  to  five 
daily.  In  appearance  the  stools  resemble  thin  scrambled  eggs.  The 
small  yellowish  masses  are  often  mistaken  for  curds.  Stools  such  as 
those  described  are  often  seen  in  nursing  infants  as  well  as  in  those 
artificially  fed,  and  the  condition  is  not  incompatible  with  steady  and 
regular  gain  in  weight.  After  it  has  persisted  any  length  of  time  mucus 
is  regularly  present,  and  an  intractable  intestinal  catarrh  may  be  pro- 
duced. 

Large,  dry,  white  or  gray  stools. — These  are  often  smooth,  and  are 
generally  due  to  an  excess  of  fat.  They  have  usually  a  peculiarly  foul 
odour,  owing  to  the  presence  of  fatty  acids;  and  may  be  distinguished 
from  curds  by  their  solubility  in  ether,  and  their  burning  readily  with 
the  odour  of  butter. 

The  Apparatus  required  for  the  Preparation  of  Milk  at  Home. — 
This  includes  an  8-ounce  glass  graduate,  a  glass  or  agate  funnel,  a  cream 
dipper,  a  pitcher  for  mixing  food,  feeding-bottles,  a  tall  cup  for  warm- 
ing the  food,  a  small  ice-box,  preferably  of  wood,  and  a  sterilizer.  Other 
articles  needed  are  lime-water,  boiled  water  fresh  every  day,  milk  sugar, 
rubber  nipples,  absorbent  cotton,  bottle-brushes,  borax  or  boric  acid,  bi- 
carbonate of  soda,  and  an  alcohol  lamp,  or  better,  if  gas  is  available, 
a  Bunsen  burner,  which  should  stand  upon  a  zinc-covered  table  in  a 
room  adjoining  the  nursery.  The  best  style  of  bottle  is  that  which 
can  be  most  readily  cleaned.  The  graduated  cylindrical  bottles  with 
wide  mouths  are  to  be  preferred.  On  no  account  should  bottles  with 
any  complicated  apparatus  be  allowed.  The  best  nipples  are  those  of 
plain  black  rubber,  which  slip  over  the  neck  of  tlie  bottle,  and  are  not 
so  thick  as  to  prevent  their  being  turned  inside  out  for  cleansing. 
Those  with  a  long  rubber  tube  going  to  the  bottom  of  the  bottle  should 
not  be  used,  as  it  is  practically  impossible  to  keep  them  clean.  In  Paris 
and  in  some  American  cities  they  are  regarded  as  so  great  a  source  of 
danger  that  their  use  is  prohibited  by  law.  The  hole  in  the  nipple 
should  be  large  enough  for  the  milk  to  drop  rapidly  when  the  bottle 
is  inverted,  but  not  so  large  that  it  will  run  in  a  stream.  When  not  in 
use,  nipples  should  be  kept  in  a  solution  of  borax  or  boric  acid.  The 
most  scrupulous  care  is  necessary  of  both  nipples  and  bottles.  Bottles 
should  first  be  rinsed  with  cold  water,  then  washed  with  hot  soap-suds 


200  NUTRITION. 

and  a  bottle-brush.  When  not  in  use  they  should  stand  full  of  water 
to  which  borax  or  boric  acid  has  been  added.  Before  the  milk  is  put 
into  them  they  should  be  rinsed  and  placed  in  boiling  water  for  ten 
minutes. 

Directions  for  preparing  the  Food. — All  the  food  needed  for  twenty- 
four  hours  is  prepared  at  one  time.  This  saves  much  time  and  trouble, 
and  is  in  every  way  simpler  than  preparing  each  feeding  separately. 
The  first  thing  to  be  decided  is  the  formula  to  be  used,  which  will 
depend  upon  the  age  and  development  of  the  child  and  the  condition 
of  its  digestive  organs ;  next,  the  quantity  of  food  for  twenty-four  hours 
with  the  number  of  feedings  into  which  it  is  to  be  divided. 

Let  us  suppose  that  we  wish  to  give  3  per  cent  fat,  6  per  cent  sugar, 
and  1  per  cent  proteids — formula  V  of  the  First  Series — and  that  we  wish 
to  prepare  7  feedings  of  5  ounces  each,  or  35  ounces  of  food.  For  a  20- 
ounee  mixture  containing  3  per  cent  fat  we  will  require  (see  page  189)  6 
ounces  of  10-per-cent  milk,  1  ounce  of  sugar,  and  1  ounce  of  lime-water; 
the  balance  will  be  water;  since  the  sugar  dissolves,  13  ounces  of  water 
will  be  needed.  Now  to  make  35  ounces,  we  will  require  three-quarters 
more  of  each  ingredient  than  for  20  ounces — i.  e.,  10-J  ounces  of  the 
milk.  If  ounces  of  sugar.  If  ounces  of  lime-water,  and  the  balance,  or 
22f  ounces,  of  water.  The  amount  of  water  need  not  be  calculated 
each  time,  but  simply  enough  should  be  added  to  make  the  quantity 
required. 

A  shorter  method  of  arriving  at  the  same  result  will  be  to  use  the 
table  on  the  same  page.  The  nearest  to  the  desired  formula  is  K,  or  36 
ounces.  This  requires  11  ounces  of  the  10-per-cent  milk,  If  ounces  lime- 
water,  and  4^  even  tablespoonfuls  milk  sugar.  In  the  above  formulas  if 
milk  and  cream  were  used,  the  proportions  of  each  would  be  one-half 
the  amount  of  the  10-per-cent  milk.  Whenever  the  amount  of  10-per- 
cent  milk  called  for  is  greater  than  the  11  ounces  which  can  be  removed 
from  one  bottle,  an  extra  pint  should  be  used,  from  which  5^  ounces 
may  be  taken  in  the  same  manner. 

If  instead  of  bottled  milk,  or  milk  and  cream,  the  patient  is  using 
milk  fresh  from  the  cow,  as  soon  as  received  it  should  be  strained  through 
three  thicknesses  of  cheese  cloth  or  a  layer  of  absorbent  cotton,  into  quart 
jars  or  milk  bottles,  and  allowed  to  stand  in  ice  water  or  cold  spring 
water  for  at  least  four  hours.    The  upper  third  is  then  removed. 

The  milk  sugar  is  in  all  cases  dissolved  in  boiled  water,  which  is  then 
mixed  with  the  milk  in  a  pitcher  and  the  lime-water  added.  The  food  is 
now  divided  into  the  seven  bottles,  which  are  stoppered  with  cotton. 
They  are  placed  at  once  in  an  ice-chest,  or  first  sterilized,  then  cooled, 
and  afterward  placed  upon  ice. 

Measuring  by  the  "  Materna  "  Glass. — Haas  (Xew  York)  has  de- 
vised a  measuring  glass  called  the  "  materna  "   (Fig.  38),  having  six 


ARTIFICIAL  FEEDING. 


201 


sides,  each  one  of  which  is  marked  with  a  different  milk  formula.  These 
formulas  in  a  general  way  indicate  the  gradations  of  increase  for  a  nor- 
mal healthy  infant  from  birth  to  one  year.  Upon  each  side,  or  panel, 
are  lines  indicating  the  point  up  to  which  are  to  be  added,  milk  sugar, 
boiled  water,  milk,  20-per-cent  cream,  etc.,  the  spaces  being  carefully 
calculated  so  as  to  give  approximately  the  desired  formula.  These 
glasses  are  made  of  one  size,  16  ounces,  so  that  only  that  quantity  of 
food  can  be  made  up  at  one  time.  The  milk  is 
bottled  and  handled  exactly  as  when  a  different 
method  of  measuring  is  used.  While  this  does  not 
compare  in  accuracy  with  the  method  of  modifica- 
tion which  we  have  given  above,  it  gives  six 
good  formulas,  and  is  an  addition  to  the  simple 
methods  for  home  modification  of  milk.  It  is 
particularly  useful  for  those  who  can  not  be 
trained  to  more  exact,  and  therefore  somewhat 
more  complicated,  methods. 

Directions  for  Feeding. — The  food  should  be 
warmed  to  about  100°  F.  before  feeding,  best  by 
placing  the  bottle  in  a  tall  pitcher  or  cup  filled 
with  water  at  a  little  above  this  temperature, 
not  by  pouring  the  food  from  the  bottle  into  a 
saucepan.  The  temperature  of  the  food  when 
prepared  may  be  tested  by  the  nurse  with  a  ther- 
mometer, or  by  pouring  a  few  drops  upon  the 
front  of  the  wrist;  it  should  feel  warm,  but  not 
hot.  The  nurse  should  never  take  the  nipple 
of  the  bottle  into  her  own  mouth  to  see  whether 
the  temperature  is  right.  A  bottle  should  not  be  warmed  over  for  a 
second  feeding.  A  child  should  not  be  more  than  twenty  minutes  in 
taking  its  food,  and  should  not  be  allowed  to  sleep  with  the  nipple 
of  the  bottle  in  its  mouth.  It  is  preferable  to  have  a  young  infant 
held  in  the  arms  of  the  nurse  while  taking  its  bottle.  If  this  is  not 
done,  the  bottle  should  at  least  be  held  in  such  a  position  that  the 
neck  of  the  bottle  is  kept  full,  so  that  the  child  gets  milk,  and  not 
air.  It  is  even  more  necessary  than  in  breast-feeding  that  rules  as 
to  frequency  and  regularity  of  meals  should  be  observed.  The  table 
on  page  202  indicates  the  size  of  the  meals  and  the  daily  quantity  of  food, 
as  well  as  the  number  of  meals  and  intervals  of  feeding.  This  is  to 
be  taken  only  as  a  general  guide.  The  number  of  daily  feedings  and  the 
intervals  here  mentioned  may  be  wisely  followed  with  nearly  all  children. 
The  quantity  for  one  feeding  can  not  be  so  definitely  stated.  Few  chil- 
dren, however,  will  require  less  than  the  lower  quantities,  and  still  fewer 
will  require  more  than  the  higher  quantities  mentioned. 


Fig.  38.— The  "materna" 
measuring  glass. 

(Chemical  Supply  Co., 
147  Centre  St.,  Kew  York.) 


202 


NUTRITION. 


Schedule  for  feeding  Healthy  Infants  during  the  First  Year. 


Age. 

Inter- 
val be- 
tween 
meals, 
by  day. 

Night 
feed- 
ings (10 

p.   M.  to 

7  A.  M.). 

No.  of 
feed- 
ings, 24 
hours. 

Quantity  for  one 
feeding. 

Quantity  for  24  hours. 

2d  to  7th  day 

Hours. 

2 
3 
2 

3 
3 

4 

2 

2 

1 
1 
1 
0 
0 

10 
10 
10 
8 
7 
6 
5 

Ounces. 

1  -H 

2^3i 

3  -5 

4  -6 

5-7i 
7  -9 

Grammes. 

30-  45 

45-110 

75-110 

90-155 

125-185 

150-235 

220-280 

Ounces. 

10-15 
15-35 
25-35 
24-40 
28-42 
30-45 
35-45 

Grammes. 
310-     460 

2d  and  3d  weeks 

4th  and  5th  weeks 

6th  week  to  3d  month  . . 

3d  to  5th  month 

5th  to  9th  month 

9th  to  12th  month 

.    460-1,090 
775-1.090 
745-1,250 
870-1.300 
930-1,400 

1,090-1,400 

The  Use  of  other  Food  thax  Milk  dueixg  the  First  Year. — 
In  the  discussion  up  to  this  point  nothing  but  the  elements  of  milk 
has  been  considered.  Upon  these  alone  I  believe  that  the  average 
healthy  infant  is  best  nourished  during  the  greater  part  of  the  first  year. 
The  use  of  the  various  cereal  decoctions  as  an  addition  to  the  milk  for 
3^oung  infants  is  a  subject  much  discussed  among  those  interested  in 
infant-feeding,  and  the  question  can  not  be  regarded  as  settled.  That 
this  is  a  useful  measure  for  some  infants  I  am  quite  convinced;  that 
it  is  desirable  for  all  is  yet  to  be  proved ;  this  is  certainly  not  my  expe- 
rience. Surely  no  point  in  infant-feeding  is  better  established  than  that 
the  early  use  of  much  farinaceous  food  has  resulted  in  serious  harm. 
The  addition  to  milk  of  farinaceous  food  in  any  considerable  quantity 
should,  I  think,  in  the  feeding  of  young  infants  be  limited  to  those 
where  some  special  conditions  are  present,  jDarticularly  where  there  is 
more  than  usual  difficulty  in  digesting  the  milk  proteids.  This  sub- 
ject will  be  considered  more  fully  under  the  discussion  of  Difficult  Cases 
of  Feeding. 

For  the  average  healthy  infant  it  is  desirable  to  begin  with  farina- 
ceous food  in  some  form  by  the  seventh  or  eighth  month.  By  this  time 
the  power  of  digesting  starch  is  sufficiently  strong  for  the  infant  to  re- 
ceive some  of  its  carbohydrates  in  this  form,  instead  of  all  of  it  in  the 
form  of  sugar,  as  has  been  previously  the  case.  As  starch  is  added,  the 
sugar  should  be  gradually  reduced.  The  form  of  starch  used  may  be  a 
gruel  made  of  barley,  oatmeal,  or  arrowroot,  or  some  of  the  farinaceous 
foods  (page  163).  If  barley  is  used,  the  proper  proportion  to  begin 
with,  is  to  make  the  food  about  one-third  its  volume  of  barley  water  of 
the  strength  mentioned  on  page  162.  This  will  take  the  place  of  the 
same  qiiantity  of  boiled  water  in  the  preparation  of  the  food.  It  is  thus 
given  with  each  of  the  feedings.  By  the  eleventh  or  twelfth  month 
the  quantity  of  barley  may  be  further  increased  by  making  the  barley 
water  stronger,  rather  than  by  using  a  larger  quantity.     The  choice  be- 


ARTIP^ICIAL  FEEDING.  203 

tween  the  different  cereals  will  depend  upon  the  individual  case.  Where 
there  is  a  tendency  to  constipation,  oatmal  is  to  be  preferred;  at  other 
times  barley. 

The  only  other  things  to  be  advised  during  the  first  year  are  beef 
juice  (for  preparation  see  page  160)  and  the  juice  of  some  fresh  fruit. 
Beef  juice  may  be  begun  in  the  tenth  or  eleventh  month;  at  first  not 
more  than  two  teaspoonfuls  should  be  given  daily.  The  best  fruit  juice 
is  that  of  the  orange,  which  may  with  advantage  be  given  to  most  in- 
fants over  ten  months  old.  Beginning  with  half  an  ounce,  the  quan- 
tity may  be  gradually  increased  to  two  ounces,  given  preferably  about 
one  hour  before  the  first  milk-feeding. 

Feeding  in  Difficult  Cases. — Thus  far  there  has  been  considered 
only  the  management  of  the  food  for  healthy  infants  with  average  diges- 
tion; in  other  words,  the  normal  cases.  The  vast  majority  of  children 
seen  in  private  practice  can  be  carried  along  successfully  and  with  little 
difficulty  in  the  manner  outlined,  provided  they  are  properly  started. 
There  remain  to  be  considered  the  modifications  in  the  food  required  for 
infants  with  feeble  digestion — the  difficult  cases.  These  are  children 
who  do  not  thrive  satisfactorily  upon  the  ordinary  milk  modifications. 
This  is  shown  by  the  fact  that  they  do  not  gain  in  weight  or  that  they 
habitually  suffer  from  the  various  symptoms  of  indigestion.  Such  condi- 
tions are  of  frequent  occurrence.  In  some  cases  the  infants  are  deli- 
cate from  birth;  in  others,  the  condition  is  the  result  of  bad  surround- 
ings— hospitals,  foundling  asylums,  tenements,  etc. ;  in  still  others,  it 
is  a  consequence  of  some  previous  acute  illness,  either  an  affection  of 
the  digestive  organs,  or  some  other  disease,  such  as  bronchitis,  whoop- 
ing-cough, or  pneumonia.  In  the  greater  number,  however,  the  condi- 
tion is  the  result  of  previous  improper  feeding  or  equally  improper  nurs- 
ing. In  other  words,  such  a  condition  is  in  most  instances  preventable 
with  intelligent  care. 

That  chronic  indigestion  in  a  young  infant  is  a  serious  thing  is  often 
not  appreciated.  There  may  be  immediate  danger  to  life  either  from 
the  supervention  of  acute  indigestion  or  from  acute  inanition.  Later 
results  may  be  rickets  or  scurvy,  or  simply  a  condition  of  general  mal- 
nutrition, so  marked  that  its  consequences  last  throughout  childhood. 
A  mother  often  thinks  the  problem  presented  is  one  easy  of  solution; 
all  that  she  wants,  she  says,  is  to  be  told  what  to  feed  her  baby,  imagin- 
ing that  a  single  food  prescription  should  set  the  child  right  at  once. 
The  physician,  too,  sometimes  looks  upon  the  condition  lightly  because 
these  infants  are  not  really  ill,  and  therefore  considers  that  these  "  feed- 
ing cases"  are  hardly  important  enough  for  his  serious,  continuous 
attention.  What  I  wish  to  emphasize  is  that  these  cases  are  serious, 
that  they  are  difficult,  that  in  most  of  them  nothing  can  be  accpmplished 
without  close  and  continuous  personal  observation,  that  they  do  not  tend 


204 


NUTRITION. 


to  right  themselves,  and  that  an  infant's  life  is  often  sacrificed  as  a  re- 
sult of  bad  management. 

While  these  infants  present  great  variety  in  their  symptoms,  and 
must  be  carefully  individualized  in  their  management,  there  are  some 
general  principles  applicable  to  all.  One  should  begin  with  a  careful 
history  of  everything  that  has  been  previously  tried,  since  in  this  way 
valuable  information  respecting  the  type  of  indigestion  may  be  ob- 


Of  A^GE  2   4  6  8  10  I  2  1 4  1  6  1  8  20  22  24  26  28  30  32  34  36  38  40  42  44  46  48  50  62 

26 

24 

23 

22 

21 

20 

10 

18 

gl7 

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2,5 

14 

13 

12 

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10 

9 

8 

7 

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Fig.  39. — Weight  chart  showing  the  effect  of  intelligent  care.  Maternal  nursing  in  the  begin- 
ning ;  A^  Degan  part  feeding ;  /?,  attack  of  indigestion  ;  C,  weaned  entirely.  The  departure 
and  return  of  the  trained  nurse  are  indicated  upon  the  chart.  In  the  interval  there  was 
constant  indigestion  for  which  no  sufficient  explanation  could  be  found  in  the  food.  Sub- 
sequently this  was  discovered  to  be  due  to  the  carelessness  and  neglect  of  the  nurse.  Im- 
mediate improvement  on  the  return  of  the  trained  nurse  without  any  important  change  in 
the  food.  It  will  be  noticed  that  during  the  four  and  one-half  months  of  the  trained  nurse's 
absence  the  net  gain  in  weight  was  only  1  pound,  3  ounces. 


tained.  The  next  point  is  a  thorough  investigation  into  the  nursery 
routine  to  ascertain  not  only  what  has  been  tried,  but  how  it  has  been 
tried.  It  is  frequently  found  that  the  failure  is  due  not  to  any  fault 
with  the  food  prescription,  but  because  the  food  has  been  improperly 
prepared  or  administered — e.  g.,  the  food  has  been  cold,  the  bottles 
dirty,  the  nipples  sour,  the  food  too  rapidly  given,  too  much  at  one 
time,  or  at  too  short  intervals,  etc.  (Fig.  39).  General  statements  of 
nurses  and  mothers,  no  matter  how  experienced,  can  not  be  trusted ;  the 
physician  should  give  these  matters  his  personal  supervision. 

In  dealing  with  these  cases  one  must  expect  little  help  from  the  use 
of  drugs;  in  most  cases  they  are  better  omitted  altogether.     One  must 


ARTIFICIAL   FEEDING.  205 

also  rid  himself  of  the  Botion  that  the  food  can  be  prescribed  according 
to  the  infant's  age  or  even  its  weight;  the  only  reliable  guide  is  the 
condition  of  the  digestive  organs  at  the  time.  One  must  begin  with  the 
best  food  possible  at  the  time,  and  get  to  the  ideal  food  as  soon  as  cir- 
cumstances will  permit. 

In  carrying  out  any  line  of  treatment  a  daily  record  of  food  taken, 
stools,  sleep,  etc.,  is  of  the  greatest  assistance.  The  weight  is  impor- 
tant, but  not  the  only  guide  as  to  progress.  It  is  desirable  that  this  be 
taken  regularly  and  frequently  in  order  that  a  steady  loss  may  not  go 
on  unnoted ;  but  the  first  signs  of  improvement  are  usually  observed  in 
other  symptoms — the  child  is  more  comfortable,  sleeps  better,  and  suf- 
fers less  from  its  special  disturbances  of  digestion.  The  gain  in  weight 
will  surely  come  later  if  these  favourable  conditions  continue. 

Quantities,  Intervals  of  Feeding,  Concentration  of  Food. — The  quan- 
tity given  at  one  feeding,  and  the  length  of  the  interval  between  feed- 
ings, can  be  determined  only  by  watching  the  effect  upon  the  child. 
With  some  children  one  succeeds  better  with  smaller  quantities  and 
more  frequent  feedings ;  with  others,  larger  quantities  and  longer  inter- 
vals are  preferable.  Generally  speaking,  the  intervals  should  be  longer 
than  in  health.  It  is  seldom  wise  to  make  them  less  than  three  hours 
for  young  infants,  or  less  than  four  hours  for  those  who  have  passed 
the  eighth  or  ninth  month.  When  symptoms  make  a  reduction  in  the 
food  necessary,  whether  in  quality  or  strength,  it  should  in  most  cases 
be  a  radical  reduction  to  produce  any  decided  effect.  On  the  other 
hand,  in  increasing  either  the  strength  or  the  quantity  of  the  food,  the 
changes  must  be  made  very  gradually,  lest  we  overtax  the  sensitive 
digestion. 

Eegarding  the  effect  upon  the  digestion  of  the  concentration  of  the 
food  (i.  e.,  a  large  quantity  of  a  weak  food,  or  a  small  quantity  of  a 
strong  food),  great  variations  are  seen  with  different  children.  The 
usual  tendency  when  an  infant  suffers  from  indigestion  is  to  dilute  the 
food,  and  in  most  cases  this  is  perfectly  proper;  but  to  continue  increas- 
ing the  dilution  because  the  patient  does  not  do  well  may  be  the  very 
worst  treatment.  This  may  do  harm  by  causing  too  much  dikition  of 
the  digestive  fluids.  Small  feedings,  not  weak  food,  are  what  benefit 
some  of  these  children  most,  the  balance  of  the  daily  amount  of  water 
needed  by  the  chikl  being  given  between  the  feedings.  Thus,  instead 
of  giving  eight  ounces  of  a  weak  food  every  four  hours,  we  may  do 
better  with  four  ounces  of  a  much  stronger  food,  allowing  the  child 
three  or  four  ounces  of  water  one  hour  or  one  hour  and  a  half  before  the 
feeding. 

As  a  general  plan  of  treatment  in  troublesome,  protracted  cases  it 
is  better,  instead  of  making  many  minor  variations  in  the  composition 
of  the  food  or  in  the  plan  of  feeding,  to  go  to  the  opposite  extreme  from 
15 


206  NUTRITION. 

that  which  has  previously  been  tried.  If  small  feedings  and  short  inter- 
vals have  failed,  one  may  succeed  with  large  feedings  and  much  longer 
intervals.  If  very  dilute  food  in  large  quantities  has  failed,  improve- 
ment may  follow  much  smaller  feedings  and  a  stronger  food.  For  sim- 
ilar reasons  the  most  brilliant  results  are  often  obtained  from  as  com- 
plete a  change  in  the  diet  as  possible.  An  infant  who  has  been  long  on 
farinaceous  foods  is  most  likely  to  improve  when  these  are  stopped 
entirely  and  suitable  percentages  of  cow's  milk  given.  One  whose  diges- 
tion has  become  seriously  deranged  while  taking  milk  is  sometimes 
helped  by  nothing  so  much  as  temporarily  withdrawing  all  milk.  (See 
Fig.  40,  page  212).  Such  a  course  is  often  better  than  wasting  time  in 
juggling  with  fractional  milk  percentages,  when  one  or  two  intelligent 
trials  have  been  entirely  unsuccessful. 

The  Modiilcation  of  Cow's  Milk  in  Difficult  Cases. — The  first  thing 
is  a  proper  adjustment  of  the  percentages  of  fat,  sugar,  and  proteids 
to  the  digestion  of  the  infant.  Some  of  the  indications  for  varying 
these  have  already  been  mentioned  on  pages  192-197.  The  sugar  is  very 
rarely  the  source  of  trouble.  It  should  never  be  raised  above  7  per  cent, 
and  seldom  is  there  any  advantage  in  reducing  it  below  4  per  cent. 

It  is  not  often  that  the  fat  can  be  raised  above  3  per  cent  with 
infants  whose  digestion  is  feeble,  even  when  they  are  over  six  months 
old.  For  most  of  those  younger  than  this  2  per  cent  is  as  much  as  it  is 
wise  to  give  if  there  is  any  disposition  to  vomiting  or  regurgitation. 
Where  such  symptoms  are  prominent,  it  may  be  necessary  for  a  time  to 
reduce  the  fat  to  1-5  or  even  to  1  per  cent.  Such  reduction  in  the  fat 
without  reducing  the  proteids  may  be  accomplished  by  simply  changing 
from  the  First  Series  of  formulas  to  the  Second,  or  from  the  Second 
to  the  Third,  the  difference  in  these  being  merely  in  the  proportion 
of  fat.  It  is  particularly  infants  suffering  from  marasmus  in  whom 
we  see  most  difficulty  in  digesting  the  fats,  and  it  is  in  just  such  cases 
that  they  are  likely  to  be  prescribed  in  large  proportions ;  but  if  given 
they  either  induce  vomiting  or  appear  undigested  in  the  white  pasty 
stools. 

It  is  with  the  proteids,  especially  the  casein,  of  cow's  milk  that  the 
greatest  trouble  is  usually  experienced,  particularly  in  the  early  months. 
There  are  four  ways  of  overcoming  this  difficulty:  (1)  By  a  reduction 
in  the  amount  of  all  the  proteids,  using  low  percentages  obtained  by  a 
large  dilution  of  the  milk;  (2)  by  a  reduction  in  the  casein  alone,  by 
the  use  of  mixtures  of  whey  and  cream;  (3)  by  predigestion  of  the 
proteids,  by  partially  peptonizing  the  milk;  (4)  by  the  addition  to  the 
milk  of  cereal  gruels  or  farinaceous  foods. 

Reduction  of  the  total  proteids. — If  the  plan  is  followed  which  we 
have  advocated — viz.,  beginning  with  the  proteids  as  low  as  0  -33  or 
0  '50  per  cent  with  very  young  infants  or  those  who  have  never  had  any 


ARTIFICIAL   FEEDING. 


207 


cow's  milk,  and  then  gradually  raising  the  proportion  as  the  child  be- 
comes accustomed  to  the  milk — it  is  seldom  that  any  serious  trouble  with 
the  proteids  occurs  afterward.  While  if  in  the  beginning  1  or  2  per 
cent  proteids  are  given,  disturbance  is  pretty  sure  to  result;  and  it  is 
just  here  that  the  digestion  of  so  many  young  infants  is  upset.  With 
most  such  cases  I  prefer  to  go  back  to  the  earlier  formulas,  Xo.  I  or  II 
of  the  First  Series,  where  the  proteids  are  one-third  the  fat. 

In  some  cases,  but  not  very  often,  formulas  succeed  in  which  the 
fat  is  relatively  much  higher  in  proportion  to  the  proteids  than  any  yet 
given.  Such  formulas  can  readily  be  derived  from  milk  containing  16 
per  cent  fat  (upper  6  ounces  from  one  quart,  page  149) — the  ordinary 
gravity  cream.  In  this  the  fat  is  exactly  five  times  the  proteids.  The 
proportions  for  making  up  the  quantities  usually  required  are  shown  in 
the  following  table : 

Table  giving  Quantities  of  Sixteen-per-cent  Milk  required  for 
obtaining  Formulas  with  High  Fat  and  Low  Proteids. 


A 

B 

C 

D 

E 

3 

32 

6 

F 

3 
37 

7 

G 

3 

42 
8 

H 

3-5 
36 

8 

I 

3-5 

40 

9 

J 

4 
40 
10 

K 

To  obtaia  fat,  per  cent 

For  total  food,  ounces 

1-6 
20 

2 

1-6 

30 

3 

2 

30 

4 

2  5 

32 

5 

4 
44 

Take  16-per-cent  milk,  ounces  . 

11 

Proteids  in  all  cases  will  be  one-fifth  the  fat. 

Sugar. — One  even  tablespoonful  for  each  8  ounces  will  give  5'5  per  cent  for  the 
lower  formulas  (A,  B,  C,  etc.)  and  6  per  cent  for  the  higher  formulas  (G,  H,  I,  etc.). 
Lime-water. — One  ounce  to  20  ounces  of  the  food  will  give  5  per  cent. 

In  using  any  series  of  milk  modifications  it  is  usually  wise  to  begin 
by  reducing  the  percentage  of  the  disturbing  element — fat  or  proteids — 
to  a  point  where  the  child's  most  obvious  symptoms  of  disturbance  dis- 
appear, and  then  gradually  but  very  slowly  to  increase,  but  to  go  no 
faster  than  the  child's  digestion  will  warrant,  regardless  of  his  appetite. 
One  must  not  cling  too  strongly  to  traditional  views  regarding  the  milk 
percentages  which  these  abnormal  cases  should  receive.  They  can  not 
be  fed  like  healthy  children,  and  it  is  impossible  to  tell  until  one  has 
tried  just  what  will  succeed.  Marked  disturbance  is  sometimes  seen 
with  low  proteids,  and  very  little  with  high  proteids,  exactly  why  it  is 
difficult  to  say. 

It  frequently  happens  that  although  comfortable  with  low  percent- 
ages, whenever  any  increase  is  made,  particularly  of  the  proteids,  the 
symptoms  of  indigestion  return,  while  if  the  lower  percentages  are  con- 
tinued the  child  will  not  gain  in  weight.  Something  else  must  then  be 
tried. 

Milk  from  which  the  casein  has  been  removed — whey  mixtures. — 
After  the  casein  has  been  coagulated  by  rennet  and  then  strained  out. 


208  NUTRITION. 

the  whey  will  be  left  (composition  on  page  159),  which  will  contain  all 
the  lactalbumin  and  some  lactoprotein.  The  fat  is  nearly  all  removed  by 
the  process,  but  this  can  be  supplied  subsequently  by  adding  cream,  in 
which  the  percentage  of  casein  is  small.  When  these  are  mixed  in  the 
proportions  given  below  the  percentage  composition  of  the  product  will 
be  as  follows : 

Per  cent.        Per  cent.  Per  cent. 

I.  Whey  19  parts;  20^  cream  1  part  gives  fat  1'8,  sugar  4  90,  proteids  1"0. 
II.       "      15     •'  "        "       "     "         "       "    2-2,     "       4-90,        "         1-0. 

III.  "        9     "  "        "       "     "        "       "    2-8,    "       4-90,        "        1-10. 

IV.  "        7     "  "        "       "    "        "      "    3-3,     "       4-80,        "        1-16. 
V.       "       5     "  "        "       "     •'        "      "    4-0,    "       4-80,        "        1-25. 

In  the  lower  formulas  (I,  II,  III)  the  casein  will  be  less  than 
0-25  per  cent;  in  the  highest  (V)  not  quite  0-50  per  cent.  Formulas 
like  these  are  of  especial  value  for  young  infants,  since  with  them  diges- 
tible proteids,  of  which  the  young  infant  stands  so  much  in  need,  can  be 
supplied  with  only  a  very  small  amount  of  the  indigestible  casein.  From 
the  milk  laboratories  can  be  ordered  the  relative  amounts  of  casein  and 
lactalbumin  desired  up  to  certain  limits  already  specified. 

The  percentage  of  sugar  in  these  formulas  is  still  somewhat  lower 
than  most  children  are  able  to  digest.  The  addition  of  one-third  ounce 
of  milk  sugar  (approximately  one  even  tablespoonful)  to  each  pint  of 
the  food  will  raise  the  sugar  to  7  per  cent;  the  addition  of  one  even 
teaspoonful  to  each  pint  will  raise  it  to  6  per  cent.  The  acidity  is  best 
overcome  by  adding  bicarbonate  of  soda,  ten  to  fifteen  grains,  to  each 
pint  of  food. 

In  preparing  this  food  the  temperature  of  the  whey  should  be 
raised  to  about  150°  F.  to  destroy  the  rennet  ferment  before  the  addi- 
tion of  the  cream.  Should  more  precipitation  occur  with  the  heat,  fil- 
tration through  muslin  should  be  repeated.  This  method  of  removing 
the  casein  from  cow's  milk  is  the  basis  of  the  preparation  of  the  "  Back- 
haus  milk,"  which  is  used  quite  extensively  in  Germany.  Some  infants 
may  be  kept  with  advantage  on  these  whey  formulas  for  two  or  three 
months,  beginning  with  simple  whey,  and  gradually  raising  the  per- 
centage of  fat  as  in  the  above  formulas.  From  the  highest  formula 
here  given  the  change  may  be  made  to  such  percentages  of  proteids  as 
those  of  the  formulas  on  page  189. 

Peptonized  milk. — Instead  of  reducing  the  casein  to  a  very  low  per- 
centage, or  removing  it  altogether,  we  may  use  larger  amounts  and 
assist  the  child  by  partially  predigesting  or  peptonizing.  This  is  done 
by  the  use  of  peptonizing  tubes  or  tablets,  and  also  by  the  "  peptogenic 
milk  powder,"  the  result  being  similar  in  all  cases.  The  process  is  de- 
scribed on  page  154.  It  is  important  that  proper  percentages  be  ob- 
tained before  the  peptonizing  is  done.     The  proportions  usually  recom- 


ARTIFICIAL  FEEDING.  209 

mended  with  the  peptogenic  milk  powder  give  4  per  cent  fat,  7  per  cent 
sugar,  and  2  per  cent  proteids;  these  are  too  high  for  most  infants  with 
feeble  digestion,  as  are  also  the  other  formulas  generally  advised  for 
use  with  the  peptonizing  tubes  or  tablets.  I  have  obtained  better  re- 
sults with  such  percentages  as  those  of  formulas  III,  IV,  and  V  of  the 
Second  Series;  sometimes,  however,  even  with  a  lower  fat  than  this, 
as  in  IV,  V,  and  VI  of  the  Third  Series.  The  duration  of  the  prediges- 
tion  of  the  food  will  depend  upon  the  amount  of  assistance  required  by 
the  child.  As  it  takes  about  two  hours  to  peptonize  milk  completely, 
the  process  at  the  end  of  fifteen  minutes  will  be  only  one-eighth  com- 
pleted, and  at  the  end  of  half  an  hour  only  one-fourth,  leaving  thus  in 
the  one  case  seven-eighths  and  in  the  other  three-quarters  of  the  work 
of  proteid  digestion  to  be  done  by  the  child.  Where  required  at  all,  I 
have  usually  found  it  best  to  continue  peptonizing  for  at  least  fifteen 
minutes,  often  for  half  an  hour  or  even  an  hour.  I  prefer  to  peptonize 
each  .bottle  separately  immediately  before  feeding,  since  the  ferment  in 
such  cases  continues  its  action  in  the  stomach.  If  the  amount  for  the 
entire  day  is  peptonized  at  one  time  and  the  milk  raised  to  boiling  point 
the  ferment  is  destroyed.  The  bitter  taste  produced  at  the  end  of  about 
fifteen  minutes  is  evidence  of  the  conversion  of  some  of  the  casein  into 
peptone,  but  in  practice  is  rarely  found  to  interfere  with  its  use,  except 
with  children  over  seven  or  eight  months  old.  After  the  first  two  or 
three  bottles  younger  infants  take  this  bitter  milk  as  willingly  as  any 
other  food. 

The  partial  predigestion  of  the  milk  proteids  may  be  continued  for 
several  weeks,  the  amount  of  assistance  given  the  child  being  gradually 
lessened  by  shortening  the  duration  of  the  process,  as  the  stomach  be- 
comes more  and  more  able  to  do  its  normal  work.  There  is  a  serious 
objection  to  the  use  of  predigested  foods  for  as  long  a  period  as  five  or  six 
months;  in  such  cases  the  organs  do  not  gain,  but  rather  lose  in  their 
digestive  power. 

The  addition  of  cereal  gruels  and  other  substances  to  milk. — I  have 
already  stated  that  for  healthy  infants  with  normal  digestion  I  think 
any  such  addition  undesirable  during  the  first  few  months ;  also,  that 
these  substances,  usually  some  form  of  farinaceous  food,  when  used  in 
considerable  amounts,  may  do  much  positive  harm;  and  further,  that, 
as  commonly  employed,  they  are  responsible  for  much  of  the  chronic 
indigestion  and  many  of  the  disturbances  of  nutrition  seen  during  the 
first  year.  The  question  now  is  whether  the  addition  of  these  sub- 
stances is  ever  useful  with  infants  whose  digestion  is  not  normal,  and 
whether  such  addition  is  of  material  assistance  in  the  digestion  of  the 
milk  elements  with  which  such  children  have  the  chief  difficulty— viz., 
the  proteids.    I  think  this  question  must  ])e  answered  in  the  affirmative. 

The  substances  most  frequently  used  as  additions  to  milk  are  gruels 


210  NUTRITION. 

made  from  barley,  oatmeal,  rice,  wheat,  arrowroot,  or  farina;  at  times 
gelatine  is  used.  Various  opinions  have  been  held  regarding  the  action 
of  these  substances.  Some  have  held  that  their  efEect  is  simply  that 
of  diluents,  acting  like  so  much  water.  The  traditional  belief,  however, 
has  been  that  the  effect,  especially  of  those  containing  starch,  is  a  purely 
physical  one,  the  mixture  of  such  substances  with  cow's  milk  prevent- 
ing the  coagulation  of  the  casein  in  the  stomach  into  large,  solid  masses, 
but  instead  producing  a  much  softer  curd,  the  digestion  of  which  is 
attended  with  much  less  difficulty.  Whatever  the  explanation,  clin- 
ical experience  points  clearly  to  the  fact  that  with  some  children  who 
digest  milk  proteids  with  difficulty,  the  amount  of  proteids  in  the 
food  may  be  increased  without  disturbance,  if  at  the  same  time  a  cereal 
gruel  is  added.  Improvement  may  be  seen  in  several  respects.  In 
the  first  place,  the  constipation  which  is  apt  to  be  present  with  chil- 
dren taking  such  low  percentages,  or  who  have  difficulty  with  the  usual 
percentages,  is  often  relieved;  second,  an  improvement  may  be  seen  in 
the  character  of  the  stools,  the  colour  and  odour  in  many  cases  showing 
a  marked  change  in  a  short  time;  third,  a  disappearance  of  the  colic, 
fretfulness,  and  general  discomfort;  and  soon  there  may  be  seen  im- 
provement in  the  general  nutrition  and  gain  in  weight.  To  be  sure, 
these  gratifying  results  do  not  always  follow,  but  they  occur  often 
enough  to  indicate  some  beneficial  effect  of  the  gruel. 

The  experiments  of  A.  Keller  (Centralb.  fiir  Inn.  Med.,  vol.  xx,  p. 
1)  indicate  that  the  effect  may  be  partly  due  to  the  checking  of  the 
decomposition  of  the  proteids  in  the  intestines  by  the  presence  of  addi- 
tional carbohydrates  in  the  form  given.  His  conclusion  is  that  nitrogen 
is  thus  saved  to  the  organism,  since  a  decided  diminution  occurs  in  the 
elimination  of  both  nitrogen  and  phosphoric  acid. 

The  ordinary  method  of  using  these  substances  is  in  the  form  of 
gruel,  which  simply  replaces  all  or  a  part  of  the  water  in  any  of  the 
foregoing  series  of  milk  modifications.*  These  gruels  are  much  more 
easily  made  from  the  prepared  flours  of  barley,  oatmeal,  rice,  arrow- 


*  A  formula  for  a  long  time  famous,  and  often  useful,  is  that  published  many 
years  ago  by  J,  Forsyth  Meigs,  and  known  as  Meigs's  food.  It  consists  of  milk,  cream, 
sugar,  gelatine,  and  arrowroot,  and  is  prepared  as  follows;  Of  Russian  gelatine  or 
isinglass,  20  grains,  or  a  piece  about  two  inches  square,  is  soaked  for  a  few  minutes  in 
cold  water  and  then  boiled  in  half  a  pint  of  water  for  fifteen  minutes,  or  until  com- 
pletely dissolved.  One  teaspoonful  of  arrowroot  is  mixed  to  a  paste  with  cold  water, 
and  then  added  to  water  to  make  half  a  pint.  This  is  now  added  to  the  gelatine  solu- 
tion, as  is  also,  with  constant  stirring,  the  desired  quantity  of  milk;  just  before 
removing  from  the  fire  the  cream  is  added.  The  amount  of  milk  and  cream  used 
should  be  varied  with  the  age  of  the  infant.  For  an  infant  under  one  month,  4  ounces 
of  milk  and  li  ounce  of  cream  are  to  be  used ;  for  those  older  the  milk  is  gradually 
increased  to  16  ounces  and  the  cream  to  2  ounces.  (Meigs  and  Pepper,  Diseases  of 
rhildren,  1887.) 


ARTIFICIAL   FEEDING.  211 

Toot,  etc.,  which  need  only  twenty  or  thirty  minutes'  cooking,  than  from 
the  grains,  which  require  four  or  five  hours.  One  rounded  tablespoonful 
of  any  of  the  Hours  to  a  pint  of  water  makes  a  gruel  of  about  the  right 
consistency.  This  will  give  a  little  more  than  1  per  cent  starch  in  the 
food.  A  caution  should  be  given  against  using  too  large  a  quantity 
of  plain  or  even  dextrinized  gruels.  For  in  this  way  the  flatulent,  intes- 
tinal indigestion  so  common  among  the  infants  of  the  poor  is  frequently 
produced. 

Substitutes  for  Milk. — There  are  conditions  in  which  for  the  time 
being  infants  seem  incapable  of  digesting  even  the  smallest  proportions 
of  the  fat  and  proteids  of  milk,  no  matter  how  modified.  This  is  most 
frequently  seen  in  acute  derangements  of  digestion,  especially  when 
associated  with  gastro-enteric  intoxication.  In  connection  with  this 
condition,  the  importance  of  stopping  milk,  and  the  reasons  therefor, 
are  fully  considered.  There  are  also  some  chronic  derangements  of 
digestion  in  which  the  same  procedure  is  of  value.  In  ordinary  prac- 
tice, however,  the  mistake  usually  made  is  that  of  resorting  too  early 
to  this  expedient  instead  of  carefully  adjusting  the  milk  percentages 
to  the  symptoms;  for  in  this  way  we  are  more  likely  to  succeed  in  the 
great  majority  of  cases.  Another  mistake  is  that  of  continuing  for 
too  long  a  time  a  food  containing  no  fresh  milk.     (See  page  16-i.) 

The  advantage  which  results  from  stopping  milk  in  these  cases  is 
due  chiefly  to  change  of  diet.  Where  fat  and  proteids  are  very  difficult 
of  digestion  it  may  become  necessary  to  give  temporarily  a  food  com- 
posed almost  entirely  of  carbohydrates.  They  may  be  administered 
either  as  some  of  the  farinaceous  or  malted  foods.  Such  a  change  is 
more  likely  to  be  successful  in  intestinal  than  in  gastric  cases,  and 
chiefly  where  colic,  constipation  and  failure  to  gain  in  weight  have  long 
been  prominent  symptoms.  If  the  bowels  are  loose,  farinaceous  foods 
are  more  likely  to  be  useful ;  if  they  are  constipated,  the  malted  foods. 
These  may  be  continued  alone  for  a  limited  time — a  few  days  or  a  few 
weeks — according  to  the  severity  of  the  symptoms,  and  then  milk  in 
some  form  added;  for  it  does  not  follow  because  a  child  at  one  time 
can  not  digest  milk  that  it  can  never  do  so.  While  one  must  begin 
with  something  which  the  child  can  digest  and  assimilate,  he  must  get 
back  to  rational  milk-feeding  as  soon  as  possible.  For  example,  it  may 
be  advisable  to  withhold  milk  for  two  or  three  weeks,  and  then  to  begin 
with  as  small  a  quantity  as  one  ounce  in  the  total  food  of  a  day;  after 
two  or  three  days  a  second  ounce  may  be  added,  and  so  on,  gradually 
increasing  the  proportion  of  milk  as  the  child  is  able  to  digest  it 
(Fig.  40).  In  some  cases  it  may  be  better  to  begin  by  adding  whey 
to  the  farinaceous  food,  and  in  still  others  small  quantities  of  con- 
densed milk.  Since  some  are  able  to  take  fat  sooner  than  proteids, 
very  small  quantities  of  cream  may  be  tried  as  an  addition  to  the  food. 


212 


NUTRITION. 


All  substitutes  are  to  be  regarded  merely  as  temporary  expedients,  and 
the  purpose  should  be  gradually  to  get  the  child  back  to  a  suitable  milk 
formula. 

If  such  addition  of  fat  or  milk  proteids  causes  digestive  disturb- 
ance, nitrogenous  food  may  be  supplied  in  the  form  of  beef  juice,  beef 


OF^AGE  2  4   6   8  10  1  2  1 4  1  6  1  8  20  22  24  26  28  30  32  34  36  38  40  42  44  46  48  50 

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Fig.  40. —  Weight  curve,  showing  the  advantage  of  temporarily  stopping  milk.  A  fairly  vigor- 
ous child,  nursed  entirely  by  a  nervous  mother  for  five  weeks,  but  did  badly.  A^  began 
part  feeding ;  B^  weaned  entirely  on  account  of  constant  indigestion ;  C*,  because  of  con- 
tinued indigestion,  colic,  and  general  discomfort,  all  milk  stopped  for  two  weeks  and  a 
malted  food  substituted  ;  Z>,  mUk  resumed.    Subsequent  progress  satisfactory. 

peptones,  broth,  white  of  egg,  somatose,  plasmon,  etc.,  these  being  added 
to  the  farinaceous  or  the  malted  food  which  is  given.  There  is  always 
great  risk  in  continuing  indefinitely  a  food  which  does  not  contain  some 
fresh  milk;  extreme  anaemia,  malnutrition,  rickets,  or  scurvy  may  be 
the  result. 

SUMMARY  OP  INFANT-FEEDING. 

Choice  of  Methods  of  Feeding. — A  faithful  trial  of  maternal  nurs- 
ing should  always  be  made  unless  there  are  some  very  urgent  reasons 
against  it  (page  165)  ;  but  nursing  should  not  be  continued  if  the 
child  is  persistently  uncomfortable,  suffers  constantly  from  symptoms 
of  indigestion,  and  does  not  gain  in  weight.  However,  if  gaining  satis- 
factorily in  spite  of  the  symptoms  mentioned,  weaning  may  be  deferred 
for  a  time. 

Maternal  nursing  is  seldom  successful  among  the  modern,  highly 
nervous,  American  mothers,  particularly  of  our  cities. 

Wet-nursing,  although  theoretically  next  choice  to  maternal  nurs- 


ARTIFICIAL   FEEDING.  213 

ing,  is  so  difficult  that  in  private  practice  it  should  be  reserved  for  cer- 
tain special  cases.  In  institutions,  infants'  hospitals,  foundling  asy- 
lums, etc.,  the  difficulties  in  all  forms  of  artificial  feeding  are  greatly 
increased,  and  wet-nursing  should  be  employed  as  far  as  possible. 

Artificial  feeding  has  become  the  general  alternative  to  maternal 
nursing.  If  circumstances  are  such  that  maternal  nursing  is  almost 
certain  to  be  a  failure,  and  if  at  the  same  time  they  permit  the  best 
form  of  artificial  feeding,  the  infant  should  not  be  put  to  the  breast 
at  all;  for  when  properly  begun,  before  the  organs  of  digestion  have 
been  upset  by  bad  nursing,  artificial  feeding  is  comparatively  a  simple 
matter,  and  when  intelligently  carried  on  it  is  most  satisfactory  in  its 
results. 

Methods  of  Artificial  Feeding. — The  answer  to  the  question.  What 
is  the  best  method  of  artificial  feeding  ?  must  be  conditioned  by  circum- 
stances, such  as  what  can  be  afforded,  and  what  is  most  likely  to  be 
carried  out. 

All  whose  experience  entitles  their  opinions  to  consideration  are 
agreed  that  so7ne  modification  of  fresh  cow's  milJc  is  the  only  reliable 
substitute  for  breast-feeding.  My  own  opinion  is,  that  for  healthy  in- 
fants it  is  best  to  use  only  the  milk  constituents — fat,  sugar,  proteids, 
and  salts — with  lime-water,  varying  the  percentages  of  these  to  suit  the 
infant's  digestion. 

The  milk  laboratories,  in  my  judgment,  afford  facilities  for  obtain- 
ing the  best  results,  and  milk  modified  by  them  according  to  intelli- 
gent prescription  should  be  placed  next  to  maternal  nursing. 

Next  to  laboratory-feeding  is  milh  modified  at  home  by  the  per- 
centage method,  the  best  materials  being  used.  Three  groups  of  for- 
mulas are  sufficient  for  healthy  infants  during  the  first  year.  In  the 
first,  to  be  used  during  the  early  months,  the  proteids  are  one-third  the 
fat;  these  formulas  are  obtained  from  10-per-cent  milk.  In  the  sec- 
ond, to  be  used  from  the  third  or  fourth  to  the  ninth  or  tenth  month, 
the  proteids  are  half  the  fat;  these  formulas  are  derived  from  7-per- 
cent milk.  The  third,  to  be  used  after  the  tenth  or  eleventh  month,  in 
which  the  proteids  and  fat  are  about  equal,  are  obtained  by  diluting 
plain  milk. 

In  institutions  where  the  number  of  children  is  so  large  as  to  make 
careful  modification  for  each  separate  child  impossible,  the  simplest 
plan  for  securing  approximate  results  is  to  have  two  standard  mixtures: 
one,  containing  fat  3  per  cent,  sugar  6  per  cent,  proteids  1  per  cent; 
the  other,  fat  4  per  cent,  sugar  7  per  cent,  proteids  2  per  cent ;  and  to 
dilute  these  with  a  standard  sugar  solution,  or,  if  preferred,  with  barley 
water,  according  to  the  child's  age  and  the  condition  of  his  digestion. 
For  other  children  a  modification  based  upon  the  dilution  of  plain  milk 
by  either  the  sugar  solution  or  the  barley  water  may  answer  the  purpose. 


214  NUTRITION. 

For  tlie  very  poor  in  cities  results  in  infant-feeding  depend  less  upon 
exact  methods  of  modification  than  upon  the  character  of  the  materials 
used.  Condensed  milk  is  sometimes  the  best  milk  available  (see  page 
156).  The  combination  of  canned  condensed  milk  and  farinaceous  foods 
is  one  that  is  greatly  abused,  and  if  long  continued  often  productive  of 
great  harm. 

For  long  journeys  milk  should  be  properly  sterilized;  if  this  is  im- 
possible, condensed  milk  is  probably  the  safest  food. 

The  Principles  of  Percentage  Milk  Modification. — In  modifying 
milk  for  healthy  infants  the  secret  of  success  is  to  begin  with  low  per- 
centages, especially  of  the  proteids,  and  gradually  increase  according 
to  the  infant's  ability  to  digest  them.  To  continue  with  very  low  prO' 
teids  frequently  leads  to  disturbances  of  nutrition,  which  are  sometimes 
very  serious.  If  one  begins  with  low  percentages,  he  must  expect  a  loss 
in  weight  during  the  first  week,  a  stationary  weight  for  the  second  week, 
and  sometimes  longer,  but  after  that  a  substantial  and  regular  gain. 

During  the  early  weehs,  in  which  the  infant's  organs  are  becoming 
trained  to  digest  cow's  milk,  the  best  guide  to  progress,  therefore,  is  not 
weight,  but  how  comfortable  the  child  is  and  how  well  it  sleeps. 

Small  stools  are  to  be  expected  when  an  infant  is  taking  a  formula  of 
cow's  milk  containing  very  low  percentages.  This  condition  needs  no 
treatment  unless  the  child  is  uncomfortable,  for  it  soon  passes  away  as 
the  strength  and  quantity  of  the  food  are  increased.  If  an  attempt  is 
made  to  remedy  this  form  of  constipation  by  rapidly  increasing  the  fat, 
habitual  vomiting  is  frequently  produced.  The  use  of  laxatives  often 
causes  intestinal  derangement  where  none  previously  existed. 

In  general,  the  most  important  indications  for  varying  the  percent- 
ages may  be  stated  as  follows :  If  not  gaining  in  weight  and  without 
special  signs  of  indigestion,  increase  the  proportions  of  all  the  ingredi- 
ents; if  habitual  colic,  diminish  the  proteids;  for  frequent  vomiting 
soon  after  feeding,  reduce  the  quantity;  for  the  regurgitation  of  sour 
masses  of  food,  reduce  the  fat,  and  sometimes  also  the  sugar ;  for  obsti- 
nate constipation,  increase  both  fat  and  proteids. 

The  digestive  organs  of  the  young  infant  are  exceedingly  sensitive, 
easily  deranged,  and  a  simple  functional  derangement  speedily  becomes 
a  gastric  or  intestinal  catarrh ;  hence  the  importance  of  close  attention 
to  all  feeding  cases  for  the  first  month  or  two,  and  of  promptly  and 
intelligently  making  necessary  changes  in  the  food  to  relieve  the  minor 
S5'mptoms  of  indigestion. 

Difiicult  Cases  of  Feeding. — Feeble  digestion  or  chronic  indigestion 
is  seldom  due  to  inherited  conditions,  but  in  most  cases  is  the  result  of 
previous  bad  feeding  or  bad  nursing. 

A  carefully  obtained  history  is  of  great  value  in  enabling  one  to 
judge  of  the  condition  and  peculiarities  of  the  digestive  organs  of  the 


ARTIFICIAL   FEEDING.  215 

individual  child.  One  should  never  ignore  the  results  of  previous  expe- 
rience, and  in  most  cases  it  is  unwise  to  repeat  what  has  once  worked 
disastrously. 

One  should  endeavour  to  determine  whether  the  trouble  is  chiefly 
with  the  fat,  the  sugar,  or  the  proteids  of  the  milk;  also  whether  it  is 
the  stomach  or  intestines  which  are  most  deranged,  the  former  being 
indicated  by  vomiting,  regurgitation  of  food  or  water,  belching  of  gas, 
and  a  coated  tongue;  the  latter  by  colic,  flatulence,  distention  of  the 
abdomen,  diarrhoea  or  constipation,  curds  or  mucus  in  the  stools. 

Drugs  have  small  place  in  the  management  of  these  cases.  The 
essential  treatment  is  the  proper  adjustment  of  the  diet  to  the  condi- 
tion. 

Failure  may  be  due  to  causes  outside  the  food  prescribed — sometimes 
to  the  surroundings,  sometimes  to  ignorance  or  carelessness  in  prepar- 
ing or  administering  the  food. 

In  all  protracted  cases,  and  in  those  in  which  the  derangement  is 
great,  change  of  diet  is  important ;  the  more  protracted  the  condition, 
the  more  radical  should  the  change  be.  Not  much  is  to  be  expected 
from  fractional  variations  in  the  milk  percentages,  when  those  given 
are  producing  a  great  deal  of  disturbance ;  changes  of  from  1  to  2  per 
cent  in  the  proteids  and  fat,  or  of  3  to  4  per  cent  in  the  sugar,  are  often 
required. 

Eadical  changes  are  necessary  in  the  manner  of  feeding  as  well  as 
in  the  food ;  with  reference  to  intervals  between  feedings  and  quantities 
at  single  feedings,  one  often  succeeds  best  by  trying  the  exact  opposite 
of  what  has  previously  failed.  Small  quantities  of  a  strong  food  often 
succeed  better  than  large  quantities  of  a  weak  food,  particularly  where 
vomiting  is  a  prominent  symptom. 

A  careful  regulation  of  the  milJc  percentages  in  intelligent  hands 
will,  in  private  practice,  be  successful  in  the  great  majority  of  cases. 
Success  by  this  method  may  be  expected  in  proportion  to  the  accuracy 
of  the  diagnosis  as  to  the  cause  of  the  symptoms,  and  to  the  degree  of 
error  in  the  previous  prescriptions  employed.  Cases  that  can  not  be 
helped  in  this  way  are  chiefly  very  young  infants,  and  those  in  which 
the  disorder  is  of  long  standing. 

Where  the  trouble  is  with  the  proteids  the  next  thing  to  be  tried, 
and  one  unfamiliar  with  the  percentage  modification  may  succeed  better 
with  it,  is  the  use  of  cereal  gruels  in  the  place  of  water  as  a  diluent, 
either  for  plain  milk  or  for  some  of  the  foregoing  milk  formulas.  As  a 
rule,  better  results  are  obtained  with  these  combinations  in  intestinal 
than  in  gastric  cases. 

Partially  peptonized  milk  may  be  used,  care  being  taken  not  to 
have  the  fat  too  high  in  the  formula  employed;  also  not  to  continue 
too  long  the  use  of  predigestcd  foods. 


216  NUTRITION. 

Whey  mixtures,  where  the  casein  is  removed  by  precipitation  and 
straining,  are  particular!}'  valuable  for  young  infants. 

Wet-nurses  are  useful  in  some  of  the  most  protracted  cases  where 
by  the  food  changes  one  can  only  get  rid  of  the  symptoms  of  indiges- 
tion, but  can  make  no  progress  in  weight;  they  are  more  likely  to  be 
of  assistance  in  intestinal  than  in  gastric  cases,  and  in  those  attended 
by  constipation  than  by  diarrhoea;  in  some  of  the  latter,  particularly 
if  in  very  young  infants,  where  the  stools  are  frequent,  thin,  sour,  and 
green,  the  high  fat  and  sugar  of  a  wet-nurse's  milk  sometimes  cause  a 
serious  aggravation  of  all  the  symptoms.  Wet-nurses  are  of  most 
signal  service  in  cases  of  acute  inanition.  They  seldom  succeed  with 
infants  over  seven  or  eight  months  old  unless  previously  nursed,  as  these 
will  rarely  take  the  breast. 

Withholding  all  milk  from  nursing  or  bottle-fed  infants  is  very 
often  necessary  in  conditions  of  acute  disease,  but  in  cases  of  chronic 
indigestion  it  is  done  too  frequently  and  often  where  a  better  treatment 
is  to  discover  and  give  correct  milk  percentages.  While  in  some  cases 
nothing  is  better  than  to  withhold  milk  temporarily,  often  nothing  is 
worse  than  to  do  so  permanently.  We  can  not  conclude  because  of  the 
benefit  seen  by  omitting  milk  that  the  child  can  never  digest  it;  but 
should  soon  begin  with  very  small  quantities  and  gradually  return  to  a 
diet  in  which  it  is  an  important  element. 

Success  in  infant-feeding  is  largely  a  question  of  close  observation 
and  careful  attention  to  details.  Without  these  the  proportion  of  fail- 
ures by  any  method  will  be  very  large. 


CHAPTEE    ly. 

FEEDING  AFTER    TEE  FIRST   YEAR. 

HEALTHY   INFANTS   DURING   THE   SECOND   YEAR. 

The  physician  should  not  relax  his  vigilance  in  the  feeding  of  a  child 
after  the  first  year  has  passed.  The  ideas  of  the  laity  in  regard  to  what  a 
child  can  digest  after  it  has  outgrown  an  exclusive  milk  diet,  are  very 
erroneous.  The  majority  of  infants  are  given  solid  food  too  early  and  in 
too  large  quantities.  Most  of  the  attacks  of  indigestion  during  the  sec- 
ond year  are  directly  traceable  to  such  gross  dietetic  errors.  The  diet  of 
a  healthy  child  during  the  second  year  should  consist  of  milk,  some 
farinaceous  food,  bread,  a  small  amount  of  animal  food — beef  or  inutton, 
beef  juice,  eggs — and  fruit. 

Milk  should  be  the  basis  of  the  diet.  Tbe  popular  idea  that  there 
are  many  children  who  can  not  take  milk  is  an  erroneous  one ;  the  real 


FEEDING   DURING   THE  SECOND    YEAR.  217 

trouble  usually  is  that  they  will  not  take  it  because  other  food  pleases 
the  palate  better,  and  they  are  allowed  to  have  their  own  way  in  this 
as  in  other  things.  It  is  of  the  utmost  importance  that  the  transition 
from  a  purely  fluid  diet  to  one  of  solid  food  should  be  made  very  slowly, 
and  that  the  habit  of  drinking  milk  should  not  be  discontinued. 

Weaning  from  the  bottle. — This  should  always  be  begun  by  the  thir- 
teenth month;  by  the  fifteenth  month  an  infant  should  drink  all  its 
milk  from  a  cup,  except  possibly  the  10  p.  m.  feeding,  when  the  bottle 
may  be  allowed  for  the  sake  of  convenience.  Early  weaning  from  the 
bottle  is  a  matter  of  no  small  importance.  Where  the  bottle  is  contin- 
ued, as  it  often  is,  until  a  child  is  two  or  three  years  old,  the  greatest 
difficulty  may  be  experienced  in  getting  rid  of  it,  and  this  difficulty  is 
increased  the  longer  it  is  delayed.  I  have  seen  many  children  with  the 
"  bottle-habit "  so  developed  that  throughout  childhood,  although  at 
any  time  they  would  take  milk  from  the  bottle,  they  could  never  be 
induced  to  take  it  in  any  other  way. 

During  the  second  year  with  average  milk  and  average  infants  very 
little  modification  of  the  milk  is  required.  The  addition  of  milk  sugar 
is  in  most  cases  unnecessary,  since  the  child  is  now  able  to  take  a  con- 
siderable part  of  its  carbohydrates  in  the  form  of  starch.  If  the  milk  is 
very  rich,  such  as  that  from  a  Jersey  herd,  it  should  always  be  diluted 
with  at  least  one-fourth  water.  In  hot  weather  even  a  greater  dilution 
may  be  necessary.  If  the  milk  is  poor  in  fat,  and  in  consequence  consti- 
pation is  present,  the  use  of  only  the  upper  two-thirds  from  each  quart 
bottle  will  make  the  percentage  of  fat  about  right. 

From  Twelve  to  Fifteen  Months. — Five  feedings  in  twenty-four 
hours  are  required,  the  interval  between  feedings  being  about  four 
hours.  The  daily  amount  of  food  needed,  is  from  forty  to  fifty  ounces 
(1,240  to  1,550  grammes).  Each  feeding,  therefore,  should  consist  of 
from  eight  to  ten  ounces,  of  which  four-fifths  is  milk  and  one-fifth  some 
form  of  farinaceous  food,  thoroughly  cooked,  and  then  strained,  so  that 
it  forms  a  thick  jelly.  This  may  be  made  from  barley,  wheat,  oatmeal, 
arrowroot,  farina,  or  from  the  farinaceous  foods.  Prepared  barley  and 
oat  flours  are  greatly  to  be  preferred  to  the  grains  (see  page  162),  as 
they  require  only  twenty  or  thirty  minutes'  cooking.  If  the  flours  are 
used,  about  one  rounded  tablespoonful  is  required  for  twelve  ounces  of 
water  to  make  a  gruel  of  the  right  consistency.  This  should  of  course 
be  made  fresh  daily. 

In  preparing  the  food,  the  milk  and  tlio  gruel  are  simply  inixcil 
together  while  the  latter  is  warm,  and  salt  and  a  small  quantity  of  cam- 
sugar  added  to  make  it  palatable.  It  is  then  divided  into  as  many 
feedings  as  are  required  for  the  day,  each  one  being  placed  in  a  sepa- 
rate bottle.  As  to  handling  the  bottles  and  pasteurizing  or  steril- 
izing, the  same  rules  apply  as  during  the  first  year. 


218  NUTKITION. 

For  four  of  the  ieedings  only  the  food  contained  in  the  bottle  is 
given;  at  the  other  one,  usually  at  midday,  the  milk  may  be  preceded 
by  beef  juice,  beginning  with  one  or  two  teaspoonfuls,  and  gradually 
increasing  up  to  two  ounces.  On  alternate  days,  from  three  to  six 
ounces  of  mutton  or  chicken  broth  may  be  given  instead.  At  this  feed- 
ing the  child  will  usually  take  but  half  or  two-thirds  of  its  milk.  The 
only  other  thing  to  be  given  is  the  juice  of  some  fruit,  which  should 
form  a  regular  part  of  the  child's  diet.  That  from  sweet  oranges  or 
ripe  peaches  is  best.  From  one  to  two  ounces  at  a  time  should  be  given 
about  one  hour  before  the  milk  feeding. 

From  Fifteen  to  Eighteen  Months. — The  only  change  desirable  is  the 
addition  of  stale  bread,  preferably  dried  crisp  in  the  oven,  or  zwieback, 
to  be  given  with  the  broth  or  beef  juice;  and  occasionally  a  soft  egg 
may  take  the  place  of  one  of  these.  The  quantity  of  milk  and  gruel 
may  be  increased  if  demanded  by  the  child's  appetite. 

From  Eighteen  Months  to  Two  Years. — The  cereal  gruels  may  now 
be  replaced  by  porridge  of  the  same  varieties  as  used  for  older  children, 
but  always  very  thoroughly  cooked,  hominy  and  oatmeal  requiring  at 
least  three  hours'  continuous  cooking.  Plain  warm  milk,  from  nine  to 
twelve  ounces,  may  now  be  given  at  the  first  and  fifth  meals;  at  the 
second  and  fourth  meals,  six  to  eight  ounces  of  milk  with  three  or  four 
ounces  of  the  cereal.  At  the  third,  the  midday  feeding,  from  one-half 
to  one  tablespoonful  of  rare  scraped  beef  or  mutton  may  be  added,  if 
most  of  the  teeth  are  through.  At  the  same  time,  broth  may  be  allowed ; 
on  alternate  days  a  soft  egg  with  beef  juice,  and  either  well-boiled  rice 
or  bread  and  butter.  In  addition,  cooked  fruits,  such  as  the  pulp  of 
stewed  prunes  or  baked  apple,  may  be  given. 

DIFFICULT  CASES  DURING  THE  SECOND  TEAR. 

The  number  of  children  whose  nutrition  is  a  matter  of  difficulty  dur- 
ing the  second  year  is  much  smaller  than  during  the  first  year ;  yet  there 
are  cases  in  which  the  difiiculties  are  just  as  great.  Some  of  these  are 
infants  that  have  been  very  delicate  from  birth,  and  carried  through  the 
first  year  only  by  the  greatest  effort.  Others  are  healthy  at  birth,  but 
their  digestion  has  been  badly  deranged  in  consequence  of  improper  feed- 
ing during  the  first  year.  Some  are  infants  who  did  well  until  they  were 
weaned,  but  from  that  time  began  to  suffer  from  constant  indigestion 
and  malnutrition,  because  they  were  put  upon  improper  food — often  un- 
diluted cow's  milk.  In  some  the  symptoms  are  the  result  of  a  severe 
attack  of  acute  disease  of  the  stomach  or  intestines  during  the  first  year. 
Many  of  them  are  rachitic.  A  frecpient  cause  of  trouble  is  that  children 
have  been  put  too  early  upon  solid  food,  the  mother  often  thinking  that 
a  child  who  is  delicate  is  only  to  be  built  up  by  giving  "  strong  food." 


FEEDING  DURING  THE  SECOND   YEAR.  219 

Very  often  the  difficulty  is  that  the  food  has  been  excessive  in  starch, 
especially  in  the  form  of  potato  or  oatmeal. 

Whatever  the  special  cause  of  the  symptoms,  cases  of  chronic  indi- 
gestion in  the  second  year  are  improved  by  putting  them  back  upon  es- 
sentially a  first-year  diet.  Usually  the  first  thing  to  be  done  is  to  stop 
all  solid  food  except  the  rare  scraped  meat.  Starches  must  be  reduced 
to  the  minimum  or  prohibited  altogether.  In  most  cases  milk,  meat, 
and  a  little  suitable  fruit  should  constitute  the  diet.  While  it  is  undoubt- 
edly true  that  the  use  of  plain  cow's  milk  often  fails  entirely,  it  is  cer- 
tain that  nothing  is  more  likely  to  succeed  than  cow's  milk  when  prop- 
erly modified.  This  must  be  continued  as  the  principal  diet,  sometimes 
as  the  sole  diet,  for  the  greater  part  of  the  second  year.  The  milk  must 
be  modified  as  for  healthy  infants  who  are  from  eight  to  twelve  months 
younger  than  the  patient  under  treatment.  Thus  a  child  of  twelve  or 
fourteen  months  should  be  given  milk  prepared  as  for  a  healthy  child 
of  four  or  five  months  (e.g..  No.  V  or  VI,  Second  Series,  page  191); 
one  from  twenty  to  twenty-four  months,  as  for  a  healthy  child  of  from 
ten  to  twelve  months  (e.  g.,  No.  VI  or  VII,  Second  Series).  Milk  con- 
taining a  larger  quantity  of  casein  than  in  these  formulae  is  rarely 
digested  unless  partially  peptonized,  and  this  may  be  required  even 
with  the  lower  percentages.  The  daily  quantity  should  generally  be 
somewhat  larger  than  for  a  young,  healthy  infant  taking  food  of  the 
same  strength.  The  regular  intervals  of  feeding  should  never  be  shorter 
than  three  hours,  and  in  many  cases  four  hours  is  to  be  preferred.  The 
number  of  meals  usually  required  in  the  twenty-four  hours  is  five. 

Few  things  cause  more  striking  improvement  in  these  patients  than 
the  administration  of  rare  meat-pulp,  especially  to  those  who  are  over 
eighteen  months  old.  From  one  to  two  ounces  may  be  given  daily. 
Generally  the  proteids  in  the  food  have  been  previously  deficient.  Many 
of  these  children  digest  meat  when  given  in  this  way  better  than  they 
do  the  casein  of  the  milk.  Eaw  beef  juice  and  the  whites  of  eggs,  par- 
tially cooked,  may  also  be  given. 

The  same  fruits  should  be  allowed  as  for  healthy  infants,  the  quan- 
tity being  smaller.  Inasmuch  as  it  is  with  the  starches  that  the  great- 
est difficulty  is  usually  experienced,  the  carbohydrates  must  be  admin- 
istered either  in  the  form  of  milk  sugar  or  some  of  the  malted  foods. 
When  starch  is  first  allowed  it  should  be  given  with  some  reliable  prepa- 
ration of  diastase. 

When  the  child  is  once  well  started  and  gaining  steadily,  the  food 
may  be  gradually  modified,  until  the  diet  recommended  for  healthy  in- 
fants of  the  same  age  is  reached.  All  changes  must,  however,  be  made 
very  gradually,  and  it  should  never  be  forgotten  that  there  is  a  constant 
disposition  on  the  part  of  all  mothers  and  nurses  greatly  to  over-feed 
these  children. 


220  NUTRITION. 

FEEDING   FROM   THE  THIRD   TO  THE  SIXTH  YEAR. 

Articles  allowed. — From  the  following  list  the  diet  of  a  healthy  child 
may  be  arranged : 

Milh. — This  should  be  the  basis  of  the  diet;  most  children  require 
about  one  quart  daily.  This  usually  needs  no  modification,  but  if  some- 
what difficult  of  digestion,  it  should  be  prepared  as  follows :  Six  ounces 
of  milk,  one  ounce  of  cream,  and  three  ounces  of  water.  The  milk 
should  usually  be  given  warm. 

Cream. — This  is  of  great  value,  especially  when  there  is  a  tendency 
to  constipation.  From  two  to  eight  ounces  may  be  given  daily.  It  may 
be  used  upon  cereals,  upon  potato,  in  broths,  and  mixed  with  milk.  In 
many  cases  it  is  advisable  to  withhold  milk  and  give  only  cream. 

Eggs. — These  are  a  valuable  form  of  proteid.  They  should  be  fresh, 
soft-boiled  or  poached,  but  never  fried.  Usually  eggs  should  not  be 
given  oftener  than  every  other  day,  as  many  children  soon  tire  of  them. 

Meats. — Some  form  of  meat  should  be  given  once  a  day.  The  best 
are  beef-steak,  mutton  chop,  and  roast  beef  or  lamb ;  next  to  these  the 
white  meat  of  chicken,  or  fresh  fish,  which  should  be  boiled  or  broiled. 
Beef  and  mutton  should  be  given  rare. 

Vegetables. — Potato  may  be  given  once  a  day,  preferably  baked,  with 
the  addition  of  cream  or  beef  juice  rather  than  butter.  Of  the  green 
vegetables  the  best  are  asparagus  tops,  spinach,  stewed  celery,  string 
beans,  and  fresh  peas.  One  of  these  vegetables  should  be  given  daily — 
always  well  cooked  and  mashed. 

Cereals. — Xearly  all  these  may  be  used — oatmeal,  wheaten  grits, 
hominy,  rice,  farina,  and  arrowroot.  The  most  important  part  of  the 
preparation  is  thorough  cooking.  If  the  grains  are  used,  cereals  should 
be  cooked  at  least  three  hours,  after  having  been  previously  soaked  for 
several  hours.  They  should  always  be  well  salted,  and  given  with  milk 
or  cream,  but  with  little  or  no  sugar. 

Broths  and  soups. — The  meat  broths  are  preferable  to  the  vegetable 
broths.  Nearly  all  varieties  may  be  given.  Plain  broths  are  not  very 
nutritious,  but  when  thickened  with  arrowroot  or  cornstarch,  and  when 
cream  or  milk  is  added,  they  are  very  palatable,  and  at  the  same  time  a 
valuable  addition  to  the  diet.  Beef  juice  may  be  used  as  directed  for 
the  second  year. 

Bread  and  biscuits  {crackers). — lu  some  form  these  may  be  given 
with  nearly  every  meal,  better  without  butter  until  the  fourth  year,  as 
for  young  children  cream  is  a  better  form  of  fat.  All  varieties  of  bread 
may  be  allowed  when  stale;  also  dried  bread,  zwieback,  and  oatmeal, 
Graham,  or  gluten  biscuits. 

Desserts. — The  only  ones  that  should  be  allowed  up  to  the  sixth  year 
are  junket,  plain  custard,  rice  pudding  without  raisins,  and,  not  oftener 


FEEDING   FROM   THE   THIRD   TO   THE  SIXTH   YEAR.  221 

than  once  a  week,  ice-cream.  Of  the  last  three,  the  quantity  given 
should  be  very  moderate. 

Fruits. — Some  fruit  should  be  given  every  day.  Oranges,  baked 
apple,  and  stewed  prunes  are  the  most  to  be  depended  upon.  Eaw 
apples  should  not  in  most  cases  be  given.  Peaches,  pears,  and  grapes 
(with  seeds  removed)  may  be  given  when  thoroughly  ripe  and  fresh, 
but  only  in  moderate  quantity.  Special  care  should  be  exercised  in  the 
use  of  fruits  in  very  hot  weather,  and  in  cities  where  they  may  not 
always  be  fresh.  The  juice  of  fresh  berries  may  be  given  in  the  second 
year;  but  the  whole  fruit  should  be  very  sparingly  given  to  all  young 
children,  and  always  without  cream. 

Articles  forbidden. — The  following  articles  should  not  be  allowed 
children  under  four  years  of  age,  and  with  few  exceptions  they  may  be 
withheld  with  advantage  up  to  the  seventh  year : 

Meats. — Ham.,  sausage,  pork  in  all  forms,  salt  fish,  corned  beef,  dried 
beef,  goose,  duck,  game,  kidney,  liver  and  bacon,  meat  stews,  and  dress- 
ings from  roasted  meats. 

Vegetables. — Fried  vegetables  of  all  varieties,  cabbage,  potatoes  (ex- 
cept when  boiled  or  roasted),  raw  or  fried  onions,  raw  celery,  radishes, 
lettuce,  cucumbers,  tomatoes  (raw  or  cooked),  beets,  egg-plant,  and 
green  corn. 

Bread  and  calve. — All  hot  bread  and  rolls ;  buckwheat  and  all  other 
griddle  cakes ;  all  sweet  cakes,  particularly  those  containing  dried  fruits 
and  those  heavily  frosted. 

Desserts. — All  nuts,  candies,  pies,  tarts,  and  pastry  of  every  descrip- 
tion; also  all  salads,  jellies,  syrups,  and  preserves. 

Drinks. — Tea,  coffee,  wine,  beer,  and  cider. 

Fruits. — All  dried,  canned,  and  preserved  fruits ;  bananas ;  all  fruits 
out  of  season  and  stale  fruits,  particularly  in  summer. 

From  the  third  to  the  sixth  year  four  meals  should  usually  be  given 
daily  and  at  regular  intervals — e.  g.,  7  and  10.30  a.  m.  ;  1.30  and  6  p.  m. 
The  second  meal  should,  in  most  cases,  be  smaller  than  the  others. 

The  following  is  a  sample  diet  for  a  child  of  four  years : 

First  meal. — Half  an  orange,  two  tablespoonfuls  of  some  cereal  well 
salted,  with  two  or  three  tablespoonfuls  of  cream,  a  glass  of  milk,  one 
piece  of  bread  with  a  little  butter. 

Second  meal. — A  glass  of  milk  or  cup  of  broth  with  bread  or  two  or 
three  biscuits  (crackers). 

Third  meal. — Two  tablespoonfuls  of  finely  divided  steak  or  chop,  one 
tablespoonful  of  baked  potato,  one  tablespoonful  of  spinach,  bread  and 
butter,  a  cup  of  junket,  water  to  drink. 

Fourth  meal. — Milk  witli  bread,  or  milk  toast. 

From  the  list  of  articles  given  above,  a  sufficient  variety  in  the  diet 
can  be  secured.    The  only  way  for  the  physician  to  be  sure  that  proper 


222  NUTRITION. 

food  is  given  to  young  children,  is  to  write  out  for  the  guidance  of  the 
mother  or  nurse  two  lists  somewhat  similar  to  the  above,  of  articles  for- 
bidden and  articles  allowed.  This  plan  I  have  followed  for  several  years 
with  the  happiest  results.  It  is  rarely  safe  to  trust  to  the  judgment  of 
the  mother. 

There  are  a  few  simple  rules  in  feeding  which  should  always  be  fol- 
lowed : 

A  child  should  be  taught  to  eat  slowly  and  thoroughly  masticate  his 
food.  The  food  must  always  be  very  finely  divided,  for,  as  a  rule,  mas- 
tication is  very  imperfect  even  up  to  the  sixth  or  seventh  year.  If  the 
child  is  fed  by  the  nurse,  plenty  of  time  should  be  taken  for  the  meal. 
It  is  almost  always  the  case  that  the  food  is  given  too  rapidly.  It  is  un- 
wise continually  to  urge  children  to  eat  when  they  are  disinclined  to  do 
so  at  the  regular  hours  of  meals,  or  when  the  appetite  is  habitually  poor, 
and  under  no  circumstances  should  children  be  forced  to  eat.  Indigesti- 
ble articles  of  food  should  not  be  given  to  tempt  the  appetite  when  ordi- 
nary simple  food  is  refused,  nor  should  these  be  allowed  because  of  the 
notion  that  "  the  child  must  eat  something."  Food  should  not  be  allowed 
between  meals  when  it  is  habitually  declined  at  meal-time.  If  a  child  re- 
fuses to  eat,  and  examination  reveals  no  fault  with  the  food  prepared,  it 
should  seldom  be  offered  again  until  the  next  feeding  time.  In  all  cases 
of  temporary  indisposition,  no  matter  of  what  nature,  and  during  peri- 
ods of  excessive  heat  in  summer,  the  amount  of  solid  food  should  be  re- 
duced and  more  water  given.     If  milk  is  the  food,  it  should  be  diluted. 

FEEDING  DURING  ACUTE  ILLNESS. 

Infants. — This  is  an  important  part  of  the  treatment  of  every  acute 
disease  in  childhood,  but  especially  so  in  infancy.  Whether  the  illness 
is  one  of  the  eruptive  fevers,  diphtheria,  pneumonia,  or  influenza,  all 
cases  must  be  fed  in  about  the  same  way.  It  is  much  easier  by  proper 
feeding  to  prevent  disturbances  of  digestion,  than  to  allay  them.  In 
infancy  this  complication  often  turns  the  scale  against  the  patient.  In 
every  severe  acute  illness,  especially  if  it  is  of  a  febrile  character,  the 
power  of  digestion  is  much  diminished.  One  evidence  of  this  is  the 
onset  with  vomiting;  another  is  the  anorexia  which  accompanies  the 
early  stage  of  nearly  all  acute  diseases.  Wo  should  respect  this  disin- 
clination and  make  it  our  guide  in  the  treatment.  But  water  is  needed ; 
withholding  this  will  often  cause  the  temperature  to  rise  even  higher 
than  before. 

In  all  acute  febrile  diseases  the  general  rule  should  be,  less  food 
and  more  water  than  in  health.*     For  bottle-fed  infants  this  is  easily 

*  Some  valuable  suggestion^!  as  to  the  character  of  foorl  most  suitable  in  acute 
disease  may  be  obtained  from  the  experiments  of  Jacubowitch  (Jahrbuch  fiir  Kinder- 


FEEDING  DURING  ACUTE  ILLNESS.  223 

accomplished  by  simply  increasing  the  dilution  of  the  food ;  for  nursing 
infants  by  making  the  nursing  time  shorter  and  giving  water  freely 
between  feedings  either  from  a  spoon  or  bottle. 

Regularity  in  feeding  is  too  often  entirely  ignored.  While  it  is  true 
that  with  some  capricious  children  all  rules  must  be  disregarded,  it  is 
with  the  great  majority  a  decided  advantage  to  adhere  to  proper  food 
and  regular  intervals.  Food  should  seldom  be  given  at  less  than  two- 
hour  intervals,  and  generally  a  three-hour  interval  is  better,  although 
there  is  no  limit  to  the  frequency  with  which  water  may  be  given,  and 
unless  the  stomach  is  irritable,  almost  no  limit  as  to  quantity.  Stimu- 
lants, when  required,  are  often  best  given  in  a  very  dilute  form  with  the 
water. 

Forced  feeding — gavage. — ISTot  a  few  cases,  however,  are  seen  in 
which,  after  a  child  has  been  several  days  sick,  in  consequence  of  deliri- 
um, stupor,  sepsis,  or  some  other  serious  condition,  it  may  refuse  all 
food  or  take  so  little  that  it  is  in  danger  of  death  from  inanition.  At 
this  juncture  forced  feeding  or  gavage  (see  page  62)  serves  an  excel- 
lent purpose.  Both  food  and  stimulants  can  thus  be  introduced  at  regu- 
lar intervals  with  slight  disturbance,  and  lives  saved  which  would  other- 
wise be  lost.  If  gavage  is  employed,  the  stomach  should  be  first  washed. 
The  intervals  of  feeding  should  be  made  at  least  one  hour  longer  than 
is  customary  in  health,  and  usually  predigested  foods  given. 

Older  Children. — The  same  conditions  with  reference  to  digestion 
exist  as  in  the  case  of  infants.  Older  patients,  however,  are  not  so 
easily  disturbed,  and  the  disturbance  of  digestion  is  not  so  likely  to  be 
serious  as  in  the  case  of  infants.  Even  here  the  physician  should  direct 
the  food  to  be  given  at  regular  intervals,  usually  not  oftener  than  every 
three  hours,  but  should  never — as  is  so  often  done — order  milk  to  be 
given  to  the  child  every  time  it  asks  for  a  drink.  In  most  cases,  for 
children  under  five  years  old,  milk  should  be  somewhat  diluted,  usually 
with  lime-water,  and  partially  peptonized  if  the  child's  digestion  is  fee- 
ble. Children  who  do  not  take  milk  readily  may  be  given  beef  tea,  broth, 
gruel,  or  kumyss,  but  rarely  ice-cream  or  jellies  so  frequently  prescribed, 
as  these,  if  given  in  any  considerable  quantity  or  very  often,  are  likely 
to  disturb  the  stomach  and  take  away  what  little  desire  for  food  the 


heilkunde,  xlvii,  195)  upon  the  activity  of  the  digestive  ferments  derived  from  the 
different  organs  of  children,  removed  immediately  after  death,  usually  occurring  from 
acute  general  disease.  The  greatest  activity  was  found  in  the  diastatic  ferment  of  the 
pancreas,  although  its  power  to  emidsify  fats  was  weak,  and  in  one-third  the  cases  it 
was  absent.  The  peptonizing  power  both  of  the  stomach  and  the  pancreas  was  very 
weak.  The  practical  inference  from  this  is  that  the  food  of  acutely  sick  cliildren 
should  consist  chiefly  of  carbohydrates,  either  as  sugars  or  starches,  that  fats  should 
be  very  sparingly  given,  and  that  proteids  in  many  cases  should  be  partially  pre- 
digested.    This  accords  with  clinical  experience. 


224  NUTRITION. 

child  may  have.  Eaw  eggs  are  palatable  when  beaten  tip  with  sherry, 
a  little  sugar,  and  cracked  ice.  Fruits,  particularly  oranges,  grapes,  and 
grape-fruit,  may  be  allowed  in  almost  every  febrile  disease,  but  never 
given  within  two  hours  of  a  milk  feeding. 

The  water  given  may  be  plain  boiled  water,  but  better,  in  most  cases, 
are  some  of  the  carbonated  waters,  Vichy,  Seltzer,  or  Apollinaris,  these 
being  less  likely  to  disturb  the  stomach. 

It  is  certainly  a  mistake  to  force  food  upon  older  children  in  any  dis- 
ease in  which  their  condition  is  not  dangerous.  But  when  there  is  sepsis, 
delirium,  or  coma  associated  with  other  dangerous  sj^mptoms,  gavage 
may  be  resorted  to  with  but  little  more  difficulty,  and  with  no  less  satis- 
factory results,  than  in  infants. 


CHAPTER   V. 
THE  DERANGEMENTS  OF  NUTRITION. 

The  derangements  of  nutrition  form  a  distinct  and  a  very  large  class 
in  the  ailments  of  infancy,  particularly  during  the  first  year.  The 
symptoms  are  sufficiently  definite  and  characteristic  for  them  to  be  re- 
garded as  separate  diseases,  and  to  be  discussed  as  such.  In  adults  such 
symptoms  are  seldom  seen  except  in  connection  with  organic  disease. 
These  cases  are  often  very  puzzling,  and  in  a  large  number  of  them  a 
diagnosis  of  some  constitutional  disease,  such  as  hereditary  syphilis,  or 
tuberculosis,  or  organic  disease  of  the  stomach  or  intestines,  is  errone- 
ously made.  At  other  times  the  symptoms  resemble  those  of  acute  tox- 
aemia. The  essential  condition  in  all  these  cases  is  the  inability  of  the 
infant  to  get  from  its  food  what  its  system  needs.  It  can  not  digest  or 
assimilate  enough  to  support  life.  ,  It  is  unable  to  replace  from  its  food 
the  daily  waste  of  its  tissues.  The  constructive  metabolism  is  not  equal 
to  the  destructive  metabolism  of  the  body;  the  process  is,  therefore, 
essentially  one  of  starvation,  which  may  be  rapid  or  slow,  according  to 
circumstances. 

The  fault  in  these  cases  is  partly  with  the  digestion,  but  principally 
with  the  food.  The  problem  is,  to  adapt  the  food  to  the  digestion  of  the 
individual  child  under  consideration.  The  solution  is  often  very  easy  at 
first,  but  the  difficulties  multiply  rapidly  the  longer  the  condition  has 
lasted.  It  is  therefore  essential  that  the  true  explanation  of  the  symp- 
toms should  be  recognised  at  the  earliest  possible  moment.  Changes 
occur  so  rapidly  in  very  young  infants  that  a  mistake  in  diagnosis  and  a 
consequent  delay  of  a  few  days,  may  be  sufficient  to  determine  a  fatal  re- 
sult.    The  outcome  in  cases  of  imperfect  nutrition  depends  almost  en- 


ACUTE  INANITION.  09^ 

tirely  upon  their  management.  The  condition  is  not  one  which  tends  to 
right  itself.  Spontaneous  improvement  or  recovery  rarely  takes  place. 
In  order  to  recognise  the  condition  and  anticipate  the  result,  nothing  is 
so  important  as  a  close  observation  of  the  body-weight.  A  child  whose 
nutrition  is  a  matter  of  difficulty  should  be  weighed  regularly,  in  the 
early  months  twice  a  week,  and  once  a  week  throughout  the  first  year. 
If  this  is  done,  the  first  symptoms  of  failing  nutrition  are  unerrinu-lv 
detected.  If  a  child  does  not  gain  in  weight  something  is  wrong,  and  a 
steady  loss  in  weight  in  an  infant  is  a  warning  which  should  never  be 
unheeded;  for,  unless  the  conditions  are  changed,  it  is  practically  cer- 
tain to  continue,  and  generally  with  increasing  rapidity,  until  the  in- 
fant's vitality  has  been  reduced  to  such  a  point  that  no  means  of  treat- 
ment can  restore  it.  The  younger  the  child,  the  more  rapid  the  loss, 
and  the  longer  it  has  continued,  the  greater  is  the  danger. 

For  convenience  of  description  these  derangements  of  nutrition  have 
been  divided  into  three  groups,  differing,  however,  rather  in  degree  than 
in  kind. 

1.  Cases  of  acute  inanition,  which  are  quite  rapid,  generally  lasting 
from  a  few  days  to  a  few  weeks.  They  are  rare  except  in  young  infants, 
being  most  frequently  seen  in  the  first  three  months. 

2.  Cases  of  malnutrition,  in  which  the  symptoms  are  much  less  se- 
vere than  in  the  other  groups,  although  they  may  be  of  long  duration. 
While  it  is  most  common  in  the  first  two  years,  malnutrition  may  be 
seen  at  any  age. 

3.  Cases  of  marasmus.  This  is  similar  to  inanition,  but  a  much 
slower  process,  lasting  usually  for  several  months.  It  may  be  seen  in 
infants  of  any  age. 

ACUTE  INANITION. 

Inanition,  or  starvation,  is  a  condition  depending  upon  lack  of  assim- 
ilation. It  is  common  in  early  infancy,  when  it  often  simulates  serious 
organic  disease.  In  older  children  it  is  not  so  frequent,  and  not  usually 
so  obscure.  In  all  the  acute  diseases  of  the  digestive  tract  many  of  the 
symptoms  are  due  to  inanition.  The  cases  considered  in  the  present 
chapter,  however,  are  those  in  which  there  is  no  such  association,  or 
where  tlu;  digestive  symptoms,  strictly  speaking,  are  not  prominent. 

Etiology. — The  essential  cause  of  inanition  is  that  the  child  does  not 
get  sufficient  food,  or  that  the  food  taken  is  not  assimilated.  It  usually 
develops  under  one  of  the  following  conditions:  (1)  When  a  child  re- 
fuses all  food,  whether  from  the  breast  or  the  bottle,  or  can  be  made  to 
take  only  an  insignificant  amount.  The  cause  of  this  it  is  often  im- 
possible to  discover.  I  have  seen  it  in  a  variety  of  circumstances,  once 
in  an  infant  five  months  old,  previously  healthy,  who  was  suffering  from 
whooping-cough.    This  infant  utterly  refused  the  breast,  and  from  the 


226  NUTRITION. 

sjjoon  would  take  less  than  two  ounces  a  da}-.  After  four  days  and  the 
production  of  most  alarming  symptoms,  gavage  was  begun,  and  its  life,  I 
think,  saved  by  it.  It  is  sometimes  seen  at  weaning,  where  a  child  per- 
sistently refuses  to  take  food  from  a  bottle  or  spoon.  (2)  When  the 
food  given  is  entirely  inadequate,  as  when  an  infant  is  nursing  upon  a 
dry  breast,  or  one  in  which  the  milk  supply  is  so  scanty  that  the  child 
gets  practically  nothing.  I  have  occasionally  seen  it  later,  when  the 
breast-milk,  for  some  unexplained  reason,  had  suddenly  failed.  (3) 
Where  the  character  of  the  food  is  improper.  Breast-milk  may  be  not 
only  scanty,  but  of  very  poor  quality.  On  account  of  extreme  povert)^, 
the  infant  may  be  getting  onl}"  tea,  as  I  have  known  to  be  true  in  several 
cases  before  admission  to  the  hospital.  Some  cases  occur  in  3'oung  in- 
fants who  are  fed  entirely  on  starchy  food.  (4)  Where  the  infant  at 
birth  has  such  feeble  powers  of  digestion,  because  premature  or  delicate, 
that  it  is  unable  to  take  or  to  digest  sufficient  food  to  maintain  life. 
Sometimes  this  food  is  breast-milk,  which,  though  abundant,  is  of  infe- 
rior quality  and  can  not  be  assimilated.  Very  often  it  is  some  proprie- 
tary food.  (5)  When  a  sudden  change  of  food  is  made  to  one  so  diffi- 
cult of  digestion  that  the  child  is  unable  to  assimilate  it.  This  vaaj 
happen  after  sudden  weaning.  In  such  cases  the  symptoms  of  inanition 
are  mingled  with  those  of  acute  indigestion,  but  the  former  usually  pre- 
dominate. 

In  children  over  one  year  old,  and  sometimes  in  younger  ones  also, 
the  symptoms  of  inanition  may  follow  those  of  some  acute  disease,  such 
as  influenza,  malaria,  pneumonia,  or  even  otitis.  Although  the  child 
may  recover  from  the  acute  process,  the  general  vitality  is  so  much  low- 
ered that  assimilation  is  not  sufficient  to  replace  the  waste  of  the  hodj. 

Symptoms. — The  mode  of  development  depends  upon  the  antecedent 
condition.  In  young  infants  inanition  often  follows  malnutrition  where 
perhaps  there  has  been  nothing  noticeable  except  a  gradual  loss  in 
weight ;  or  if  the  weight  has  not  been  watched,  it  may  be  observed  only 
that  the  infant  has  not  been  doing  well.  Severe  symptoms  may  come  on 
quite  suddenly,  and  if  the  nature  and  the  gravity  of  the  condition  are  not 
appreciated  the  case  may  terminate  fatally  in  two  or  three  days.  The 
loss  in  weight  is  now  rapid,  amounting  often  to  three  or  four  ounces  a 
day.  The  temperature  in  the  newly  born  may  be  high,  but  it  is  more 
often  subnormal.  The  pulse  is  always  weak  and  rapid.  The  urine  is 
scanty  and  very  low  in  chlorides.  The  extremities  are  cold,  and  the 
peripheral  circulation  poor.  There  is  usually  complete  muscular  relaxa- 
tion, almost  collapse.  The  skin  may  be  dry  or  covered  with  a  clammy 
perspiration.  There  is  extreme  pallor,  and  often  there  is  cyanosis. 
This  is  always  a  grave  symptom,  and  when  it  is  marked  the  case  usually 
ends  fatally.  Cyanosis  may  be  present  in  children  who  have  previously 
cried  well  and  in  whom  there  is  no  suspicion  of  atelectasis.    The  respira- 


ACUTE  INANITION.  227 

tions  are  rapid  and  may  be  irregular.  There  may  be  constant  worrying 
and  fretfulness,  or  a  condition  of  semi-stupor,  in  which  the  child  makes 
no  sign  of  wanting  food.  The  fontanel  is  sunken  and  the  pupils  are 
often  contracted.  The  stools  contain  undigested  food,  or  if  predigested 
foods  are  given  they  seem  to  pass  through  the  intestines  unchano-ed. 
The  bowels  usually  move  frequently,  although  there  may  be  constipation, 
due  to  the  small  amount  of  food  taken.  When  all  food  is  refused  for 
two  or  three  days  the  stools  may  resemble  meconium,  as  I  once  saw  in 
a  child  six  months  old.  While  no  desire  for  food  is  manifested,  infants 
will  sometimes  swallow  food  when  it  is  offered,  retaining  everything 
given  for  several  feedings,  when  the  whole  quantity  is  vomited. 

The  course  of  the  disease  depends  much  upon  the  age  of  the  infants. 
Those  under  one  month  succumb  most  quickly.  In  them  the  symptoms 
sometimes  last  but  two  or  three  days,  seldom  more  than  a  week  or  ten 
days,  the  children  simply  drooping  steadily  until  death  occurs.  With 
proper  treatment  complete  recovery  may  take  place  in  a  week.  In 
older  infants  the  progress,  whether  upward  or  downward,  is  usually  less 
rapid. 

Prognosis. — The  outcome  of  these  cases  is  always  uncertain.  In  few 
conditions  is  it  more  so.  It  is  hard  for  one  who  is  not  familiar  with  the 
condition  to  appreciate  the  great  and  even  the  immediate  danger  in 
which  a  young  infant  may  be  from  inanition,  especially  in  the  ab- 
sence of  both  vomiting  and  diarrhoea.  It  is  difficult  to  estimate  the 
gravity  of  an  individual  case  except  after  twenty-four  hours'  observa- 
tion. The  best  of  all  guides  is  perhaps  the  weight.  Where  the  loss 
is  several  ounces  each  day  the  chances  of  recovery  are  small.  The  pres- 
ence also  of  frequent  vomiting  or  of  diarrhoea  makes  the  outlook  very 
bad.  A  high  temperature,  very  marked  relaxation,  copious  perspiration, 
cold  extremities,  and  cyanosis  are  all  bad  symptoms. 

Diagnosis. — Inanition  is  distinguished  from  malnutrition  by  its 
greater  severity,  and  from  marasmus  by  its  more  acute  character.  The 
usual  mistake  is  that  of  confounding  inanition  with  some  local  or  consti- 
tutional disease.  It  may  be  mistaken  for  acute  indigestion,  meningitis, 
gastro-enteritis,  pneumonia,  and  some  of  the  fevers.  The  temperature 
when  elevated  is  especially  likely  to  mislead.  In  some  cases  the  absence 
of  chlorides  from  the  urine  may  be  of  diagnostic  value. 

Treatment. — The  existence  of  inanition  in  young  infants  presupposes 
only  the  feeblest  powers  of  digestion  and  assimilation.  If  possible,  a 
good  wet-nurse  should  be  secured,  for  in  most  of  the  cases  the  time  for 
action  is  so  short  that  there  is  no  opportunity  to  experiment  with  arti- 
ficial feeding. 

The  breast-milk  should  usually  be  diluted,  at  first  with  an  equal  vol- 
ume of  water  or  lime-water,  and  the  quantity  should  be  only  a  few 
drachms.    It  may  be  given  with  a  spoon  or  a  medicine-dropper.    If  there 


228  NUTRITION. 

is  diarrhoea,  the  milk  should  be  pumped  from  the  breasts,  and  the  cream 
removed,  since  the  high  fat  of  good  breast-milk  is  apt  to  excite  vomit- 
ing or  copious  purgation.  Gradually  the  quantity  and  strength  of  the 
milk  are  increased  until  the  child  is  allowed  to  take  the  breast  entirely. 

When  no  wet-nurse  can  be  obtained,  whey  mixtures  (page  208)  may 
be  tried  or  a  milk  formula  containing  low  proportions  of  fat  and  proteids, 
such  as  No.  II,  Second  Series  (page  191),  or  jSTo.  I,  Third  Series  (page 
192).  Sometimes  these  should  be  peptonized.  When  food  is  not  readily 
taken,  it  may  be  given  by  gavage.  Eectal  feeding  may  be  of  some  assist- 
ance for  a  short  period.  Other  things  which  may  be  tried  are  diluted 
kumyss,  animal  broths,  malted  foods,  farinaceous  foods,  and  beef  pep- 
tones. 

Often  the  symptoms  are  due  quite  as  much  to  a  lack  of  water  as  to  a 
lack  of  food.  Injections  of  a  normal  salt  solution  may  be  given  per  rec- 
tum or  even  under  the  skin  with  very  great  advantage.  Rectal  injec- 
tions should  be  given  at  10-1°  to  110°  F.  and  carried  high  into  the  colon 
by  a  catheter;  they  should  be  repeated  every  four  or  five  hours. 

The  other  treatment  required  by  these  cases  is  the  reduction  of  high 
temperatures  by  sponging  or  tepid  baths,  and  the  raising  of  subnormal 
temperatures  by  hot-water  bags,  rolling  in  cotton,  or  even  by  the  use  of 
an  incubator.  Stimulants  are  indicated,  but  are  not  very  well  borne; 
alcoholic  preparations  by  the  mouth  often  excite  vomiting,  but  by  the 
rectum  they  may  be  better  tolerated.  Drugs  are  of  no  use  whatever. 
Oxygen  inhalations  are  of  the  greatest  value,  and  should  be  used  if  pos- 
sible in  all  very  acute  cases  whether  cyanosis  is  present  or  not.  Heat, 
oxygen,  and  diet  are  really  the  sum  of  treatment. 

Inanition  in  older  infants  is  usually  seen  at  weaning  or  in  connec- 
tion with  or  following  some  acute  illness.  Completely  peptonized  milk 
by  gavage  is  often  useful.  There  are  some  patients,  usually  over  ten 
months  old,  who  refuse  fluid  food  of  every  description,  and  vomit  it 
when  it  is  coaxed  or  forced,  yet  who  will  take  and  digest  in  a  most 
surprising  manner  some  form  of  solid  food,  such  as  beef-steak,  oatmeal, 
bread,  crackers,  or  even  potatoes.  For  the  time  one  must  give  what- 
ever the  child  will  take,  and  gradually  change  to  a  suitable  diet  as  soon 
as  circumstances  will  permit.  The  needed  water  may  be  given  per 
rectum. 

All  children  who  have  suffered  from  acute  inanition  need  the  closest 
attention  for  a  long  time,  particularly  as  to  their  feeding,  regarding 
which  suggestions  will  be  found  in  the  pages  devoted  to  Infant-Feeding. 

MALNUTRITION. 

Cases  of  malnutrition  are  exceedingly  common,  and  occupy  a  large 
part  of  the  time  and  attention  of  one  engaged  in  practice  among  chil- 
dren.    Although  these  children  can  not  be  said  to  be  actually  ill,  they 


MALNUTRITION.  229 

are  very  far  from  well,  and  their  condition  is  often  the  cause  of  the  great- 
est solicitude  on  the  part  of  anxious  parents,  not  only  from  the  existing 
state  of  health,  but  from  the  apprehension  of  the  development  of  some 
serious  organic  or  constitutional  disease,  especially  tuberculosis. 

Etiology. — Malnutrition  may  depend  upon  inherited  conditions. 
Certain  children  are  delicate  from  birth,  possessing  only  feeble  physical 
vitality,  though  without  giving  evidence  of  any  actual  disease.  They  are 
often  the  offspring  of  parents  of  delicate  constitution,  or  of  those  with 
inherited  tuberculosis,  gout,  syphilis,  or  alcoholism.  Very  many  city 
children  are  included  in  this  group.  They  are  a  product  of  modern  life, 
and  inherit  a  too  highly  developed  nervous  organization  with  a  corre- 
sponding amount  of  physical  deterioration.  In  another  group  of  cases 
the  children  are  premature  or  very  small  at  birth,  weighing  perhaps  only 
three  or  four  pounds.  Many  cases  are  traceable  to  improper  feeding  or 
equally  poor  nursing  during  the  first  few  months.  These  children  get  a 
poor  start  in  life,  and  on  that  account  are  handicapped  throughout  in- 
fancy. In  many  cases  malnutrition  develops  as  a  result  of  the  patient's 
surroundings.  While  this  is  common  among  the  poor,  it  is  not  rare 
among  the  better  classes.  One  of  the  most  frequent  causes  is  the  perni- 
cious custom  of  keeping  infants  in  close  apartments  where  the  thermom- 
eter ranges  from  73°  to  78°  F.,  and  where  the  greatest  anxiety  is  con- 
stantly felt  lest  the  children  take  cold.  Such  infants  may  lose  in  weight, 
become  anemic,  and  exhibit  all  the  signs  of  malnutrition  where  nothing 
else  is  wrong  except  the  conditions  mentioned.  In  infants,  malnutri- 
tion often  depends  upon  some  previous  acute  disease,  especially  of  the 
stomach  and  intestines,  and  sometimes  of  the  lungs. 

In  children  who  are  over  two  years  old  the  condition  of  malnutrition 
may  be  due  to  any  of  the  factors  above  mentioned — inherited  feebleness 
of  constitution,  bad  feeding  and  its  resulting  indigestion,  too  little  fresh 
air,  and  close  confinement  indoors.  It  is,  however,  at  this  period  much 
more  frequently  than  in  infancy,  dependent  upon  some  previous  acute 
disease.  This  may  be  acute  broncho-pneumonia,  acute  ileo-colitis,  in- 
fluenza, malaria,  or  any  of  the  eruptive  fevers.  As  a  result,  an  im- 
pression is  left  upon  the  child's  constitution  which  lasts  for  months, 
often  for  years,  and  which  manifests  itself  not  by  any  special  local  symp- 
toms, but  by  a  general  condition  of  debility  or  malnutrition.  Sometimes 
such  diseases,  instead  of  being  directly  the  cause  of  the  symptoms,  are 
the  occasion  which  brings  out  some  latent  inherited  taint  or  constitu- 
tional weakness  in  children  who  up  to  this  time,  perhaps,  have  apjiearod 
exceptionally  healthy.  In  other  cases  malnutrition  depends  upon  faulty 
methods  in  oducation,  especially  upon  overpressure  in  schools. 

Symptoms. — In  infants. — The  weight  is  much  below  the  average,  and 
is  either  stationary  or  the  gain  is  very  slow,  often  only  five  or  six  ounces 
a  month  at  a  period  when  it  should  be  from  one  to  two  pounds.    In  a 


230  NUTRITION. 

case  recently  under  treatment,  a  child  at  fourteen  months  weighed  but 
eight  and  a  half  pounds.  This  infant  at  birth  weighed  three  and  a  half 
pounds,  but  in  a  few  weeks  the  weight  dropped  to  two  pounds. 

N'ot  only  the  weight  but  the  general  physical  development  is  much 
below  the  normal.  At  one  year  the  body  length  may  be  three  or  four 
inches  less  than  the  average.  Dentition  is  usually  but  not  always  de- 
layed. Muscular  development,  too,  is  backward;  many  of  these  chil- 
dren do  not  sit  alone  until  a  year  old,  and  barely  walk  at  two  and  a  half 
3^ears.  The  muscles  are  soft  and  flabby,  and  the  ligaments  so  weak  that 
paralysis  is  often  suspected.  The  body  is  so  small  that  the  head  seems 
unnaturally  large,  and  a  diagnosis  of  incipient  hydrocephalus  is  fre- 
quently made.  Mentally  these  infants  are  often  above  the  average. 
Some  symptoms  of  rickets  may  be  present,  but  often  there  are  none; 
to  apply  the  term  rachitic  to  all  of  them  seems  to  me  a  mistake. 

Anaemia  is  invariably  present,  and  varies  much  in  degree,  being  rare- 
ly extreme.  The  circulation  is  usually  poor,  the  hands  and  feet  are  fre- 
quently cold.  In  many  children  the  skin  is  unnaturally  dry;  in  others 
there  is  a  disposition  to  excessive  perspiration,  particularly  about  the 
head.  Nervous  symptoms  are  usually  present.  These  children  are  rest- 
less, fretful,  and  irritable;  they  sleep  badly  during  the  day,  and  often 
worse  at  night.  Enlargement  of  the  Ij^mph  glands  is  common,  especially 
those  of  the  neck.  The  cervical  adenitis  may  have  started  from  a  slight 
catarrhal  cold,  but  the  glands  continue  to  swell  after  this  has  subsided 
and  may  remain  enlarged  for  months. 

One  of  the  most  characteristic  things  about  these  infants  is  their 
feeble  powers  of  digestion  and  assimilation.  Unremitting  care  and  con- 
stant watchfulness  are  required  to  keep  them  up  to  even  a  moderate 
standard  of  health.  The  most  trivial  changes  in  food  may  upset  them. 
Attacks  of  acute  indigestion  are  usually  brought  on  by  overfeeding — the 
mistake  which  is  almost  invariably  made  by  mothers  who  are  discouraged 
with  the  slow  progress  made,  and  are  anxious  to  make  their  children  grow 
fat  and  strong.  The  balance  is  so  delicately  adjusted  that  the  slightest 
deviation  from  proper  rules  of  feeding,  either  as  to  the  quality  of  the 
food  or  the  quantity  given,  is  immediately  followed  by  an  attack  of  acute 
indigestion,  often  by  severe  diarrhoea.  As  a  result,  the  child  may  lose  as 
much  in  two  or  three  days  as  it  has  gained  in  a  month  or  more.  These 
acute  attacks,  if  in  summer,  not  infrequently  prove  fatal.  Not  only  do 
these  patients  have  but  little  resistance  to  acute  disturbances  of  the 
stomach  and  intestines,  but  any  acute  disease  is  serious — measles,  whoop- 
ing-cough, and  pneumonia  being  especially  fatal. 

Among  the  poor  or  in  institutions,  cases  of  malnutrition  like  those 
described,  if  in  children  under  nine  months  old,  are  almost  certain  to  go 
on  from  bad  to  worse  until  they  have  reached  the  condition  described 
as  marasmus.    Between  this  and  malnutrition  no  sharp  distinction  can 


MALNUTRITION.  231 

be  drawn ;  they  are  rather  different  degrees  of  the  same  general  process. 
In  private  practice,  where  it  is  possible  to  have  the  best  care  and  sur- 
roundings, with  the  co-operation  of  an  intelligent  mother  or  nurse,  a 
very  large  number  of  these  infants  can  be  reared.  After  the  second  year 
has  passed  the  problem  becomes  a  much  simpler  one,  and  if  infectious 
diseases  and  other  forms  of  acute  illness  can  be  avoided,  the  probabili- 
ties are  in  favour  of  the  child's  becoming  stronger  each  year  and  growing 
to  maturity. 

In  older  children. — In  general  appearance  these  children  are  thin, 
pale,  and  very  often  undersized,  particularly  if  the  condition  is  constitu- 
tional or  hereditary.  Sometimes  they  are  taller  than  the  average  for 
their  age,  and  their  symptoms  are  often  attributed  to  too  rapid  growth. 
One  of  the  most  striking  things  about  children  suffering  from  malnutri- 
tion is  their  vulnerability.  They  "  take  "  everything.  Catarrhal  pro- 
cesses in  the  nose,  pharynx,  and  bronchi  are  readily  excited,  and,  once 
begun,  tend  to  run  a  protracted  course.  There  is  but  little  resistance  to 
any  acute  infectious  disease  which  the  child  may  contract.  One  illness 
often  follows  another,  so  that  these  children  are  frequently  sick  for 
almost  an  entire  season.  Their  muscular  development  is  poor,  they  tire 
readily,  are  able  to  take  but  little  exercise,  and  their  circulation  is  slug- 
gish. Mentally  they  are  usually  bright,  often  precocious.  Many  would 
be  called  nervous  children.  They  are  cross,  fretful,  and  any  unusual 
excitement  produces  an  effect  which  lasts  for  some  time;  for  example, 
after  a  children's  party  or  a  Christmas  tree  they  may  lie  awake  half 
the  succeeding  night,  and  may  be  really  ill  for  two  or  three  days.  Their 
sleep  is  usually  disturbed  and  restless ;  they  waken  frequently,  and  occa- 
sionally suffer  from  night-terrors.  At  a  later  age  they  are  favourable 
subjects  for  chorea,  neuralgia,  and  all  functional  nervous  disorders. 

Digestive  symptoms,  if  not  constant,  are  very  easily  excited.  In  fact, 
they  do  not  suffer  so  much  from  chronic  indigestion  as  from  a  delicate  or 
feeble  digestion,  which  is  easily  upset  by  the  slightest  deviation  from 
the  regular  routine.  Children  of  five  or  six  years  have  to  be  fed  as  care- 
fully as  infants  of  eighteen  months  or  two  years.  The  appetite  is  usu- 
ally poor,  and  mothers  are  distressed  because  their  children  eat  so  little, 
yet,  when  food  is  urged  upon  them,  attacks  of  indigestion  follow  with 
singular  uniformity.  The  tongue  is  slightly  coated  the  greater  part  of 
the  time.  The  bowels  are  apt  to  be  constipated,  apparently  more  from 
lack  of  muscular  tone  than  from  anything  else.  From  time  to  time, 
from  slight  causes,  such  as  exposure  to  cold,  or  even  from  fatigue,  there 
may  be  large  quantities  of  mucus  in  the  stools  for  two  or  three  days  at 
a  time,  although  this  is  not  a  prominent  feature  of  most  of  these  cases. 
When  they  are  not  fed  with  the  greatest  care  these  children  suffer  con- 
stantly from  indigestion.  A  moderate  amount  of  anaemia  is  always 
present,  and  this  may  be  the  most  striking  feature.    In  very  many  chil- 


232  NUTRITION. 

dren  with  a  marked  disturbance  of  nutrition,  there  is'  an  excessive  elimi- 
nation of  nric  acid. 

The  duration  of  the  condition  depends  very  much  upon  the  cause.  If 
the  cause  is  constitutional  or  inherited,  the  condition  may  last  through- 
out childhood.  Where  it  follows  some  acute  illness  it  commonly  lasts 
for  a  few  months  only;  but  the  effect  of  an  acute  attack  of  broncho- 
pneumonia or  of  ileo-colitis  may  last  for  years.  If  the  malnutrition  is 
the  result  only  of  the  child's  surroundings,  like  the  confinement  incident 
to  city  life,  very  rapid  improvement  may  follow  a  removal  to  the  coun- 
try. In  some  children  marked  improvement  is  seen  about  the  seventh 
year;  in  others,  a  great  change  comes  at  puberty. 

Diagnosis. — The  physician  should  not  be  too  ready  to  make  a  diagno- 
sis of  simple  malnutrition.  Before  accepting  such  a  diagnosis,  he  should 
examine  the  child  with  the  greatest  care,  to  exclude  the  common  organic 
and  constitutional  diseases.  Much  regarding  inherited  constitutional 
tendencies  can  be  learned  from  the  family  history  and  from  the  condi- 
tion of  other  children  in  the  family.  In  the  first  place,  tuberculosis, 
syphilis,  and  rickets  should  be  excluded;  then  chronic  malaria  and  the 
diseases  of  the  blood ;  and,  finalh^  organic  diseases  of  the  lungs,  heart, 
stomach,  intestines,  liver,  and  kidneys.  Even  malignant  disease,  though 
rare,  should  not  be  overlooked.  It  may  take  careful  observation  for  sev- 
eral days,  and  sometimes  for  weeks,  with  repeated  physical  examina- 
tions, before  all  these  conditions  can  be  positively  excluded. 

The  next  step  in  the  diagnosis  is  to  discover  upon  which  one  of  the 
many  possible  causes,  malnutrition  depends.  In  private  practice  the 
great  proportion  of  cases  are  due  to  improper  feeding  or  nursing ;  next 
in  importance  are  improper  surroundings ;  and  last  come  inlierited  con- 
stitutional conditions.  In  other  words,  most  of  these  children  are  born 
healthy,  but  become  ill  or  delicate  in  consequence  of  improper  manage- 
ment. 

In  older  children,  after  excluding  constitutional  and  local  diseases, 
the  whole  life  of  the  child  must  be  investigated  to  discover  the  funda- 
mental condition  which  is  at  fault.  A  carefully  obtained  history  from 
infancy  is  of  the  greatest  assistance.  It  is  often  difficult,  and  some- 
times impossible,  to  get  at  the  primary  factor,  for  in  cases  of  long  stand- 
ing there  may  be  symptoms  connected  with  almost  every  function  of  the 
body.  One  should  scrutinize  closely  the  quality  and  quantity  of  food 
given,  the  amount  of  sleep,  the  hours  of  study  and  recreation,  the 
amount  of  exercise  in  the  open  air,  and  the  physical  conditions  sur- 
rounding the  child.  Usually  the  most  important  factor  in  the  case  can 
be  discovered. 

Prognosis. — This  depends  much  upon  the  cause  of  the  condition ;  if 
it  is  one  that  can  be  removed,  the  prognosis  is  good  not  only  for  im- 
provement but  for  complete  recovery.     The  longer  the  condition  has 


MALNUTRITION.  233 

lasted  and  the  greater  the  general  disturbance  the  slower  will  be  the 
improvement.  The  great  danger  is  the  supervention  of  some  acute 
disease  while  the  child's  resistance  is  so  greatly  reduced.  Acute  indi- 
gestion, gastro-enteritis,  and  broncho-pneumonia  are  especially  to  be 
dreaded. 

Since  everything  depends  upon  the  fidelity  with  which  directions  as 
to  diet  and  general  management  are  carried  out,  the  cases  which  present 
the  greatest  difficulties  are  those  in  which  these  conditions  are  hardest 
to  control.  When  a  child  is  not  only  suffering  from  malnutrition,  but 
has  been  indulged  and  spoiled  in  every  way  by  anxious  but  unwise  par- 
ents, no  success  is  to  be  expected  unless  the  child  can  be  placed  in  the 
hands  of  an  experienced  and  trustworthy  nurse.  Cases  due  to  improper 
feeding  or  to  bad  surroundings  usually  improve  when  these  are  cor- 
rected, and  the  worse  these  conditions  have  previously  been  the  greater 
the  improvement  to  be  expected.  Those  depending  upon  an  inherited, 
delicate  constitution  are  not  so  hopeful,  and  require  the  closest  atten- 
tion throughout  childhood. 

Treatment. — This  is  a  problem  of  nutrition  to  be  solved  by  diet  and 
general  management,  drugs  occupying  a  very  small  place. 

In  infants. — In  very  young  infants  treatment  is  chiefly  a  question  of 
feeding.  This  should  be  carried  on  according  to  the  rules  given  in  the 
chapter  upon  Feeding  in  Difficult  Cases  (page  206).  These  children 
often  do  fairly  well  during  the  first  year,  but  after  this  time  frequently 
do  very  badly,  on  account  of  the  failure  to  appreciate  the  fact  that, 
although  over  twelve  months  old,  in  point  of  development  they  re- 
semble healthy  infants  of  four  or  five  months,  and  are  to  be  managed 
as  such.  If  they  are  nursing,  weaning  should  often  be  deferred 
until  the  sixteenth  or  eighteenth  month,  or  at  least  partial  nursing 
should  be  continued  until  that  time.  When  cow's  milk  is  begun  it 
should  always  be  very  largeh^  diluted,  usually  modified  as  for  a  healthy 
infant  two  or  three  months  old.  It  is  surprising  to  sec  witli  what 
uniformity  the  giving  of  cow's  milk,  pure  or  slightly  diluted,  will 
produce  attacks  of  indigestion  in  some  of  these  infants.  I  have  seen 
a  single  feeding  in  which  one  ounce  of  milk  was  given,  and  that  diluted 
three  times,  produce  a  violent  attack  of  acute  indigestion  which  proved 
Avell-nigh  fatal.  Feeding  during  the  entire  second  year  should  be  car- 
ried on  very  much  as  in  ordinary  healthy  children  from  the  sixth  to  the 
twelfth  month.  A  deviation  from  this  rule  almost  invariably  results 
disastrously.  One  must  be  guided  as  to  the  amount  and  character  of  the 
food  not  so  much  by  the  child's  age  as  by  his  digestive  capacity,  and  in 
most  cases  this  is  much  feebler  than  the  mother  or  even  the  physician 
supposes.  In  many  of  these  cases,  cow's  milk — for  them  the  most  valu- 
able of  all  foods — has  been  excluded  from  the  diet,  when  the  only  trou- 
ble is  that  it  has  not  been  given  in  sufficient  dilution.    For  some  children 


234  NUTRITION. 

it  must  be  partially  peptonized  during  periods  when  digestion  is  espe- 
cially feeble. 

JSText  in  importance  to  diet  is  fresh  air.  Often  these  patients  will 
not  improve  with  any  variation  in  diet  until  fresh  air  is  secured. 
Then  increased  digestive  power  is  seen  in  the  course  of  a  few  weeks, 
sometimes  in  a  few  days.  The  natural  tendency  of  a  mother  who  has 
a  delicate  infant,  or  one  suffering  from  malnutrition,  is  to  house  it 
closely  and  never  allow  it  a  breath  of  fresh  air.  It  is  of  the  greatest 
assistance  if  these  children  can  be  sent  to  a  warm  climate  for  the  winter. 
If  this  is  not  possible,  fresh  air  may  be  obtained  by  changing  apartments, 
or  by  an  airing  in  the  room  with  the  windows  open.  In  the  beginning 
this  should  be  done  for  a  few  minutes  only,  the  time  being  gradually  in- 
creased to  two  or  three  hours  each  day.  The  child  should  be  clothed 
as  for  the  street,  and,  if  necessary,  hot  bottles  should  be  placed  at  the 
feet. 

Cold  sponging  is  another  valuable  tonic.  After  the  morning  bath  is 
given,  at  95°  F.,  the  entire  body  should  be  sponged  for  a  moment  with 
water  at  a  temperature  of  60°,  or  even  55°  P.  This  produces  a  certain 
amount  of  shock  and  causes  loud  crying,  which  is  of  itself  beneficial. 
How  frequently  this  should  be  done  will  depend  upon  the  reaction  fol- 
lowing it.  If  the  child  remains  blue  and  cold  for  some  time  afterward, 
the  cold  sponging  should  not  be  repeated.  If  there  is  a  good  reaction, 
it  may  be  used  daily. 

Friction  and  massage  are  useful  in  many  cases.  The  child  should  be 
laid  upon  the  lap  of  the  nurse,  if  possible  before  an  open  fire,  and  should 
always  be  covered  with  a  blanket.  The  entire  body  should  then  be  rubbed 
for  ten  or  twenty  minutes  with  the  bare  hand,  or,  better,  with  cocoa  but- 
ter. Simple  rubbing  may  be  used,  or  the  movements  of  massage  em- 
ployed. If  the  latter,  they  should  be  very  gentle  at  first,  and  only  for 
a  short  time.  Professional  operators  are  inclined  to  be  too  energetic 
for  little  children.  There  is  no  advantage  in  rubbing  with  cod-liver 
oil  instead  of  cocoa  butter,  while  the  odour  makes  it  decidedly  objec- 
tionable. 

The  only  tonics  I  have  found  of  much  value  are  alcohol,  nux  vomica, 
and  cod-liver  oil.  Alcohol  may  be  given  in  the  form  of  port  or  sherry 
wine,  l^ux  vomica  may  be  given  alone  or  with  the  wine.  Cod-liver  oil 
is  too  much  used  in  these  cases,  and  in  too  large  doses.  Many  of  these 
infants  can  not  take  it  at  all.  It  should  rarely  be  given  when  the  tongue 
is  coated  and  the  appetite  very  poor.  The  dose  should  always  be  small, 
e.  g.,  ten  drops  of  the  pure  oil  three  times  a  da}'-,  or  twice  as  much  of  an 
emulsion.  In  these  doses  it  may  be  given  for  a  long  time  without  dis- 
turbance. 

The  secret  of  success  in  treating  cases  of  malnutrition  is,  to  hold  the 
patient  to  a  regular  routine  in  feeding,  sleep,  and  in  everything  relating 


MALNUTRITION.  235 

to  his  life.  Experiments  are  nearly  always  unfortunate.  The  physician 
should  lay  down  in  writing  for  the  guidance  of  the  mother,  specific  rules 
with  regard  to  the  amount  of  food,  the  time  at  which  it  is  to  be  given,  the 
hours  of  bathing,  sleep,  and  airing.  He  should  see  the  patient  at  regu- 
lar intervals  and  often  enough  to  be  sure  that  his  orders  are  being  en- 
forced. Good  results  are  obtained  only  by  constant  watchfulness,  and 
although  improvement  may  not  be  seen  at  once,  it  is  in  most  cases 
sure  to  come  if  the  mother  will  co-operate.  In  my  own  experience  no 
class  of  patients  have  given  me  so  much  satisfaction  as  cases  of  malnu- 
trition in  infancy. 

In  older  children. — The  same  general  principles  are  to  be  applied  to 
them  as  to  infants.  The  diet  is  of  the  first  importance.  Only  the  sim- 
plest, plainest,  and  most  easily  digested  articles  of  food  should  be  given. 
Milk,  beef,  eggs,  the  lighter  and  more  easily  digested  cereals,  bread,  and 
fruit  should  form  the  diet.  All  sweets,  pastry,  highly  seasoned  food, 
candy,  nuts,  tea,  and  coffee  should  be  absolutely  prohibited,  and,  in  fact, 
all  the  articles  mentioned  as  "  forbidden  "  on  page  221.  When  the  appe- 
tite is  poor  and  simple  food  not  well  taken,  the  child  should  not  be 
allowed  to  take  indigestible  articles  for  the  sake  of  eating  something. 
Nothing  should  be  given  between  meals,  and  regular  hours  of  feeding 
must  be  followed.  Usually  I  have  found  three  meals  a  day,  for  children 
over  three  years  old,  better  than  the  practice  of  giving  more  frequent 
feedings.  But  this  is  not  always  the  case.  Under  no  circumstances 
should  children  be  coaxed,  urged,  or  hired  to  eat ;  much  less  should  they 
be  forced  to  do  so.  There  is  a  popular  misapprehension  in  regard  to 
the  variety  in  diet  which  children  need.  Most  cases  do  better  when 
a  very  simple  and  fairly  uniform  diet  is  continued. 

The  general  habits  of  children  should  be  directed;  there  should  be 
regular  and  early  hours  for  retiring,  freedom  from  undue  excitement, 
and  interest  should  be  awakened  in  out-of-door  amusements.  A  pony  or 
dog  will  be  found  useful.  Children  should  be  kept  as  much  as  possible 
in  the  open  air ;  usually  they  do  much  better  if  they  can  be  in  the  coun- 
try during  the  entire  year.  Only  a  limited  amount  of  reading  and  study 
should  be  allowed;  and  if  children  are  at  school,  care  should  be  taken 
that  overpressure  is  not  the  cause  of  the  symptoms,  particularly  in  an 
ambitious  child.  The  cold  sponging  given  in  the  morning,  as  described 
on  page  55,  is  extremely  beneficial  to  children  who  take  cold  readily. 
Massage  is  useful  for  the  benefit  which  it  affords  to  the  chronic  consti- 
pation which  is  so  frequently  a  symptom  of  malnutrition. 

Of  the  tonics,  iron,  arsenic,  and  cod-liver  oil  are  required  in  most 
cases,  and  the  amount  and  combination  may  be  varied  from  time  to 
time,  with  the  season  of  the  year  and  the  condition  of  the  child's  diges- 
tion. In  general,  these  children  require  early  hours,  a  simple  diet,  a 
quiet,  regular  life,  and  very  little  medicine. 


236  NUTRITION. 


MARASMUS. 
Synonyms :  Athrepsia,  infantile  atrophy,  simple  wasting. 

Wasting  is  a  symptom  of  many  conditions  in  infancy.  It  occurs  in 
tuberculosis,  in  infantile  syphilis,  and  also  as  a  result  of  acute  or  chronic 
disease  of  the  stomach  and  intestines.  Cases  of  wasting  dependent  upon 
such  causes  are  not  included  in  this  chapter. 

Marasmus  is  the  extreme  form  of  malnutrition  seen  in  infancy,  occur- 
ring, so  far  as  is  known,  without  constitutional  or  local  organic  dis- 
ease.    It  is  a  vice  of  nutrition  only. 

Etiology. — Marasmus  is  not  very  often  seen  in  the  country  or  in  pri- 
vate practice ;  but  it  is  frequent  in  dispensary  practice  in  all  large  cities, 
and  is  especially  common  in  institutions  for  young  infants.  In  mj^  own 
experience  in  four  institutions,  more  than  one  half  the  deaths  under  one 
year  were  directly  or  indirectly  from  this  cause.  Marasmus  is  a  very 
large  factor  in  the  immense  infant  mortality  of  large  cities  in  summer. 
Although  the  cause  of  death  is  usually  reported  under  some  other  name, 
the  determining  factor  in  the  fatal  result  is  the  previous  marantic  condi- 
tion of  the  patient.  The  primary  cause  may  be  a  congenital  weakness 
of  constitution  which  may  depend  upon  heredity.  It  is  often  seen  in 
premature  children  and  in  the  illegitimate  offspring  of  girls  of  sixteen 
or  eighteen.  In  the  vast  majority  of  cases,  however,  it  depends  upon  two 
factors — the  food  and  the  surroundings.  Among  the  poor  who  live  in 
tenements,  infants  who  are  artificially  fed  almost  invariably  do  badly. 
This  is  due  to  ignorance  in  regard  to  the  proper  methods  of  infant-feed- 
ing and  inability  to  procure  what  the  child  requires,  especially  pure 
cow's  milk.  A  country  infant  may  be  neglected  in  many  respects,  and  is 
often  badly  fed ;  but  it  has  plenty  of  pure  air,  and  usually  thrives.  In 
the  city,  as  long  as  an  infant  has  a  plentiful  supply  of  good  breast-milk 
it  continues  to  do  well  in  most  instances,  in  spite  of  the  fact  that  its 
surroundings  are  bad.  When  there  are  not  only  bad  feeding  and  un- 
healthful  surroundings,  but  also  an  inherited  constitutional  vice,  we 
have  all  the  factors  required  to  produce  marasmus  in  its  most  marked 
form.  The  odds  are  so  against  the  infant  that  its  feeble  spark  of  vital- 
ity flickers  for  a  few  months  only  and  gradually  goes  out. 

Another  prominent  factor  in  the  production  of  marasmus  is  the  over- 
crowding of  infants  in  institutions.  Even  though  artificially  fed  after 
the  most  approved  methods,  I  have  seen  scores  of  infants  who  were 
plump  and  healthy  on  admission  lose  little  by  little,  uutil  at  the  end  of 
three  or  four  months  they  had  become  wasted  to  skeletons — hopeless 
cases  of  marasmus,  dying  of  some  mild  acute  illness,  such  as  an  attack  of 


MARASMUS.  237 

indigestion  or  bronchitis,  the  essential  cause,  however,  being  marasmus. 
The  common  mistake  is  that  of  placing  too  many  children  in  one  ward, 
with  no  chance  of  obtaining  a  proper  amount  of  fresh  air.  No  house- 
plant  is  more  delicate  or  sensitive  to  its  surroundings  than  an  infant 
during  the  first  few  months  of  life. 

Lesions. — The  post-mortem  findings  in  cases  of  marasmus  are  ex- 
ceedingly unsatisfactory,  and  throw  little  if  any  light  upon  the  disease. 
Every  now  and  then  general  tuberculosis  is  discovered  in  patients  dying 
apparently  of  marasmus,  the  existence  of  which  was  not  previouslv 
suspected.  An  occasional  lesion  is  fatty  liver.  This  may  lead  to  such 
enlargement  of  the  organ  that  its  M^eight  is  increased  by  one  half.  Both 
to  the  naked  eye  and  under  the  microscope  the  usual  changes  of  fatty 
infiltration  are  present,  often  to  an  extreme  degree.  In  the  past  too 
much  has  doubtless  been  made  of  this  condition  of  the  liver  in  maras- 
mus. From  figures  given  elsewhere  (see  article  on  Fatty  Liver),  it  will 
be  observed  that  the  lesion  is  not  more  frequent  in  this  condition  than 
in  infants  dying  from  other  diseases.  The  most  marked  examples  are 
seen  in  cases  of  marasmus  which  have  lasted  for  seven  or  eight  months. 
Its  exact  relation  to  the  condition  of  wasting  has  not  yet  been  deter- 
mined. 

With  these  exceptions  the  autopsies  show  nothing  striking,  and 
I  have  had  the  opportunity  to  make  at  least  two  hundred  of  them.  The 
lesions  usually  found  are  the  following :  The  brain  is  commonly  anasmic, 
with  dark  fluid  blood  in  the  sinuses,  marantic  thrombi  being  rare.  A 
strip  of  hypostatic  pneumonia,  from  one  to  two  inches  wide,  may  be 
seen  along  the  posterior  border  of  both  lungs,  involving  the  lung  to  the 
depth  of  half  an  inch,  or  less.  In  the  younger  infants  there  are  fre- 
quently areas  of  atelectasis  in  the  lower  lobes.  The  pleura  is  almost 
invariably  normal.  The  heart  is  pale,  with  perhaps  a  slight  increase  in 
the  pericardial  fluid.  The  spleen  and  kidneys  are  pale,  but  otherwise 
normal.  The  stomach  may  be  dilated ;  the  mucous  membrane  is  usually 
pale,  often  coated  with  tenacious  mucus.  The  intestines  contain  undi- 
gested food,  sometimes  mucus.  The  solitary  follicles  of  the  colon  and 
small  intestine,  and  sometimes  Peyer's  patches,  are  slightly  enlarged, 
the  mucous  membrane  in  other  respects  being  normal.  The  mesenteric 
glands  are  often  slightly  enlarged.  In  addition  to  the  above,  there  may 
be  evidence  of  some  recent  infection,  which  has  been  the  cause  of  death ; 
there  may  be  acute  bronchitis,  broncho-pneumonia,  or  intestinal  ca- 
tarrh. 

The  above  lesions  represent  what  has  been  found  in  the  great  ma- 
jority of  the  cases,  and  very  disappointing  they  are  to  one  who  sees  them 
for  the  first  time.  Nor  does  the  microscopical  examination  of  the  organs 
throw  any  light  upon  these  cases.  I  have  personally  examined  witli  care 
the  stomach  and  intestines  of  more  than  a  dozen  cases,  several  of  them 
17 


238 


NUTRITION. 


in  which  autopsies  were  made  only  two  or  three  hours  after  death,  with- 
out finding  anything  of  pathological  importance.  The  theory  advanced 
by  certain  German  writers,  that  atrophy  of  the  intestinal  tubules  is  the 
explanation  of  marasmus,  has  found  no  support  in  my  observations,  nor 
in  those  of  other  American  writers. 


Fig.  41. — Marasmus;  a  patient  in  the  Babies'  Hospital,  ten  months  old,  weight  six  pounds. 
Weight  at  birth  reported  to  have  been  nine  pounds. 

The  true  pathology  of  marasmus  seems  to  me  to  be  a  failure  of  as- 
similation, owing  to  imperfect  digestion,  improper  food,  unhygienic 
surroundings,  or  feeble  constitution.  As  a  result,  there  is  a  progressive 
loss  in  weight,  feeble  circulation,  imperfect  lung  expansion,  imperfect 
oxidation  of  the  blood,  lowered  body  temperature,  and,  finally,  a  deteri- 
oration of  the  blood  itself.  Each  of  these  effects  becomes  in  turn  a  cause 
aggravating  all  the  others,  continuing  until  a  condition  is  reached  which 


MARASMUS.  239 

is  incompatible  with  life,  for  resistance  becomes  so  feeble  that  the  slight- 
est functional  disturbance  proves  fatal. 

Symptoms. — The  general  history  of  these  cases  is  strikingly  uniform. 
The  following  is  the  story  most  frequently  told  at  the  hospital:  "At' 
birth  the  baby  was  plump  and  well  nourished,  and  continued  to  thrive  for 
a  month  or  six  weeks  while  the  mother  was  nursing  it ;  at  the  end  of  that 
period,  circumstances  made  weaning  necessary.  From  that  time  the 
child  ceased  to  thrive.  It  began  to  lose  weight  and  strength,  at  first 
slowly,  then  rapidly,  in  spite  of  the  fact  that  every  known  form  of  in- 
fant-food was  tried."  As  a  last  resort  the  child,  wasted  to  a  skele- 
ton, is  brought  to  the  hospital. 

The  most  constant  symptom  is  a  steady  loss  in  weight.  The  general 
appearance  of  these  patients  is  characteristic.  They  have  an  old  look; 
the  skin  is  wrinkled,  has  lost  its  tone,  and  hangs  in  folds  upon  the  ex- 
tremities (Fig.  41).  The  legs  are  like  drumsticks;  the  abdomen  is 
prominent;  the  temples  are  hollow;  the  fontanel  is  sunken;  the  eyes 
large ;  the  features  sharp ;  and  the  hands  resemble  bird-claws.  Often  the 
children  are  reduced  literally  to  skin  and  bones.  Ansemia  is  a  very 
marked  and  almost  a  constant  symptom,  the  amount  of  haemoglobin 
being  frequently  reduced  to  30  per  cent,  and  in  one  of  my  cases  to  18 
per  cent.  Anaemic  heart-murmurs  are  frequently  heard.  The  body 
temperature  is  usually  subnormal,  unless  artificial  heat  is  used.  A 
rectal  temperature  of  95°  or  96°  F.  is  very  common,  and  one  of  93° 
or  94°  F.  is  occasionally  seen.  In  addition  to  the  pallor  of  the 
face,  there  may  be  a  leaden  hue  due  to  congenital  or  acquired  atelec- 
tasis. A  frequent  symptom  is  general  oedema,  depending  upon  the 
abnormal  condition  of  the  blood  or  blood-vessels.  The  first  thing 
which  calls  attention  to  this  is  often  an  unexpected  gain  in  weight. 
The  oedema  may  increase  until  the  cellular  tissue  of  the  whole  body  is 
affected.  I  have  never,  however,  seen  effusions  into  the  large  cavities. 
CEdema  is  usually  associated  with  marked  anaemia,  and  is  generally  a 
grave  symptom.  The  stools  are  sometimes  normal,  but  usually  contain 
undigested  food,  and  are  large  in  proportion  to  the  amount  of  food 
taken.  No  matter  how  carefully  fed,  these  patients  are  easily  upset. 
Now  and  then  mucus  is  seen  in  the  stools,  but  this  is  not  a  constant  nor 
a  marked  feature.  Vomiting  is  excited  from  the  sligbtest  cause,  and 
often  food  is  regurgitated  almost  as  soon  as  swallowed.  The  appetite, 
in  a  severe  case,  is  almost  entirely  lost;  children  refuse  to  take  food 
from  the  bottle  or  spoon,  and  unless  fed  by  gavage  they  die  of  inanition. 
In  the  earlier  cases  there  may  be  an  unnatural  hunger,  so  that  the  chil- 
dren cry  much  of  the  time,  and  are  relieved  only  when  the  bottle  is 
given. 

The  complications  are  thrush,  erythema  of  the  buttocks,  and  bed- 
sores, sometimes  over  the  sacrum  and  heels,  but  most  frequently  upon 


240  NUTRITION. 

the  occiput.  Occasionally  there  is  seen  a  reflex  spasm  of  the  muscles  of 
the  neck;,  producing  a  marked  opisthotonus,  which  may  last  for  several 
days  or  weeks. 

The  course  of  the  disease  in  most  cases  is  steadily  downward.  It  may 
be  cut  short  at  any  time  by  acute  disease.  Frequently  these  infants  die. 
suddenly  when  apparently  they  have  been  as  well  as  for  several  weeks. 
In  many  instances  the  autopsy  reveals  no  explanation  of  the  sudden 
death;  but  in  other  cases  it  may  be  due  to  the  regurgitation  of  food, 
and  its  aspiration  into  the  larynx,  the  patient  being  too  weak  to 
cough.  Earely,  death  occurs  from  convulsions.  In  summer,  these  chil- 
dren wilt  with  the  first  days  of  very  hot  weather,  and  die  often  in  a 
few  hours  from  a  slight  functional  derangement  of  the  stomach  and 
bowels. 

Diagnosis. — ISTo  sharp  line  can  be  drawn  between  marasmus  and  mal- 
nutrition. In  the  wasting  which  follows  chronic  disease  of  the  stomach 
and  intestines  there  is  usually  a  history  of  an  antecedent  acute  attack. 
The  chief  difficulty  in  the  diagnosis  of  marasmus  is  to  exclude  tubercu- 
losis. In  some  cases  a  differential  diagnosis  is  impossible  during  life. 
Not  infrequently  tuberculosis  is  found  at  autopsy,  even  in  infants  of  a 
few  months,  in  whom  there  have  been  no  symptoms  except  those  of 
marasmus.  Even  when  signs  in  the  lungs  are  present,  if  situated  pos- 
teriorly, they  may  be  due  either  to  tuberculosis  or  to  the  hypostatic 
pneumonia  which  is  present.  Signs  in  front  are  more  significant;  and 
consolidation  anteriorly  makes  tuberculosis  almost  certain.  In  simple 
wasting  there  is  often  a  history  that  the  child  was  in  splendid  condi- 
tion at  birth,  and  continued  so  until  it  was  weaned,  from  which  date 
it  had  gone  down  steadily.  In  tuberculosis  no  such  definite  cause  may 
be  present;  the  children  are  often  very  delicate  from  birth.  Simple 
wasting  is  so  much  more  common  that  the  chances  are  always  in  its 
favour. 

Prognosis. — This  depends  on  the  age  of  the  infant  and  the  extent 
and  duration  of  the  disease.  If  the  child  is  over  eight  months  old,  the 
chances  of  recovery  are  much  better  than  in  one  under  four  months,  for 
the  fact  that  it  has  lived  so  long  is  generally  evidence  of  pretty  strong 
vitality.  Very  young  infants  are  always  difficult  subjects  to  deal  with. 
They  go  down  more  rapidly,  and  build  up  more  slowly  than  those  who 
are  older.  In  most  other  circumstances  the  prognosis  is  much  worse 
in  cases  of  long  duration.  In  a  given  case  much  depends  upon  whether 
everything  possible  can  be  done  for  the  child :  whether  a  wet-nurse  can 
be  secured  or  artificial  feeding  done  in  the  best  manner,  and  whether  the 
patient  can  have  the  benefit  of  the  best  surroundings,  in  the  country  in 
summer  and  in  winter  a  warm  climate  where  it  can  be  kept  out  of  doors 
the  greater  part  of  the  time.  In  institutions  cases  under  four  months  old 
are  usually  hopeless.    Of  those  over  eight  months  quite  a  proportion  can 


MARASMUS.  241 

be  saved  by  proper  treatment,  even  though  the  body-weight  is  reduced  to 
eight  or  nine  pounds.  When  recovery  occurs  it  may  be  complete,  and 
the  child  at  three  years  may  be  as  vigorous  as  any  child  of  its  age.  All 
these  statements  refer  only  to  cases  of  simple  marasmus.  The  presence 
of  organic  disease  puts  the  case  into  another  category. 

Treatment. — The  most  important  is  that  which  relates  to  prophy- 
laxis. This,  for  large  cities,  may  be  summed  up  in  a  single  sentence : 
Give  the  poor  the  opportunity  to  obtain  pure  cow's  milk  and  teach 
them  how  to  feed  it  to  young  infants,  and  at  the  same  time  give  ample 
opportunities  for  obtaining  fresh  air.  In  institutions  the  most  impor- 
tant thing  is  to  give  adequate  air-space  for  each  child.  Often  only  four 
or  five  hundred  cubic  feet  are  allowed,  when  one  thousand  are  necessary, 
even  with  the  best  ventilation.  Children  should  be  changed  from  one 
apartment  to  another  and  opportunity  given  for  thorough  airing,  and 
there  should  be  perfect  ventilation,  not  only  in  the  daytime  but  at 
night. 

As  far  as  possible,  wet-nurses  should  be  obtained  if  the  infants  are 
under  four  months  old.  For  these  very  young  patients  success  by  arti- 
ficial feeding  is  generally  impossible.  With  those  of  six  months  or  over, 
good  artificial  feeding  is  very  frequently  successful.  In  modifying  cow's 
milk  for  these  cases  the  formulas  most  likely  to  agree  are  those  with  low 
fat,  low  proteids — partially  peptonized  in  many  cases — and  relatively 
high  sugar.  Further  suggestions  will  be  found  in  the  chapter  on  Feed- 
ing in  Difficult  Cases.  In  institutions  we  seldom  succeed  without  wet- 
nurses. 

For  very  young  infants,  with  a  temperature  which  is  habitually  sub- 
normal, the  incubator  may  be  used.  If  this  is  impossible,  children 
should  be  rubbed  with  oil,  rolled  in  cotton,  and  surrounded  with  hot- 
water  bags  or  bottles.  The  general  management  should  be  much  the 
same  as  described  in  the  chapter  on  Malnutrition.  At  least  once  every 
day — by  means  of  spanking,  mild  flagellation,  or,  better,  by  the  alternate 
use  of  the  hot  and  cold  baths — children  should  be  made  to  cry  vigorously, 
in  order  to  insure  proper  expansion  of  the  lungs.  They  require  no 
drugs,  but  a  great  deal  of  careful  nursing. 


24:2  NUTRITION. 


CHAPTEE    VI. 

DISEASES  DUE  TO  FAULTY  NUTRITION. 

The  diseases  due  to  faulty  nutrition  are  numerous.  There  are  two, 
however,  which  have  been  so  clearly  shown  to  originate  in  this  way  that 
they  may  be  put  in  a  class  by  themselves.  These  are  scorbutus  and 
rickets.  The  prevailing  opinion  of  the  medical  profession  is  that  both 
of  these  are  essentially  "  food-diseases."  The  purpose  of  considering 
them  in  connection  with  the  disturbances  of  nutrition  is  to  emphasize 
this  relationship. 

SCORBUTUS  (SCURVY). 

Scorbutus  is  a  constitutional  disease,  due  to  some  prolonged  error  in 
diet.  It  is  characterized  by  spongy,  bleeding  gums,  swellings  and  ecchy- 
moses  about  the  joints,  especially  the  knee  and  ankle,  haemorrhages  from 
the  nose,  and  occasionally  from  other  mucous  membranes,  extreme  hy- 
persesthesia,  and  often  pseudo-paralysis  of  the  lower  extremities.  Added 
to  these  local  symptoms  there  is  usually  a  general  cachexia  with  marked 
anaemia.  While  scorbutus  and  rickets  are  very  frequently  associated, 
they  are  not  necessarily  connected,  and  can  hardly  be  considered  as  dif- 
ferent forms  of  the  same  disease ;  although  cases  of  scorbutus  have  been 
described  in  older  writings  under  the  title  of  Acute  Eickets.  In  Ger- 
many it  is  known  as  Barlow's  disease. 

For  the  statistical  matter  here  presented  I  am  indebted  to  the  report 
of  the  American  Psediatric  Society's  Collective  Investigation  of  Infantile 
Scurvy  in  1898,  embracing  379  cases,  reported  by  138  observers.  Of 
these,  31  cases  were  from  my  own  practice. 

Etiolog-y. — Age  is  an  important  factor;  more  than  four-fifths  of  the 
cases  occur  between  the  sixth  and  the  fifteenth  months,  and  half  of 
them  between  the  seventh  and  the  tenth  months.  Scurvy  has  been  seen 
in  infants  under  a  month  old.  The  great  majority  of  the  cases  reported 
have  been  observed  in  private  practice,  often  in  the  best  surroundings. 
Previous  disease  is  not  a  factor  of  much  importance.  Most  of  the^  chil- 
dren attacked  have  been  in  good  health  up  to  the  development  of 
scurv5^  In  about  one-fourth  of  the  number  some  previous  derangement 
of  the  digestive  tract  has  existed. 

The  only  etiological  factor  yet  known  to  bear  any  constant  relation 
to  the  production  of  scurvy  is  diet.  The  important  facts  regarding 
the  previous  diet  brought  out  by  the  Society's  investigation  are  as 
follows: 


Previous  food  ■{ 


SCORBUTUS. 

'  Breast-milk in    12  cases  ; 

alone  in  10 

Raw  cow's  milk "       5     " 

"      "     4 

Pasteurized  milk "     20     " 

"      "  16 

Condensed  milk "     60     " 

"      "  32 

Sterilized  milk "   107     " 

"      "  68 

.  Proprietary  infant-foods  "   214  cases. 

243 


This  table  shows  that  while  scurvy  may  occasionally  develop  with 
almost  any  variety  of  food,  three  stand  out  prominently — viz.,  pro- 
prietary infant-foods,  condensed  milk,  and  sterilized  milk.  In  all  of 
these  it  would  appear  that  something  needed  for  normal  healthy  nutri- 
tion is  wanting.  Scurvy  is  not  likely  to  follow  unless  an  improper  diet 
is  continued  for  a  long  period,  usually  several  months.  In  some  in- 
stances where  it  developed  in  nursing  infants,  the  nurse's  milk  has  been 
examined  and  found  totally  inadequate  to  the  needs  of  nutrition,  many 
of  the  children  having  exhibited  serious  disturbances  of  nutrition  before 
any  signs  of  scurvy  appeared. 

In  several  of  the  cases  reported  as  occurring  with  a  diet  of  raw  or 
pasteurized  milk  it  is  certain  that  the  milk  formula  used  was  at  fault, 
the  most  common  condition  being  low  proteids.  Several  cases  have  come 
under  my  personal  observation  where  children  had  been  kept  for  four  or 
five  months  upon  percentages  which  should  have  been  continued  only  a 
few  weeks.  However,  I  have  seen  at  least  three  cases  of  scurvy  which 
developed  while  taking  pasteurized  milk  where  no  such  explanation  was 
possible,  and  the  heating  (167°  F.  for  thirty  minutes)  seemed  to  be  the 
cause.  The  number  of  cases  occurring  while  upon  a  diet  of  sterilized 
milk  (usually  heated  to  212°  F.  for  one  hour)  is  so  large  that  we  are 
driven  to  the  conclusion  that  the  heating  alone  was  the  cause,  especially 
since  prompt  recovery  has  frequently  followed  when  no  other  change  was 
made  than  to  discontinue  the  heating.  These  facts  show  that  steril- 
ized milk  should  always  be  prescribed  with  caution,  its  effects  watched, 
and  patients  warned  of  its  possible  danger;  it  should  not  be  continued 
as  the  sole  diet  for  long  periods. 

No  one  fact  in  the  etiology  of  scurvy  is  better  established  than  its 
development  after  the  prolonged  use  of  condensed  milk  or  the  proprie- 
tary infant-foods.  In  this  respect,  as  with  reference  to  sterilized  milk, 
my  personal  experience,  including  now  upward  of  sixty  cases  of  scurvy, 
coincides  with  the  findings  of  the  Society's  report. 

While  it  may  be  regarded  as  established  that  the  cause  of  scurvy  is 
dietetic,  no  single  dietetic  error  can  be  held  responsible  for  the  disease. 
At  present  it  seems  impossible  to  go  further  than  to  say  that  something 
necessary  to  normal  nutrition  is  lacking  in  the  food.  None  of  the  the- 
ories yet  advanced  in  explanation  of  how  diet  causes  scurvy  is  wholly 
satisfactory. 

Lesions. — The  most  marked  effects  of  scurvy  are  seen  in  the  bones, 
blood-vessels,  and  the  blood.    The  number  of  recorded  autopsies  is  not 


244  NUTRITION. 

yet  largG;,  only  six  being  included  in  the  Society's  report.  I  have 
myself  had  the  opportunity  of  making  examinations  in  three  cases. 
The  findings  are  remarkably  uniform,  but  represent,  of  course,  the  ex- 
treme results  of  the  disease.  The  most  striking  lesion  is  subperiosteal 
hgemorrhage,  which  is  practically  constant  and  may  occur  almost  any- 
where in  the  body,  but  affects  chiefly  the  bones  of  the  lower  extremities  ;. 
it  is  often  very  extensive,  and  may  reach  from  the  knee  to  the  great 
trochanter,  or  from  the  ankle  nearly  to  the  knee.  Extravasations  may 
also  be  found  between  the  muscles,  and  blood  may  infiltrate  the  cellular 
tissue  in  the  neighbourhood  of  the  joints.  Besides  these  lesions  result- 
ing from  hsemorrhagic  periostitis  the  bone  itself  may  be  affected.  Sepa- 
ration of  the  epiphyses  from  the  shaft  of  some  of  the  long  bones,  gen- 
erally at  the  lower  end  of  the  femur  or  lower  end  of  the  tibia,  is  found 
in  most  of  the  fatal  cases.  Xotwithstanding  the  serious  lesions  near 
the  large  joints,  the  joints  themselves  are  usually  normal. 

The  minute  bone  changes  are  very  similar  to  those  of  rickets.  But 
there  are  also  differences  of  importance.  The  disposition  to  haemorrhage, 
which  is  altogether,  the  most  characteristic  feature  of  scurvy,  is  entirely 
wanting  in  rickets.  The  visceral  lesions  are  inconstant.  Those  most 
frequently  found  are  small  haemorrhages  beneath  the  pleura,  pericardi- 
um, and  peritonseum,  sometimes  into  the  various  organs,  also  broncho- 
pneumonia, and  nephritis.  There  may  be  small  extravasations  found 
upon  the  surface  of  any  of  the  mucous  membranes.  The  alterations  in 
the  blood-vessels  are  undoubtedly  an  important  factor  in  bringing  about 
the  disposition  to  hgemorrhage,  but  as  yet  they  have  been  very  imper- 
fectly studied.  The  changes  in  the  blood,  in  the  gums,  and  the  lesions  of 
the  skin  will  be  considered  with  the  symptoms. 

Symptoms. — In  most  cases  a  period  of  indisposition,  fretfulness,. 
pallor,  and  failing  nutrition  precedes  the  local  symptoms,  but  usually 
tenderness  of  the  legs  is  the  first  symptom  noticed.  In  the  beginning' 
this  is  occasional  and  so  slight  as  to  cause  the  infant  to  cry  only 
upon  handling.  Later  it  becomes  almost  constant  and  is  very  acute. 
At  first  this  soreness  is  not  very  definitely  localized,  but  is  generally 
more  marked  about  the  knees  and  ankles.  Some  swelling  may  be  no- 
ticed, often  just  above  the  ankle-joints.  Coincident  with  these  may  be- 
seen  the  changes  in  the  mouth.  The  gums  are  of  a  deep  purplish  colour,, 
swollen,  particularly  about  the  upper  central  incisors,  and  may  quite 
cover  the  teeth.  They  bleed  from  the  slightest  rubbing,  and  sometimes 
spontaneously.  The  child  becomes  fretful  and  cross,  sleeps  badly,  loses 
colour,  weight,  and  appetite.  It  may  become  quite  cachectic  in  appear- 
ance. All  these  symptoms  come  on  graduall}'',  often  with  periods  of  a 
few  days  in  which  apparent  improvement  is  seen.  Sometimes  they  may 
continue  for  several  weeks  without  making  any  perceptible  impression- 
upon  the  child's  previously  good  condition. 


SCORBUTUS.  245 

If  the  disease  is  recognised,  and  proper  treatment  instituted,  rapid 
improvement  follows,  with  complete  and  permanent  recovery.  If  not 
recognised,  and  the  faulty  diet  is  continued,  the  disease  advances  to  the 
more  severe  form.  The  tenderness  of  the  legs  becomes  exquisite,  so  that 
any  movement  or  even  the  slightest  touch  causes  the  child  to  scream 
with  pain  or  apprehension.  The  legs  often  lie  motionless,  and  no  vol- 
untary movement  can  be  excited  by  any  means.  Paralysis  is  often  sus- 
pected. The  disability  is  chiefly  owing  to  the  extreme  pain  which  mo- 
tion provokes,  but  may  depend  upon  epiphyseal  separation.  Small 
ecchymoses  are  frequently  seen  about  any  of  the  large  joints,  resembling 
the  ordinary  "  black-and-blue  "  spots,  and  these  often  confirm  the  opin- 
ion previously  formed  that  the  child  has  met  with  some  accident.  The 
swelling  near  the  joints,  particularly  the  knee,  may  be  so  great  that  the 
limb  is  nearly  twice  the  size  of  its  fellow.  The  mouth  symptoms  are 
usually  striking.  In  addition  to  spongy,  swollen,  bleeding  gums,  dark 
purplish  bags  may  be  seen  over  teeth  not  yet  through.  There  may  be 
bleeding  from  the  roof  of  the  mouth  or  from  the  pharynx.  The  pain  is 
sometimes  so  severe  as  seriously  to  interfere  with  taking  food;  there  is 
moderate  though  rarely  extreme  salivation.  Blood  may  be  vomited  or 
passed  with  the  faeces  or  the  urine.  In  the  severe  cases  the  stools 
are  rarely  normal,  more  or  less  catarrhal  colitis  usually  being  present. 
The  general  condition  is  one  of  grave  anaemia,  accompanied  by  a 
marked  cachexia  and  progressive  wasting.  The  child  cries  almost  con- 
stantly, sleeps  little,  and  is  truly  a  pitiable  object.  Slight  fever  is  often 
present  during  the  last  few  weeks.  Unless  recognised  and  the  cause 
removed,  the  condition  grows  steadily  worse,  the  symptoms  continuing 
until  death  occurs  either  by  a  slow  asthenia,  suddenly  from  heart  failure, 
or  from  some  intercurrent  disease,  such  as  broncho-pneumonia  or  acute 
gastro-enteritis.  The  duration  of  the  illness  in  the  fatal  cases  is  from 
two  to  four  months. 

The  onset  is  gradual  in  the  great  majority  of  the  cases,  the  earliest 
symptoms  noticed  in  the  order  of  frequency  being  pain  and  tenderness 
of  the  legs,  soreness  and  sponginess  of  the  gums,  disability,  antemia, 
cutaneous  haemorrhages,  and  very  rarely  heematuria. 

Pain  and  tenderness  are  very  prominent,  being  noted  in  95  per  cent 
of  the  Society's  cases ;  in  the  majority  they  were  present  only  on  motion 
or  handling.  The  location  of  the  pain  and  tenderness  in  184  cases  was 
as  follows:  Lower  extremities  alone,  133;  upper  extremities  alone,  2; 
lower  and  upper,  42;  lower  and  trunk,  7.  In  all  but  two  cases,  there- 
fore, the  lower  extremities  were  affected,  the  lower  part  of  the  thigh 
and  the  leg  just  above  the  ankle  being  the  usual  seat. 

Disability,  or  pseudo-paralysis,  is  a  very  common  symptom,  and  in 
all  severe  cases  a  constant  one.  It  exists  in  varying  degrees  from  the 
slight  disinclination  to  use  the  limb  to  complete  helplessness.    In  many 


246  NUTRITION. 

cases  it  is  more  marked  than  the  pain,  and  has  led  to  a  diagnosis  of 
poliomyelitis. 

Swellings  are  associated  with  pain  and  tenderness  in  most  of  the 
severe  cases.  They  are  most  marked  near  the  joints,  but  may  extend 
for  some  distance  along  the  shafts  of  the  bones.  In  nearly  all  cases  the 
location  is  the  lower  part  of  the  thigh  or  the  lower  part  of  the  leg,  and 
usually  of  both  sides.  Swellings  are  occasionally  seen  near  the  wrists, 
elbows,  shoulders,  and  hip- joints ;  in  rare  cases,  over  the  ribs,  scapula, 
or  ilium.  Eedness  is  not  generally  present,  but  the  parts  may  have  a 
dark  purplish  colour.  It  is  to  the  haemorrhage  that  both  the  swellings 
and  the  discoloration  are  chiefly  due. 

Protrusion  of  the  eyeball  is  present  in  about  10  per  cent  of  the 
cases ;  an  extreme  exophthalmus  is  sometimes  seen,  and  is  due  to  orbital 
haemorrhage. 

The  gums  are  affected  in  nearly  all  cases,  the  exceptions  being  those 
recognised  and  treated  early.  Haemorrhage  occurs  in  about  one-half  the 
cases,  and  frequently  there  is  ulceration  not  unlike  that  of  a  mercurial 
stomatitis.  It  is  rather  curious  that,  though  the  lower  teeth  are  cut  first, 
the  upper  gum  is  almost  always  most  affected,  and  in  the  milder  cases 
usually  alone  involved.  Of  45  cases  in  which  no  teeth  had  been  cut,  the 
gums  were  affected  in  34  and  normal  in  21.  This  is  sufficient  to  dis- 
prove the  old  opinion  that  the  gums  are  affected  only  when  teeth  have 
appeared.  The  severe  inflammation  and  ulceration  sometimes  seen 
seem  to  be  the  result  of  secondary  infection. 

Haemorrhages  beneath  the  skin  are  present  in  about  half  the  cases. 
They  are  rarely  extensive,  usually  multiple,  and  their  location  is  no 
doubt  often  determined  by  a  slight  traumatism.  Haemorrhages  from 
the  mucous  membranes  are  not  quite  so  frequent.  There  may  be  bleed- 
ing from  the  gums,  nose,  bowels,  kidneys,  and  rarely  from  the  stomach. 
Haemorrhages  in  most  cases  are  frequently  repeated,  but  seldom  profuse. 

Epiphyseal  separation  is  seen  only  in  very  severe  cases.  It  is  nearly 
always  either  of  the  lower  epiphysis  of  the  femur  or  the  tibia,  and  is 
often  bilateral.  The  separation  is  usually  caused  by  some  slight  injury, 
the  condition  of  the  bone  predisposing  to  this  occurrence.  In  a  case  of 
my  own  which  recovered,  rapid  union  occurred  under  anti-scorbutic  treat- 
ment. 

Anaemia  is  slight  in  the  early  stage,  but  steadily  increases  as  the 
disease  progresses.  Blood  examinations  show  great  reduction  of  the 
haemoglobin,  sometimes  to  35  or  40  per  cent ;  also  in  nearly  all  cases  a 
proportionate  reduction  of  the  red  cells.  Leucocytosis  and  poikilocytosis 
may  be  present. 

The  urine  contains  albumin  in  one-fourth  of  the  cases ;  in  nearly  half 
of  those  containing  albumin  casts  also  are  found.  In  rare  cases  haema- 
turia  has  been  the  flrst  symptom  noticed;  usually,  however,  it  occurs 
later,  and  is  seen  in  about  5  per  cent  of  the  patients. 


SCORBUTUS. 


247 


Evidences  of  general  malnutrition  are  present  in  all  advanced  cases, 
varying,  of  course,  greatly  in  degree.  In  a  few  infants  under  my  own 
observation  the  weight,  colour,  and  general  appearance  of  health  have 
continued  in  spite  of  very  decided  local  symptoms.  In  most  of  them 
the  impaired  nutrition  is  shown  by  loss  of  appetite,  occasional  attacks  of 
vomiting,  and  still  more  frequently  by  derangements  of  the  bowels,  which 
vary  from  slight  indigestion  to  a  serious  catarrhal  condition  of  both 
small  and  large  intestine.  It  is  with  the  latter  that  the  discharge  of 
blood  is  usually  seen. 

Association  with  Rickets. — In  the  Society's  investigation  great  pains 
were  taken  to  obtain  definite  and  accurate  data  regarding  this.  Of 
the  cases,  340  in  number,  in  which  this  point  was  noted,  symptoms  of 
rickets  were  present  in  152,  or  45  per  cent;  these  symptoms  were  re- 
corded as  slight  in  72;  marked  in  64;  and  not  specified  in  16.  In  the 
remainder  of  the  cases,  55  per  cent,  it  is  definitely  stated  that  symptoms 
of  rickets  were  absent.  It  is  also  stated  that  in  50  of  the  patients  which 
were  rachitic,  the  rickets  antedated  the  development  of  the  scurvy. 
From  these  facts  it  would  seem  to  be  pretty  well  established  that 
though  rickets  and  scurvy  have  points  of  resemblance,  such  as  the  age 
when  they  are  seen,  bony  changes,  dependence  on  defective  nutrition, 
etc.,  they  can  not  be  regarded  as  different  forms  of  the  same  disease. 
The  two  most  striking  characteristics  of  scurvy — viz.,  tendency  to  haem- 
orrhages and  prompt  curability  by  fresh  food  and  fruit  juices — have  no 
counterpart  in  rickets.  However,  their  coexistence  in  the  same  patient 
is  of  common  occurrence. 

Diagnosis. — The  disease  with  which  infantile  scurvy  is  most  fre- 
quently confounded  is  rheumatism.  In  fully  four-fifths  of  the  cases 
which  have  come  to  my  own  notice  this  has  been  the  previous  diagnosis. 
The  extreme  rarity  of  rheumatism  under  one  year  should  always  make 
one  cautious ;  pain  and  tenderness  of  the  legs  only,  should,  in  an  infant, 
invariably  suggest  scurvy  rather  than  rheumatism.  The  extreme  disa- 
bility has  often  led  to  a  diagnosis  of  poliomyelitis,  but  here  again  the 
acute  tenderness  should  set  one  right.  Many  cases  of  scurvy  come 
into  the  hands  of  the  orthopaedic  surgeon  with  a  diagnosis  of  joint  or 
spinal  disease.  Where  the  swelling  was  mainly  of  one  limb  I  have  twice 
known  a  diagnosis  of  malignant  disease  to  be  made,  from  the  cachexia, 
the  shape  of  the  swelling,  the  discoloration,  and  the  pain.  I  have  known 
two  cases  to  be  operated  upon  by  eminent  surgeons,  once  with  a  diag- 
nosis of  sarcoma  and  once  of  ostitis  of  both  tibiae.  Not  until  the  sub- 
periosteal haemorrhages  and  epiphyseal  separation  were  discovered  was 
the  nature  of  the  trouble  suspected. 

The  diagnosis  of  scurvy  seldom  presents  any  difficulties  to  one  who 
has  once  seen  a  case.  No  one  need  err  if  the  essential  features  of  the 
disease  are  kept  in  mind:  the  extreme  soreness  of  the  legs,  spongy. 


248  nutritio:n". 

swollen  glims,  swelling  near  the  large  joints,  a  tendency  to  hsenior- 
rhages,  and  usually  a  history  of  the  prolonged  use  of  some  proprietary 
infant-food,  of  sterilized  or  condensed  milk.  If  any  doubt  exists,  this 
will  be  removed  by  the  prompt  improvement  and  generally  rapid  cure 
following  an  anti-scorbutic  diet. 

Prognosis. — This  is  invariably  good  if  the  disease  is  recognised  early. 
Xo  patients  with  symptoms  so  serious  improve  with  such  marvellous 
rapidity  as  do  the  great  majority  of  those  with  scurv}"  under  proper 
management.  The  figures  of  the  Societ3''s  report  on  this  point  are 
interesting.  The  average  duration  of  the  disease  before  treatment  was 
begun  in  over  three  hundred  cases  was  somewhat  over  three  weeks.  In 
80  per  cent  striking  improvement  was  noticed  during  the  first  week  of 
treatment,  and  in  40  per  cent  within  three  days.  Over  two-thirds  of 
these  cases  were  well  within  three  weeks,  and  nearly  one-third  within 
one  week,  after  the  beginning  of  treatment. 

It  is  only  when  the  disease  is  of  long  standing,  when  the  malnutri- 
tion is  severe,  or  when  serious  complications,  usually  involving  the 
digestive  tract,  are  present  that  the  symptoms  persist  and  the  issue 
becomes  doubtful.  It  is  difficult  to  tell  what  the  exact  mortality  of 
scurvy  is.  Any  case  allowed  to  go  on  may  result  fatally.  The  3'Ounger 
the  infant  the  more  likely  is  this  to  occur.  I  have  seen  three  deaths 
in  about  sixty  cases.  Barlow's  early  article  included  thirt3-one  cases 
with  seven  deaths.  It  is  rare  that  scurvy  leaves  any  permanent  effects. 
Eecovery  is  not  only  rapid  but  complete.  Eelapses  are  extremely  rare 
and  have  been  observed  only  in  one  or  two  cases,  where  chronic  indiges- 
tion existed  of  so  extreme  a  character  that  proper  feeding  was  impossible. 
The  after-effects  are  usually  the  result  of  prolonged  malnutrition,  of 
which  the  attack  of  scurvy  was  only  one  manifestation. 

Treatment. — This  is  remarkably  simple — viz.,  to  discontinue  all  pro- 
prietary foods,  condensed  milk  or  sterilized  milk,  and  to  substitute  a 
diet  of  fresh  coVs  milk,  modified  to  suit  the  child's  digestion.  With 
this  treatment  alone  improvement  will  soon  begin  and  complete  recov- 
ery follow.  However,  the  addition  of  fresh  fruit  juice  is  of  the  greatest 
value,  and  when  it  is  given  improvement  is  much  more  rapid.  Hence 
it  should  always  be  combined  with  the  change  in  diet.  Orange  juice  is 
possibly  to  be  preferred,  but  the  juice  of  any  fresh  ripe  fruit  will  answer 
the  purpose.  From  half  an  ounce  to  four  ounces  a  day  may  be  given, 
best  in  divided  doses,  given  about  one  hour  before  the  milk-feeding. 
The  only  really  difficult  cases  to  manage  are  those  in  which  the  general 
condition  approaches  one  of  marasmus,  or  when  scurvy  is  accompanied 
by  marked  gastric  or  intestinal  disturbance.  When  an  intestinal  catarrh 
is  present,  with  the  bowels  moving  five  or  six  times  a  day,  one  may  hesi- 
tate to  give  the  fruit  juice  for  fear  of  increasing  these  symptoms.  In 
a  number  of  instances  I  have  seen  intestinal  symptoms,  which  had  re- 


RICKETS.  249 

•sisted  ordinary  measures,  immediately  improved  by  the  fruit  juice,  thus 
establishing  their  intimate  connection  with  the  scorbutic  condition. 

Other  things  of  value  are  fresh  beef  juice,  and  for  older  children 
fresh  vegetables,  especially  potato.  The  anaemia  and  malnutrition  call 
for  iron,  cod-liver  oil,  and  other  tonics,  which  should  be  given  after 
active  symptoms  of  the  disease  have  disappeared.  Infants  with  scurvy 
should  be  handled  as  little  as  possible,  and  should  be  particularly  pro- 
tected against  exposure  in  their  extremely  susceptible  condition. 


RICKETS  (RACHITIS). 

Eickets  is  a  chronic  disease  of  nutrition.  While  the  only  important 
anatomical  changes  are  found  in  the  bones,  it  is  not  to  be  regarded  as  a 
bone  disease  ;  but  as  a  very  complex  pathological  process  which  affects  the 
bones,  muscles,  ligaments,  mucous  membranes,  and  nearly  all  the  organs 
■of  the  body,  particularly  those  of  the  nervous  system.  It  occurs  esjjecially 
between  the  ages  of  six  months  and  two  years.  It  is  not  common  in  the 
•country,  but  is  exceedingly  frequent  in  most  large  cities.  While  not  a 
fatal  disease  per  se,  rickets  adds  very  greatly  to  the  danger  from  all  acute 
diseases  in  infancy,  and  even  to  some  degree  also  to  those  of  later  life. 
Under  proper  conditions  of  diet  and  hygiene  it  tends  to  spontaneous 
-recovery. 

Etiology. — The  essential  cause  of  rickets  is  dietetic,  although  hygienic 
influences  play  a  very  important  role  in  its  production.  While  it  seems 
to  be  demonstrated  that  diet  alone  may  produce  rickets,  nevertheless  this 
condition  is  much  more  easily  produced  when  there  are  also  unfavourable 
hygienic  surroundings.  Eickets  is  not  common  in  nursing  children  un- 
less lactation  be  unduly  prolonged,*  as,  for  examjsle,  where  nursing  is 
continued  for  fifteen  to  eighteen  months  without  other  food.  Arti- 
ficially-fed children  are  much  more  prone  to  the  disease,  especially  tliose 
who  are  badly  fed.  The  diet  in  these  cases  is  usually  very  deficient  in  fat, 
a^nd  often  at  the  same  time  in  proteids,  while  it  contains  an  excess  of  car- 
bohydrates. It  is  somewhat  difficult  to  separate  the  effects  which  these 
different  conditions  produce.  It  appears,  however,  that  the  most  impor- 
tant factor  is  a  great  deficiency  in  fat.  Eickets  is  exceedingly  common  in 
children  reared  upon  the  proprietary  foods,  nearly  all  of  which  are  very 
low  in  fat  and  contain  an  excess  of  carbohydrates.  It  is  also  common  in 
children  who  are  reared  upon  sweetened  condensed  milk,  and  for  precisely 
the  same  reason.  When  both  fat  and  proteids  are  low, 'rickets  is  more 
liable  to  result  than  when  only  the  fat  is  deficient. 

*  An  exception  to  this  statement  must  be  made  in  the  ease  of  Italian  children.  In 
this  class  as  observed  in  New  York  it  is  very  common  to  see  marked  rickets  in  those 
getting  nothing  but  the  breast. 


250  NUTRITION. 

Hygienic  surroundings  are  next  in  importance  to  diet.  Although,  as 
previously  stated,  rickets  is  essentially  a  disease  of  cities,  being  princi- 
pally seen  in  children  living  in  crowded  tenements  where  the  effects  of 
improper  food  are  most  strikingly  shown,  yet  even  here  the  disease  is  rare 
in  those  who  get  a  plentiful  supply  of  good  breast  milk. 

Aniynal  experiments. — Bland- Sutton  experimented,  in  the  Zoological 
Gardens,  London,  upon  lion  whelps.  Those  which  were  weaned  early  and 
fed  solely  upon  raw  meat  invariably  became  extremely  rachitic.  Two 
young  cubs,  fed  upon  rice,  biscuits,  and  raw  meat,  died  from  rickets. 
Two  young  monkeys,  upon  an  exclusively  vegetable  diet,  became  rachitic. 
To  the  young  lions  who  had  developed  rickets,  milk,  cod-liver  oil,  and 
pounded  bones  were  given  in  addition  to  the  meat,  and  in  three  months, 
although  the  hygienic  condition  of  the  animals  remained  unchanged,  all 
signs  of  rickets  had  disappeared.  Guerin  produced  typical  rickets  in 
puppies  which  were  kept  upon  a  meat  diet  for  four  or  five  months,  while 
others  of  the  same  litter,  which  were  suckled,  remained  in  good  health. 
Other  animal  experiments  by  various  observers  with  different  articles  of 
food  have  given  results  that  were  not  uniform.  It  seems,  however,  to  be 
pretty  positively  established,  that  wdthholding  milk  from  young  animals 
and  putting  them  upon  a  diet  of  meat,  vegetables,  or  starches  is  sufficient 
to  produce  rickets,  and  that  the  earlier  this  is  done  the  more  certain  is 
the  result.  This  may  occur  apart  from  any  change  in  the  hygienic  sur- 
roundings. These  animal  experiments  strengthen  the  opinion  above 
given,  that  the  essential  cause  of  rickets  is  improper  food,  and  that  the 
element  most  uniformly  lacking  is  fat. 

Distribution  of  rickets. — According  to  Palm,  the  disease  is  almost  un- 
known in  the  extreme  north — Greenland,  Iceland,  Xorway,  and  Den- 
mark. It  is  also  very  rare  in  China,  Japan,  Greece,  Turkey,  and  the 
southern  portions  of  Italy  and  Spain.  Its  greatest  frequency  is  in  the 
temperate  zone.  The  general  immunity  of  children  in  southern  latitudes 
appears  to  be  due  to  the  out-of-door  life,  and  the  almost  universal  custom 
of  maternal  nursing.  In  the  cities  of  America  no  race  is  exempt  from 
the  disease.  In  New  York  the  greatest  susceptibility  is  among  the  Xegroes 
and  the  Italians.  Extreme  cases  of  rickets  are  almost  invariably  in  one 
of  these  nationalities.  It  is  exceptional  to  see  in  a  dispensary  or  hospital 
a  child  of  either  of  these  races  who  does  not  show,  to  a  greater  or  less 
degree,  the  signs  of  rickets.  These  two  southern  races  seem  to  bear  very 
badly  the  climate  and  the  confined  life  of  the  northern  cities.  So  far  as 
my  observations  are  concerned,  there  is  no  peculiarity  in  the  food  of  these 
people  which  explains  the  prevalence  of  rickets  among  them,  and  this 
must  be  attributed  to  a  race  peculiarity.  In  the  country,  the  immunity 
from  rickets  is  due  partly  to  the  more  prevalent  custom  of  maternal  nurs- 
ing, and  partly  to  the  better  surroundings ;  the  increased  resistance  of  the 
children  rendering  them  much  less  susceptible  to  the  influences  of  bad 


RICKETS.  2ot 

feeding  than  those  of  the  cities.  In  Xew  York  among  dispensary  and 
hospital  patients,  rickets  is  exceedingly  common,  and  is  seen  in  all  na- 
tionalities, although  chiefly  in  the  foreign  elements  of  the  population. 

Heredity. — There  is  no  evidence  that  rickets  is  a  hereditary  disease. 
Any  cachexia  in  the  parents,  such  as  syphilis,  tuberculosis,  or  alcoholism, 
may,  however,  by  diminishing  the  child's  resistance,  be  a  predisposing 
cause  of  rickets.  The  later  children  in  a  family  are  more  likely  to  be 
affected  than  the  earlier  ones,  especially  when  the  interval  between  the 
pregnancies  has  been  short,  or  where  anything  else  has  caused  a  deterio- 
ration in  the  general  health  of  the  mother. 

Previous  disease. — Eickets  not  infrequently  develops  in  syphilitic 
children;  the  connection,  however,  seems  to  be  no  closer  than  with  any 
other  cachexia.  The  relation  of  rickets  to  other  diseases,  particularly 
to  those  of  the  digestive  tract,  is  very  much  less  intimate  than  one 
would  expect.  Acute  diseases  of  the  stomach  and  intestines  are  very 
frequently  followed  by  marasmus,  but  only  exceptionally  by  marked 
rickets.  There  is  no  sufficient  ground  for  believing  that  rickets  exerts 
any  protective  influence  against  tuberculosis,  as  has  been  asserted.  In 
fact  the  thoracic  deformity  of  rickets  may  be  a  predisposing  cause  to 
tuberculosis. 

Rickets  affects  both  sexes  with  equal  frequency.  The  symptoms  usu- 
ally manifest  themselves  between  the  sixth  and  fifteenth  months.  Con- 
genital and  late  rickets  will  be  considered  separately. 

Rickets  is  therefore  a  complex  disease  of  nutrition,  whose  exact 
pathology  has  not  yet  been  definitely  settled.  It  is  more  difficult  to 
believe  that  the  general  nutritive  disturbances  are  the  result  of  the  bone 
changes,  than  to  regard  both  as  having  a  common  origin.  Kassowitz 
regards  the  bone  changes  as  inflammatory,  excited  by  the  presence  of 
some  irritant.  The  irritant  has  been  believed  by  many  to  be  lactic  acid, 
originating  in  the  digestive  tract ;  but  the  evidence  in  support  of  this 
theory  is  not  conclusive.  It  is  very  doubtful  whether  the  process  is  as 
simple  as  the  formation  of  lactic  acid  in  the  intestine  and  its  circulation  in 
the  blood.  It  is,  however,  clear  that  it  is  something  which  interferes  with 
the  assimilation  of  the  lime  salts.  At  the  present  time,  the  disposition  is  to 
regard  rickets  as  a  disease  of  nutrition,  which  may  be  produced  in  animals 
by  certain  dietetic  changes.  In  infants,  it  seems  to  be  settled  that  it  may 
be  produced  by  similar  changes  in  diet,  aided  very  greatly,  however,  by 
unhygienic  surroundings.  The  effect  of  these  abnormal  conditions  is 
shown  upon  the  whole  organism,  but  the  only  constant  and  regular  ana- 
tomical changes  are  in  the  bones.  These  osseous  lesions  resemble  those 
of  chronic  inflammation.  Precisely  how  the  dietetic  and  other  causes 
produce  the  bone  changes  is  still  a  matter  of  speculation.  The  constancy 
of  bone  changes  in  rickets  gives  it  a  place  as  an  essential  disease,  and  not 
merely  a  form  of  malnutrition. 


252  NUTRITION. 

Lesions. — The  only  constant  and  characteristic  lesions  of  rickets  are 
found  in  the  bones.  It  is  still  a  matter  of  dispute  whether  these  bony 
changes  are  to  be  considered  as  inflammatory,  or  simply  as  the  result  of 
disordered  nutrition.  Disordered  nutrition  and  chronic  inflammation 
are  closely  allied,  and  it  really  makes  but  little  difference  which  view  is 
taken.  Occurring  at  a  time  when  the  growth  of  bone  is  so  rapid,  the 
effects  of  rickets  are  very  striking  and  very  serious. 

In  order  to  appreciate  how  the  bones  are  affected  by  rickets,  it  must  be 
remembered  that  the  long  bones  grow  in  length  by  the  production  of  bone 
in  the  cartilage  between  the  epiphysis  and  the  shaft ;  that  the  shaft  grows 
in  thickness  by  the  production  of  bone  beneath  the  inner  layer  of  the 
periosteum  ;  and  that  the  medullary  canal  is  continually  increasing  in 
size  by  the  absorption  of  the  inner  layers  of  the  bone.  In  rickets  there  is 
an  exaggerated  production  of  cartilage  at  the  epij^hysis,  and  excessive  cell- 
growth  beneath  the  periosteum,  while  the  process  of  ossification  in  these 
tissues  goes  forward  slowly  and  imperfectly,  or  is  entirely  arrested.  At 
the  same  time  the  absorption  of  the  medullary  layers  may  be  even  more 
rapid  than  normal.  In  health  the  growth  of  bone  in  length  is  much 
more  rapid  than  its  increase  in  diameter,  owing  to  the  greater  activity  of 
the  changes  taking  place  at  the  epiphysis ;  so,  in  rickets,  it  is  at  the 
extremities  of  the  long  bones  that  the  most  marked  changes  are  seen. 

One  of  the  most  striking  features  of  rachitic  bones  is  their  unnatural 
flexibility.  This  is  due  to  deficient  ossification  in  the  superficial  layers  of 
the  shaft  of  the  long  bones,  and  also  at  their  extremities.  Xormally, 
bone  contains  about  one  third  organic  and  two  thirds  inorganic  matter. 
In  marked  rickets  the  proportions  are  reversed,  the  bones  often  containing 
twice  as  much  organic  as  inorganic  matter.  Changes  are  seen  in  all  the 
long  bones,  but  all  are  not  affected  to  the  same  degree.  Sometimes  those 
most  affected  will  be  the  bones  of  the  leg,  sometimes  those  of  the  forearm, 
and  sometimes  the  ribs.    The  extent  varies  with  the  severity  of  the  j^rocess. 

There  are  characteristic  changes  in  form.  The  most  constant  is  en- 
largement of  the  epiphyses  of  all  the  long  bones.  This  is  most  strikingly 
seen  in  the  lower  extremities  of  the  radius  and  tibia.  The  enlargement 
may  be  so  marked  that  the  width  of  the  epiphysis  is  increased  by  one 
half.  All  the  sharp  angles,  borders,  and  prominences  of  the  bones  are 
rounded  off.  The  curvatures  of  rachitic  bones  are  more  fully  described 
under  the  head  of  Symptoms.  They  may  be  due  to  a  variety  of  causes. 
Some  are  simply  an  exaggeration  of  the  normal  curves,  much  increased 
by  the  swelling  of  the  epiphyses;  others  are  due  to  muscular  action,  to 
atmospheric  pressure,  to  some  unnatural  posture,  such  as  the  cross-legged 
position,  to  the  weight  of  the  limbs,  or  to  the  weight  of  the  body.  The 
principal  change  in  the  form  of  the  flat  bones  consists  in  the  production 
of  large  bosses  or  prominences  due  to  thickening  of  the  bone,  usually 
about  the  centre  of  ossification.    These  bosses  are  soft  and  spongy.    Frac- 


PLATE   IV. 


■rL>---X^^'-''' J^     '-'!'  ^, 


^i-d 


B 


*viS^'J^if3L*^ 


BoxE  IX  Rickets. 

Longitudinal  section  of  a  rib  at  the  junction  of  the  costal  cartilage,  in  a  severt 
case  of  rickets  (slightly  magnified).  C  =  costal  cartilage.  B  =  bone._ A  =  prohferatmg 
cartilao-e-zone,  which  'is  much  widened.  Between  the  hypertrophied  cartilage  cell- 
columns  (a)  making  up  this  proliferating  zone,  are  seen  medullary  spaces  (h)  contain- 
ing blood-vessels.  In  this  zone  lie  masses  of  bone  {c)  not  calcified.  1  he  calcification 
zone  is  almost  wanting,  onlv  scattered  islands  (d)  of  calcified  cartilage-cells  being  seen. 

Bevond  this  proliferating  zone  (A)  is  a  laver  of  bony  tissue  (B)  made  up  of  small 
bands' of  which  onlv  a  few  have  a  nucleus  containing  lime  ie).  These  nuclei  appear 
black.  The  bonv  bands  differ  both  in  form  and  arrangement  from  those  of  normal 
ossification.  Between  the  bonv  masses  are  medullary  spaces  which  appear  light  m  the 
illustration.  At  (q)  the  beginning  of  cartilage  proliferation  is  sejjn.  Above  this  zone 
the  cartilage  is  normal.  (From  Karg  and  bchmorl.) 


RICKETS.  253 

tures  are  not  uncommon.  The  bones  most  frequently  broken  are  tne 
radius  and  ulna  ;  next,  the  ckwicle  or  the  ribs.  The  fractures  are  usually 
of  the  green-stick  variety.  There  is  a  bending  of  the  outer  and  a  frac- 
ture of  the  inner  layers  of  the  shaft  of  a  long  bone.  This  results  in  more 
or  less  impaction,  and  is  usually  followed  by  the  production  of  consider- 
able callus.  The  epiphyseal  changes  result  in  arrested  growth  in  length, 
rachitic  bones  being  usually  much  shorter  than  normal.  Increased  vascu- 
larity is  seen  in  the  bosses  upon  the  flat  bones,  at  the  extremities  of  the 
long  bones  and  upon  stripping  the  periosteum  from  the  shaft. 

In  a  longitudinal  section  of  one  of  the  long  bones,  the  principal  change 
seen  at  the  extremity  is  that  the  cartilaginous  layer  which  unites  the  epi- 
physis and  the  shaft  is  very  much  enlarged,  both  in  width  and  thickness, 
the  latter  being  sometimes  four  or  five  times  the  normal.  This  cartilagi- 
nous area  is  of  a  bluish  colour,  rather  softer  than  normal  cartilage.  On  one 
side  it  blends  with  the  cartilage  of  the  epiphysis,  on  the  other  it  presents 
an  irregular  dentated  border,  and  in  it  the  calcified  areas  are  irregular  and 
scattered.  The  epiphyseal  centres  of  ossification  are  enlarged,  softer,  and 
more  vascular  than  normal,  thus  increasing  the  size  of  the  extremity  of 
the  bone.  In  the  shaft,  the  outer  layers  of  bone  are  thickened  and  soft, 
like  decalcified  bone,  the  deeper  parts  being  firmer,  while  the  deepest 
layers  may  be  completely  ossified.  The  medullary  canal  is  much  more  vas- 
,cular  than  normal,  its  contents  resembling  granulation  tissue.  Toward 
the  extremities  the  trabecular  spaces  are  much  increased  in  size,  so  that 
the  bone  appears  unnaturally  porous.  On  vertical  section  of  one  of  the 
flat  bones — e.  g.,  one  of  the  bosses  uj)on  the  skull — there  is  found  a  great 
increase  in  the  size  of  the  trabecular  spaces.  The  bosses  are  made  up  of 
large  spongy  masses,  so  soft  as  to  be  easily  indented  with  the  finger,  and 
on  pressure  there  oozes  blood  and  serum  in  a  considerable  quantity. 

Microscopical  clianges.-^Ki  the  junction  of  bone  and  cartilage  at  the 
extremity  of  one  of  the  long  bones,  there  are  readily  traced  in  normal 
bone  (Fig.  42)  several  distinct  zones.  Next  to  the  hyaline  cartilage  {a) 
there  is  a  proliferating  zone  {h),  made  up  of  cartilage  cells  and  matrix, 
the  cells  having  no  orderly  arrangement.  Xext  to  this  is  a  columnar 
zone  (c,  d),  in  which  the  cartilage  cells  are  arranged  in  regular  rows  or 
■columns.  Adjoining  this  is  the  zone  of  calcification  (e) ;  and,  finally,  there 
is  the  zone  of  ossification  (/,  ()),  where  true  bone  is  formed. 

In  rickets  (Plate  IV  and  Fig.  43),  the  principal  changes  are  seen  in  the 
proliferating  and  columnar  zones.  The  proliferating  zone  (Fig.  43,  b)  is 
increased  chiefly  by  the  multiplication  of  new  cells ;  it  is  also  more  vas- 
-cular  than  normal.  The  columnar  zone  (c)  is  aflfected  in  a  similar  way 
and  to  a  much  greater  degree.  It  is  less  regular  in  its  formation,  and, 
instead  of  containing  but  few  vessels,  it  shows  large  vascular  channels, 
sometimes  surrounded  by  medullary  spaces  {e).  The  ossification  zone, 
instead  of  being  narrow  and  sharply  outlined,  is  broad  and  very  irregular. 
18 


254 


NUTRITION. 


Calcified  areas  (/)  may  be  seen  in  the  midst  of  regions  which  are  carti- 
laginous, while  masses  of  cartilage  (A)  occupy  areas  which  should  be  com- 
pletely calcified.  In  some  places  there  appears  to  be  a  transformation  of 
cartilage  into  bone-tissue  of  an  inferior  sort  by  a  direct  or  metaplastic 
process.  In  the  shaft  there  is  seen  more  or  less  thickening,  and  an  in- 
creased vascularity  of  the  periosteum.     Beneath  the  inner  layer  there  is 


Fig.  42. — Section  through  ossification  zone  of  normal  bone  (Zie<rler').  a,  hyaline  cartilage;  b^ 
zone  of  beginning  cartilage  proliferation  ;  c,  columns  of  cartilage  cells  ;  </,  columns  of  hyper- 
trophic cartilage;  e,  zone  ot  temporary  calcification;/,  zone  of  primary  medullary  spaces; 
g,  zone  of  primary  bone  formation ;  A,  fully  developed  spongy  bone ;  i,  blood-vessels ;  k^ 
layer  of  osteoblasts. 


excessive  cell-proliferation,  while  calcification  of  this  new  tissue  is  imper- 
fect or  absent,  and  instead  of  hard,  compact  bone,  we  find  irregular,  spongy 
masses.  In  the  spongy  bone  there  is  considerable  thickening,  with  an 
erosion  of  bony  trabeculae,  which  results  in  the  formation  of  large  medul- 
lary spaces  filled  with  blood-vessels  and  connective  tissue  rich  in  cells. 


RICKETS. 


255 


Ter7ninatio7i  of  the  racliitic  process. — After  a  variable  time,  usually 
from  three  to  fifteen  months,  the  active  proliferative  process  going  on  in 
the  cartilage  and  beneath  the  periosteum  ceases,  and  is  gradually  replaced 


.  43. — Racliitic  bone  (Zie<,'lcr).  Loniritudinul  section  throui,''))  ossification  zone  of  the  upper 
diajihysis  of  the  femur  of  a  moderately  racliitic  cliikl  one  year  old  (liiL'hlv  majmified).  a, 
unchanged  hyaline  cartihif^e  ;  A,  be^zinninj,'  cartihiire  proliferation;  c,  coJimi'ns  of  jirolifcrated 
cartilage  cells;  d,  columns  of  proliferated  hypertrophic  cells:  e,  nietlullary  spaces  contain- 
ing blood-vessels  lying  within  the  cartilage ;./',  calcified  cartilage;  j/,  btiny  tissue;  //.re- 
mains of  cartilage  within  the  bony  tissue ;  i,  point  of  uncalcified  bony  tissue ;  i;  calcified 
bony  tissue. 


by  ossification.  The  bone  becomes  less  vascular,  and  a  ra])id  formation 
of  bone  takes  place  in  the  normal  way.  In  addition,  there  is  in  some 
places  a  direct  transformation  of  cartilage  into  bone.     Condensation  and 


256  NUTRITION. 

contraction  take  place  in  the  spongy  masses  of  bone.  As  the  result  of 
this,  the  affected  bone  may  become  even  harder  than  normal ;  often  it  is 
ivory-like.     Its  structure,  however,  is  never  quite  like  that  of  healthy  bone. 

In  the  long  bones  the  epiphyseal  swellings  slowly  diminish,  and  may 
quite  disappear ;  the  slighter  curvatures  may  be  entirely  overcome,  and 
the  greater  ones  much  lessened.  The  beading  of  the  ribs  becomes  almost 
imperceptible  ;  the  bosses  upon  the  skull  shrink  very  markedly,  and  may 
leave  scarcely  a  trace  of  their  existence.  In  most  cases  the  active  process 
in  rickets  has  come  to  an  end  by  the  time  the  child  is  two  and  a  half  years 
old,  often  at  two  years. 

Visceral  lesions. — These  are  not  infrequent,  but  are  not  essential  to 
rickets.  In  the  lungs  they  are  due  to  deformities  of  the  chest  wall  and 
to  complications.  Beneath  the  deep  lateral  furrows  which  are  so  common, 
there  is  found  a  part  of  the  lung  in  a  state  of  more  or  less  complete  col- 
lapse. This  is  accompanied  by  em^ohysema  of  the  portion  just  anterior  to 
it.  Acute  and  chronic  bronchitis  and  broncho-pneumonia  are  exceed- 
ingly frequent.  A  low  grade  of  chronic  catarrhal  inflammation  of  the 
stomach  and  intestines  is  common,  and  is  often  associated  with  dilata- 
tion of  these  organs.  The  spleen  is  enlarged  in  most  cases  during  the 
period  of  active  symptoms.  This  is  usually  moderate  in  degree,  although 
marked  enlargement  is  not  at  all  rare.  The  swelling  of  the  spleen  is  due 
to  simple  hyjjerplasia,  and  not  to  amyloid  degeneration.  Enlargement 
of  the  liver  is  less  frequent,  and  may  occur  with  or  without  that  of 
the  spleen.  There  are  no  constant  changes  in  the  structure  of  these 
organs.  The  lymph  nodes  (lymphatic  glands)  are  frequently  enlarged. 
Eachitic  patients  are  more  prone  to  these  swellings  than  are  other  chil- 
dren. They  are  due  to  simple  hyperplasia,  and  have  no  close  connection 
with  rickets.  Cerebral  changes  are  rare,  and  those  described  are  rather 
of  accidental  occurrence  than  dependent  upon  the  rachitic  process.  As 
stated  under  Symptoms,  enlargement  of  the  head  is  usually  due  to  thick- 
ening of  the  cranial  bones.  Although  hydrocephalus  is  occasionally  seen, 
it  is  extremely  doubtful  whether  it  is  more  frequent  than  in  patients  not 
rachitic.  Hypertrophy  of  the  brain  has  been  described  in  connection 
with  rickets,  but  as  yet  this  does  not  seem  to  be  established  by  sufficient 
pathological  evidence.  The  muscles  are  flabby  from  imperfect  nutrition, 
and  sometimes  atrophied  from  disuse,  but  no  essential  anatomical  changes 
have  been  demonstrated  in  them. 

Symptoms. — A  well-marked  case  of  rickets  makes  a  striking  picture 
(Plate  V),  and  one  not  easily  mistaken.  There  are  seen  the  large  head, 
beaded  ribs,  narrow  chest,  prominent  abdomen,  symmetrical  swellings  of 
the  epiphyses  of  the  wrists  and  ankles,  and  curvatures  of  the  extremities. 
The  beginning  of  symptoms  is  nearly  always  insidious,  and  the  patient 
does  not  usually  come  under  observation  until  they  have  existed  for  sev- 
eral weeks,  often  several  months. 


PLATE  V. 


Typical  Rickets. 

Showinr^  the  \arge  head,  narrow  chest,  prominent  abdomen,  marked  enlarprement 
of  the  epiphyses  at  the  wrists  and  ankles.  There  are  also  curvatures  of  the  forearms 
and  legs  which  are  not  so  well  shown. 

The  patient  a  child  two  and  a  half  years  old. 


RICKETS.  257 

Early  Symptoms. — The  most  constant  early  symptoms  are  sweating 
of  the  head,  extreme  restlessness  at  night,  constipation,  beading  of  the 
ribs,  and  cranio-tabes.  The  head-sweating  is  rarely  absent,  and  may  con- 
tinue for  several  months.  It  is  especially  profuse  during  sleep,  the  per- 
spiration standing  out  in  large  drops  upon  the  forehead,  often  being 
sufficient  to  wet  the  pillow.  This  is  one  of  the  causes  of  the  nasal  and 
bronchial  catarrhs  so  common  in  rachitic  infants.  There  is  marked  rest- 
lessness during  sleep  :  the  children  tossing  about  the  crib,  kicking  off  the 
clothes,  and  never  having  the  quiet,  natural  slumber  of  healthy  infants. 
This  may  be  due  to  many  causes,  but  when  persistent  and  associated  with 
marked  perspiration  of  the  head,  rickets  should  be  suspected.  Constipa- 
tion is  frequently  seen  as  an  early  symptom,  although  it  is  more  marked 
in  the  later  stages  of  the  disease. 

The  beading  of  the  ribs  is  almost  invariably  the  first  appreciable 
change  in  the  bones,  and  it  is  well-nigh  constant.  This  forms  the  so- 
called  "  rachitic  rosary,"  consisting  of  nodules  at  the  line  of  junction  of 
the  costal  cartilages  and  the  ribs.  It  may  be  slight,  or  there  may  be  a 
row  of  knobs  as  large  as  small  marbles.  In  many  cases  with  marked 
thoracic  deformity,  little  or  no  beading  of  the  ribs  is  seen  externally, 
although  at  autopsy  it  is  found  to  be  very  marked  upon  the  internal  sur- 
face of  the  chest  (Plate  VI).  Beading  of  the  ribs  was  noted  in  all  but 
two  of  one  hundred  and  forty-four  successive  cases  of  rickets,  at  the  time 
of  the  first  examination.  In  infants  under  six  months  there  may  be 
found  soft  spots  in  the  cranium,  usually  over  the  occiiDital  or  posterior 
portions  of  the  parietal  bones.  These  are  from  one  fourth  to  one  inch  in 
diameter,  and  there  are  usually  several  of  them  present.  By  pressure  with 
the  finger  they  give  a  sort  of  parchment-crackling  sensation.  This  condi- 
tion is  known  as  cranio-tabes.  Cranio-tabes  is  believed  to  be  more  fre- 
quent w^hen  syphilis  is  associated  with  rickets,  and  it  is  seen  also  in 
syphilitic  cases  which  are  not  rachitic.  A  rachitic  cachexia  is  not  usu- 
ally present  until  the  symptoms  have  existed  for  several  months,  and  in 
many  cases  it  is  not  seen  at  all. 

Deformities. — The  deformities  of  rickets  are  almost  invariably  sym- 
metrical in  character,  and  usually  numerous.  In  extreme  cases  almost 
every  bone  in  the  body  is  affected. 

Head. — This  usually  appears  to  be  too  large,  and  although  it  may  not 
be  greater  in  circumference  than  that  of  a  healthy  child  of  the  same  age, 
it  is  out  of  proportion  to  the  rest  of  the  body.  In  marked  cases  the 
increase  in  circumference  may  be  one  or  two  inches.  The  enlargement 
is  chiefly  due  to  thickening  of  the  cranial  l)()ni's.  In  one  case  witli 
marked  deformity,  I  found  the  skull  over  the  parietal  bones  half  an  inch 
in  thickness  (Fig.  44).  This  thickening  diminishes  Avith  recovery,  but 
in  most  cases  the  head  remains  througliout  life  larger  than  it  should 
be.    The  shape  of  the  rachitic  head  is  somewhat  square  (Fig.  45),  owing 


258  NUTRITION. 

to  the  formation  of  large  bosses  over  the  parietal  and  frontal  eminences. 
It  is  flattened  at  the  occiput  from  pressure,  and  flattened  also  at  the  ver- 
tex. In  extreme  cases,  the  prominences  upon  the  frontal  and  parietal 
bones  may  be  so  great  as  to  produce  quite  a  marked  furrow  along  the  line 
of  the  sagittal  and  frontal  sutures,  and  one  at  right  angles  to  this  along 
the  coronal  suture  (Fig.  46).  This  condition  gives  unusual  prominence 
to  the  forehead.  Marked  deformity  of  the  head  has  been  observed  in 
thirty-three  per  cent  of  my  cases.     The  sutures  may  remain  open  for  an 


Fig.  44.— Eachitic  skull  from  colored  child  two  years  old,  horizontal  section,  inner  surface ; 
showing  thickening  of  the  bones,  especially  the  frontal,  and  open  fontanel. 

unnatural  time,  occasionally  until  the  end  of  the  first  year.  The  fontanel 
is  late  in  closing,  being  frequently  found  open  at  two  and  a  half,  and 
sometimes  even  at  three  years.  Often  at  eighteen  or  twenty  months 
the  fontanel  is  two  inches  in  diameter.  The  veins  of  the  scalp  are 
often  prominent,  and  the  hair  is  frequently  worn  from  the  occiput, 
owing  to  restlessness  during  sleep.  Occasionally  rickets  and  hydrocepha- 
lus are  associated,  but  the  latter  is  the  least  frequent  of  all  causes  of  the 
enlargement  of  the  head. 


PLATE  VI. 


Deformity  of  the  Chest  ix  Severe  Kickets. 

In  the  upper  picture,  giving  the  external  view,  is  shown  a  deep  oblique  furrow  at 
the  junction  of  the  ribs  and  costal  cartilages,  these  meeting  at  an  acute  angle. 

In  the  lower  picture  the  ribs  have  been  separated  from  tlie  spine  and  spread  open, 
showing  the  same  deformity  as  it  appears  from  within,  looking  forwards. 

From  a  coloured  child  ten  months  old. 


RICKETS. 


259 


Chest. — Beading  of  the  ribs  has  already  been  mentioned.  This  is  the 
most  characteristic  feature,  but  in  the  majority  of  cases  there  are,  in 
addition,  lateral  depressions  over 
the  lower  third  of  the  chest,  at 
the  line  of  junction  of  the  car- 
tilages with  the  ribs,  with  ever- 
sion  of  the  lower  borders  of  the 
ribs.  In  severe  cases  these  de- 
pressions or  furrows  are  so  great 
as  to  cause  serious  deformity 
(Plate  VI).  Usually  there  is  a 
great  diminution  in  the  trans- 
verse and  an  increase  in  the 
antero-posterior  diameter  of  the 
chest.  Fig.  47  shows  the  out- 
line of  the  chest  of  a  rachitic 
child  of  two  years,  compared 
with  that  of  a  healthy  child  of 
the  same  age.  Another  frequent 
deformity  is  the  "  rachitic  gir- 
dle," which  consists  in  a  trans- 
verse depression  about  two 
inches  broad,  extending  from 
one  side  of  the  chest  to  the 
other,  just  above  its  lower  bor- 
der. A  less  frequent  deformity  is  the  "  funnel  chest,"  a  deep  central  de- 
pression over  the  ensiform  cartilage.  This  is  sometimes  nearly  an  inch 
and  a  half  in  depth.  Marked  thoracic  deformity  was  seen  in  twenty  per 
cent  of  my  cases,  but  in  only  a  small  proportion  was  the  chest  normal. 

The  factors  in  the  production  of  the  thoracic  deformity  are  atmos- 
pheric pressure  and  soft  chest  walls,  these  sinking  in  at  the  point  where 
they  have  least  resistance,  viz.,  at  the  junction  of  the  costal  cartilages  and 
the  ribs.  When  there  is  any  obstruction  to  the  entrance  of  air,  as  with 
bronchitis,  hypertrophied  tonsils,  or  adenoid  growths  of  the  pharynx,  the 
thoracic  deformities  are  exaggerated.  Irregular  chest  deformities  depend 
upon  the  coexistence  of  pathological  conditions  in  the  lungs.  Pigeon- 
breast  is  occasionally  seen,  but  it  is  doubtful  if  this  depends  upon  rickets 
alone. 

Spine. — In  very  many  of  the  milder  cases  this  is  normal.  The  most 
characteristic  deformity  consists  in  a  posterior  curve  (kyphosis),  which 
is  a  general  one,  usually  extending  from  the  mid-dorsal  to  the  sacral  re- 
gion. This  existed  in  forty-six  per  cent  of  my  cases.  In  the  early  part 
of  the  disease  it  disappears  entirely  on  suspending  the  child,  or  making 
extension  upon  the  extremities ;  but  in  cases  of  long  standing  it  may  not 


Fig.  45. — Kachitic  head;  Italian  child  two  years  old; 
square,  prominent  forehead  and  flat  verte.\. 


260  NUTRITION. 

disappear  entirely  by  these  tests.  Very  much  less  frequently  there  is  seen 
a  rotary  curvature.  This,  in  my  experience,  has  been  more  frequently  to 
the  left  side  than  to  the  right — the  opposite  of  the  common  form  of  lat' 


Fig.  46.— Rachitic  skull  from  child  one  year  old,  showing  frontal  and  parietal  bosses  and  wide 

fontanel. 

eral  curvature  seen  in  young  girls.     Marked  lateral  curvature  in  children 
under  three  years  is  usually  rachitic. 

The  clavicle  is  affected   only  in  severe  cases.     The  usual  deformity 
consists  in  an  exaggeration  of  the  anterior  curve  at  the  inner  third  of  the 


Fig.  47.— a,  horizontal  section  of  a  rachitic  chest,  child  two  years  old,  showing  lateral  furrowsv 
B,  section  of  chest  of  healthy  child  of  the  same  age. 

bone,  which  is  somewhat  shortened  and  its  extremities  enlarged.     It  is 
not  infrequently  the  seat  of  green-stick  fracture. 


RICKETS. 


261 


Deformities  of  the  pelvis  belong  to  obstetrics  rather  than  to  pediatrics. 
The  most  common  rachitic  change  is  a  diminution  of  the  antero-posterior 
diameter  and  a  narrowing  of  the  subpubic  arch.  Irregular  deformities 
sometimes  described  as  "  crumpling  of  the  pelvis,"  are  not  infrequent. 

Extremities. — Deformities  of  the  upper  extremities  are  usually  sym- 
metrical. The  humerus  is  affected  only  in  severe  cases.  It  has  a  forward 
and  outward  curve,  although  rarely  a  very  marked  one.  Both  the  epi- 
physes are  enlarged,  although  the  upper  one  can  not  often  be  made  out 
unless  the  child  is  very  thin.  The  radius  and  ulna  are  frequently  affected. 
They  present  a  convexity  upon  their  extensor  surfaces  (Plate  V),  which  in 
some  cases  is  very  marked,  particularly  in  children  who  have  been  creep- 
ing about.  Green-stick  fractures  here  are  quite  frequent.  Eachitic 
changes  at  the  epiphyses  are  more  common  than  in  the  shaft,  enlarge- 
ment of  the  epiphyses  at  the  wrist  being  one  of  the  most  constant  bony 
deformities  of  rickets  (Plate  V).  It  was  present  in  ninety- five  per  cent 
of  my  cases.  Less  frequently  similar  swellings  are  seen  at  the  elbow. 
Enlargement  of  the  ends  of  the  meta- 
carpal bones  or  the  phalanges  I  have  ,,  - 
seen  in  but  two  or  three  extreme  cases. 

The  lower  extremities  are  rather 
more  frequently  affected  than  the  upper, 
but  in  a  similar  way.  The  femur  is  in- 
volved only  in  severe  cases  ;  it  common- 
ly presents  a  general  forward  and  out- 
ward curve,  which  is  mainly  due  to  the 
weight  of  the  legs  as  the  child  sits. 
Occasionally  there  is  also  an  outward 
rotation  of  the  femur,  where  children 
have  been  allowed  to  sit  much  in  a 
cross-legged  posture.  When  such  chil- 
dren begin  to  walk,  the  toes  are  turned 
very  far  outward.  The  principal  de- 
formities of  the  lower  extremity  are 
bow-legs  (Fig.  48)  and  knock-knees 
(Fig.  49).  Kjiock-knees  are  more  com- 
mon in  females,  and  are  believed  to  be 
due  to  an  overgrowth  of  the  inner  con- 
dyles of  the  femur.  Enlargement  of 
both  condyles  can  be  demonstrated  in 
most  of  the  marked  cases  of  rickets.  The 

cases  of  slight  bow-legs  may  be  due  simply  to  swelling  of  the  epiphyses, 
the  shaft  of  the  bone  being  quite  normal.  This  point  I  have  verified  by 
post-mortem  observations.  Such  are  probably  most  of  the  deformities 
which  disappear  spontaneously.    The  most  severe  cases  of  bow-legs  are 


Fig.  48. — Typical  how-leg.s  of  severe 
form. 


252  NUTRITION. 

often  associated  with  some  degree  of  antero-posterior  curvature,  and  the 
latter  may  be  the  principal  deformity.  An  exaggerated  case  of  this  kind 
is   shown   in  Fig.   50.      Enlargement  of   the  epiphyses  at  the  ankle  is 

usually  present  when 
it  is  seen  at  the  wrists, 
and  nearly  to  the  same 
degree.  Enlargement 
of  the  upper  epiphyses 
of  the  tibia  and  the 
fibula  is  seen  only  in 
severe  cases.  The  cause 
of  the  deformities  of 
the  leg  is  not,  prima- 
rily at  least,  walking 
too  early,  since  they 
are  common  in  chil- 
dren who  have  never 
walked ;  slight  deform- 
ities, however,  may  be 
aggravated  by  early 
walking.  A  change 
which  has  not  been 
>ufficiently  emphasized 
is  the  arrested  growth 
>^'>"««-^  .     of  the  long  bones ;  this 

„      ,„     T-      1  1  is  one  of  the  most  char- 

FiG.  49.— Knock-knees. 

acteristic  features  of 
rickets.  A  rachitic  child  of  three  years  often  measures  in  height  six  or 
eight  inches  less  than  a  healthy  child  of  the  same  age,  the  difference  being 
almost  entirely  in  the  lower  extremities. 

All  the  ligaments,  but  particularly  those  about  the  large  joints,  are  lax 
and  frequently  elongated.  This  may  lead  to  the  deformity  known  as  weak 
ankles,  or  to  an  over-extension  at  the  knee  {genu  recurvatum)  ;  also  to 
unnatural  mobility  at  the  hips,  shoulders,  elbows,  and  wrists.  The  condi- 
tion of  the  ligaments  plays  an  important  part  in  the  production  of  spinal 
deformities. 

Muscles. — The  muscular  symptoms  of  rickets  are  almost  as  constant 
and  as  characteristic  as  those  of  the  bones.  The  muscles  are  small,  very 
flabby,  and  poorly  developed ;  hence  rachitic  children  are  unable  to  sit 
erect,  or  to  stand  or  walk  at  the  proper  age.  Of  one  hundred  and  fifty- 
one  cases  in  which  the  date  of  walking  alone  was  investigated,  only  twenty- 
seven,  or  eighteen  per  cent,  walked  before  the  fifteenth  month  ;  forty- 
seven  per  cent  were  not  walking  at  the  eighteenth  month  ;  twenty  per 
cent  not  at  two  years  ;  and  ten  per  cent  not  at  two  and  a  half  years.    Late 


RICKETS. 


263 


walking  is  one  of  the  most  common  symptoms  for  which  advice  is  sought 
by  parents  with  rachitic  children.  The  muscular  power  in  the  extremities 
is  sometimes  so  feeble  as  to  suggest  paralysis.  I  have  seen  a  number  of 
cases  in  which  the  symptoms  so  resembled  paralysis,  that  even  expert  diao^- 
nosticians  were  unable  to  differentiate  rickets  from  poliomyelitis  except 
by  the  electrical  reactions,  those  in  rickets  being  usually  normal  or  exag- 
gerated. In  other  cases  the  symptoms  may  suggest  cerebral  palsy  of  the 
flaccid  type.  The  muscular  symptoms  may  be  marked  when  the  bony 
changes  are  slight,  and  conversely.  As  no  lesions  of  the  muscles  have 
been  demonstrated,  the  symptoms  are  probably  due  to  imperfect  nutri- 
tion. Two  other  symptoms  depend  chiefly  upon  the  condition  of  the  mus- 
cles, viz.,  pot-belly  and  constipation. 

Pot-belly  is  quite  an  early  symptom,  and  in  most  cases  a  very  marked 
one  (Plate  V).      It  was  noted  in  sixty  per  cent  of  my  cases.     The  en- 
largement of  the  abdomen  is  uniform.     It  is  everywhere  tympanitic,  and 
it  may  be  as  tense  as 
a  drumhead.     It  is  due 

to   a  loss   of   tone  in  / 

the    abdominal     mus-  /  ^ 

cles,  and  in  the  mus-  /  : 

cular  walls  of  the  stom-  ' 
ach  and  intestine.  It  ': 
is  aggravated  by  chron- 
ic indigestion  and  con- 
sequent intestinal  pu- 
trefaction. The  en- 
largement is  thus 
mainly  from  tympa- 
nites. There  may  be 
a  marked  degree  of 
dilatation  both  of  the 
stomach  and  the  colon. 
To  a  very  small  degree 
only,  does  the  large 
abdomen  depend  upon 
swelling  of  the  liver  or 
spleen. 

The  constipation  of 
rickets,      as      already 

suggested,  depends  upon  the  loss  of  tone  in  the  muscular  walls  of  the  in- 
testines. It  may  alternate  with  diarrhoea.  It  rarely  happens  that  a 
rachitic  child  has  habitually  normal  evacuations  from  the  bowels.  Hard, 
dry,  constipated  stools  frequently  set  up  a  condition  of  chronic  catarrh 
of  the  colon  in  which  laro:e  masses  of  mucus  are  discharged. 


^Hb....^ 


\^ 


Fig.  50. — Extreme  rachitic  deformities  of  the  le<,'.s. 


264 


NUTRITION. 


During  the  most  active  part  of  the  disease — viz.,  from  the  third  to 
the  ninth  month — tenderness  may  sometimes  be  elicited  by  pressure  upon 
the  epiphyses.  This,  however,  is  not  a  constant  symptom,  and  a  very 
unreliable  one  for  diagnosis.  In  my  own  experience  it  has  been  present 
in  but  a  very  small  proportion  of  the  cases.  Acute  tenderness  should 
always  suggest  scurvy  rather  than  rickets. 

Fever. — According^  to  some  observers  there  is  a  febrile  movement 
which  belongs  to  the  active  stage  of  rickets,  but  I  have  never  been  able  to 
satisfy  myself  of  the  truth  of  this  observation. 

Dentition. — As  a  rule,  dentition  is  late  and  apt  to  be  difficult — i.  e.,  it 
is  associated  with  attacks  of  indigestion  or  other  disturbances  which  may 
be  serious.  Individual  cases,  however,  present  great  variations  in  regard 
to  this  symptom.  A  study  of  the  progress  of  dentition  in  one  hundred 
and  fifty  rachitic  children  gave  the  following  results :  in  fifty  per  cent  the 
first  teeth  were  cut  on  or  before  the  eighth  month,  and  in  thirteen  per 
cent  on  or  before  the  fifth  month ;  however,  twenty  per  cent  of  the  cases 
had  no  teeth  at  twelve  months,  and  in  eight  per  cent  none  had  appeared 
at  fifteen  months.  Even  though  the  first  teeth  come  at  the  usual  time, 
the  progress  of  dentition  is  often  arrested  by  the  development  of  rickets, 
and  no  advance  made  for  five  or  six  months.  The  difference  in  the 
cases  appears  to  depend  very  much  upon  the  age  of  the  child  when  rick- 
ets begins.  Those  who  give  no  evidence  of  it  until  nine  or  ten  months 
old  often  have  a  nearly  normal  dentition,  while  the  cases  developing 
early  show  a  marked  retardation  of  this  process.  The  order  in  which 
the  teeth  appear  may  be  very  irregular,  but  there  is  no  rule  in  this 
respect.  The  character  of  the  teeth  in  rickets,  in  the  great  majority  of 
cases,  is  good.  This  was  true  in  eighty-four  per  cent  of  one  hundred  and 
twenty-six  cases  examined  with  reference  to  this  point.  This  is  in  strik- 
ing contrast  to  hereditary  syphilis,  where  the  tendency  to  early  decay  is 
so  constantly  seen. 

General  appearance. — Rachitic  patients  are  almost  always  anaemic. 
The  blood  is  low  in  haemoglobin,  often  down  to  thirty  or  forty  per  cent. 
In  some  few  cases  there  is  in  addition  quite  marked  leucocytosis.  The 
number  of  red  globules  is  not  often  nor  uniformly  affected.  The  majority 
of  rachitic  patients  are  fat  and  flabby.  The  tissues  are  soft  and  have  but 
little  resistance.  Earely,  they  may  be  thin,  like  patients  suffering  from 
marasmus. 

Eachitic  patients  are  very  prone  to  suffer  from  hypertrophied  tonsils, 
adenoid  growths  of  the  pharynx,  and  enlargements  of  the  lymph  nodes  of 
the  neck.  In  all  forms  of  acute  illness  the  feeble  resistance  of  these 
patients  is  very  evident.  This  is  especially  true  of  acute  disease  of  the 
lungs. 

The  mucous  membranes  are  very  vulnerable  in  all  rachitic  patients. 
From  the  slightest  indiscretion  in  diet  an  attack  of  acute  indigestion  or 


RICKETS.  265 

diarrhcea  is  brought  on,  and  from  a  very  insignificant  exposure,  catarrhal 
inflammation  of  the  upper  or  lower  air  passages  is  excited.  In  rachitic 
patients  all  such  attacks  are  prone  to  run  a  protracted  course.  Inflam- 
mation of  the  trachea  and  larger  bronchi  is  liable  to  extend  to  the  smaller 
bronchi  and  the  lungs. 

The  downward  displacement  of  the  liver  and  spleen  from  contractioii 
of  the  chest  should  not  be  mistaken  for  enlargement  of  these  organs. 
Moderate  enlargement  of  the  spleen  is  very  common  during  the  stage  of 
most  active  symptoms — i.  e.,  from  the  sixth  to  the  twelfth  month.  Great 
enlargement  of  either  liver  or  spleen  is  infrequent. 

Blood. — From  a  study  of  the  blood  in  twenty  cases  of  rickets, 
Morse  (Boston)  concludes  that  anaemia  is  present  in  most  cases,  its  in- 
tensity varying  with  the  severity  of  the  rachitic  process.  All  the  usual 
forms  of  anemia  are  seen.  Leueocytosis  may  or  may  not  be  present ;  it 
is  more  marked  in  cases  attended  by  an  enlarged  spleen.  All  or  any  of 
the  white  cells  may  be  increased. 

Nervous  symptoms  are  among  the  most  frequent  manifestations  of 
rickets.  Eestlessness  at  night  has  already  been  mentioned  as  a  promi- 
nent early  symptom.  Pain  and  tenderness  are  rare.  A  disposition  to 
muscular  spasm  is  seen  in  many  cases.  There  may  be  laryngismus  strid- 
ulus, tetany,  or  general  convulsions.  The  first  two  are  rare  except  in 
rachitic  patients.  All  of  these  probably  depend  upon  defective  nutrition 
of  the  nervous  centres.  While  in  all  infants,  owing  to  the  irritability  of 
the  nervous  centres,  con^^llsions  are  easily  excited  from  relatively  slight 
causes,  in  those  who  are  rachitic  this  susceptibility  is  greatly  intensified. 
As  a  predisposing  cause  of  convulsions  in  infancy,  rickets  takes  the  first 
place.  The  younger  the  child  and  the  more  active  the  rachitic  process, 
the  more  frequently  do  convulsions  occur.  They  belong  especially  to  the 
first  year,  being  most  frequent  between  the  third  and  ninth  months. 
The  exciting  cause  of  convulsions  in  these  cases  is  usually  to  be  found  in 
the  stomach  or  intestine. 

Course  and  termination. — Eickets  is  essentially  a  chronic  disease,  and 
its  course  is  measured  by  months.  The  active  symptoms  in  most  cases 
continue  from  three  to  fifteen  months,  although  they  occasionally  last 
a  much  longer  time.  The  duration  of  the  symptoms  depends  chiefly 
upon  tlie  duration  of  the  exciting  cause.  That  active  symptoms  cease 
wlicu  a  child  reaches  the  age  of  eighteen  inniilhs  or  two  years,  is  no 
doubt  due  largely  to  the  fact  that  at  this  age  the  diet  is  more  general, 
and  is  more  likely  to  furnish  what  the  child  needs,  and  that  more  fresh 
air  is  likely  to  be  secured  than  at  an  earlier  age. 

The  earliest  symptoms  of  inii)rovement  are  a  diminution  in  the  nerv- 
ous symptoms,  especially  in  the  i-estlessness  at  night :  increased  muscular 
power,  as  shown  by  a  disposition  to  stand  or  walk :  diminution  in  the 
head-sweats  :  disappearance  of  the  cranio-tabes  ;  and  improvement  in  the 
ana?mia.    The  changes  in  the  deformities  are  very  slow,  and  from  month 


266  NUTRITION. 

to  month  almost  imperceptible.  When  improvement  once  begins,  how- 
ever, it  usually  goes  steadil}'  forward,  relapses  being  exceedingly  rare. 

Congenital  rickets. — Infants  may  present  at  birth  the  characteristic 
deformities  of  rickets,  and  there  may  be  found  even  the  minute  bone 
changes  of  the  disease.  Such  cases  are  reported  to  be  common  in  Vienna 
and  other  large  cities  of  Europe,  where  mothers  during  pregnancy  have 
lived  under  unfavourable  surroundings.  In  America,  however,  congeni- 
tal rickets  is  a  very  rare  disease.  Single  cases  have  been  reported  by 
several  writers;  I  have  myself  seen  but  two.  Cases  of  cretinism  have 
sometimes  been  improperly  included  under  this  term. 

Late  rickets. — Eare  instances  have  been  reported  of  bony  deformities 
in  all  respects  like  those  of  rickets,  developing  in  children  from  six  to 
twelve  years  old.  A  number  of  such  cases  have  been  observed  in  England. 
I  have  not  seen  this  disease,  nor  has  a  case  been  seen  during  the  past 
twenty  years  at  the  Hospital  for  Ruptured  and  Crippled,  j^ew  York, 
where  more  deformities  come  under  observation  than  anywhere  else  in 
this  country. 

Acute  rickets. — Although  from  time  to  time  cases  have  been  reported 
with  this  title,  from  a  study  of  the  histories  it  is  clear  that  the  great 
majority,  if  not  all  of  them,  were  cases  of  infantile  scurvy.  It  is  doubtful 
whether,  strictly  speaking,  there  is  such  a  thing  as  acute  rickets. 

Diagnosis. — The  diagnosis  of  rickets  is  not  usually  difficult,  and  after 
carefully  examining  a  case  one  can  not  often  be  in  doubt.  It  is  the  mild 
cases  and  the  early  stages  of  the  disease  that  are  most  likely  to  be  over- 
looked. The  most  important  early  symptoms  for  diagnosis  are  sweating 
of  the  head,  cranio-tabes,  great  restlessness  at  night,  delayed  dentition, 
and  enlarged  fontanel.  All  these,  taken  separately,  may  mean  something 
else,  but  collectively  they  can  mean  nothing  but  rickets.  In  the  later 
stages  some  of  the  characteristic  deformities  are  usually  present;  the 
most  constant  are  beading  of  the  ribs,  enlargement  of  the  epiphyses  of 
the  wrists  and  ankles,  and  bow-legs. 

Special  symptoms,  when  unusually  prominent,  may  give  rise  to  diffi- 
culty in  diagnosis.  The  enlargement  of  the  head  may  be  mistaken  for 
hydrocephalus.  The  delayed  dentition  and  large  fontanel  of  the  cretin 
may  be  mistaken  for  rickets.  Muscular  weakness  may  be  so  great,  espe- 
cially when  affecting  the  legs,  as  to  make  it  easy  to  mistake  a  rachitic 
pseudo-paralysis  for  actual  paralysis  due  to  a  cerebral  or  spinal  lesion. 
When  walking  is  much  delayed,  rickets  may  be  passed  over  as  simple 
backwardness.  In  nearly  all  of  the  last-mentioned  group  of  cases  the 
diagnosis  may  be  cleared  up  by  a  careful  search  for  the  bony  changes, 
and  by  the  fact  that  in  rickets  there  is  only  a  general  weakness  of  all 
the  muscles,  and  not  actual  paralysis  of  any  limb  or  group  of  muscles. 
The  greatest  difficulty  is  usually  found  where  the  muscular  symptoms  are 
marked  and  the  bony  changes  slight, as  is  not  infrequently  the  case.  Here 


RICKETS.  207 

the  question  is,  whether  rickets  is  sufficient  to  explain  all  the  symptoms, 
or  whether  in  addition  some  other  condition  is  present.  The  electrical 
reactions  will  decide  the  question  of  poliomyelitis,  while  the  presence  of 
cerebral  symptoms,  exaggerated  knee-jerks,  and  rigidity  of  the  legs,  will 
usually  mark  a  cerebral  birth-palsy.  The  bony  enlargements  of  syphilis 
are  not  likely  to  be  confounded  with  rickets,  if  it  is  remembered  that  the 
early  lesions  of  syphilis  are  more  like  boggy  infiltrations  over  the  bones 
than  actual  swelling  of  the  bone  itself,  and  that  when  the  bone  is  affected 
it  is  not  at  the  extremity,  but  at  the  junction  of  the  epiphysis  and  the 
shaft ;  the  bone  changes  of  late  syphilis  affect  the  shaft  rather  than 
the  extremities  of  the  long  bones ;  where  the  bone  is  enlarged  near 
the  joint  it  is  usually  upon  one  side  only.  In  syphilis  there  may  be 
necrosis,  while  in  rickets  breaking  down  of  bone  is  never  seen.  From 
scurvy,  rickets  is  differentiated  by  the  absence  of  marked  hypersesthe- 
sia,  ecchymoses,  and  other  haemorrhages,  the  changes  in  the  gums,  and 
most  of  all  by  the  fact  that  anti-scorbutic  diet  produces  no  immediate 
change  in  the  symptoms.  The  diagnosis  of  rachitic  curvature  of  the 
spine  from  vertebral  caries  will  be  considered  in  connection  with  the 
latter  disease. 

Prognosis.— Rickets  per  se  is  never  a  fatal  disease.  It  is,  however,  a 
large  factor  in  the  mortality  of  the  first  two  years,  as  the  cachexia  which 
it  produces  predisposes  strongly  to  every  form  of  acute  disease.  It  is  an 
important  etiological  factor  in  certain  serious  nervous  conditions,  espe- 
cially convulsions.  According  to  Gowers,  ten  per  cent  of  the  cases  of 
epilepsy  are  in  children  who  previously  suffered  from  rickets.  Rickets 
adds  very  greatly  to  the  danger  from  all  acute  diseases  of  infancy,  par- 
ticularly those  of  the  respiratory  tract.  This  depends  partly  upon  the 
feeble  muscular  power  and  partly  upon  the  thoracic  deformities.  The 
encroachment  upon  the  capacity  of  the  lungs  by  a  marked  thoracic  de- 
formity, may  in  itself  be  enough  to  keep  a  child  in  a  delicate  condition 
and  retard  its  growth.  At  the  same  time  such  a  condition  is  a  constant 
invitation  to  acute  attacks  of  bronchitis  or  pneumonia.  The  effect  of 
rickets  upon  the  future  health  of  the  child,  depends  chiefly  upon  the 
presence  and  extent  of  the  thoracic  deformity.  When  this  is  absent,  as 
a  rule  no  serious  after-effects  are  seen,  and  although  children  may  re- 
main somewhat  dwarfed  on  account  of  their  short  legs,  in  other  respects 
they  may  be  as  well  as  if  they  had  never  been  the  subjects  of  rickets. 

Prophylaxis. — As  rickets  is  primarily  due  to  improper  food  or  feed- 
ing, and  secondarily  to  bad  surroundings,  it  may  be  prevented  by  the 
observance  of  proper  rules  of  feeding  as  laid  down  elsewhere,  and  by  re- 
moving children  from  their  faulty  surroundings.  Especial  care  should  be 
given  to  the  later  children  of  a  family  where  the  earlier  ones  have  shown 
even  the  mildest  symptoms  of  rickets,  as  the  predisposition  is  sure  to  in- 
crease with  each  successive  child. 


268  NUTRITION. 

Treatment. — In  considering  the  treatment  of  rickets,  the  natural 
course  of  the  disease  is  to  be  kept  in  mind,  viz.,  that  active  symptoms 
frequently  continue  only  until  the  tenth  or  twelfth,  rarely  longer  than  the 
eighteenth  month,  and  that  after  this  time  the  patient  suffers  more 
from  the  results  of  the  disease  than  from  the  disease  itself.  The  most 
important  period  for  treatment,  therefore,  and  the  one  in  which  it  is 
most  effective,  is  from  the  sixth  to  the  fifteenth  month.  The  earlier 
the  treatment  is  begun  the  better  will  be  its  results.  Constitutional  treat- 
ment after  the  fifteenth  or  eighteenth  month,  has  very  little  effect  upon 
the  disease,  for  by  this  time  most  of  the  harm  has  been  done.  The  course 
of  the  disease  when  untreated  is  toward  spontaneous  recovery,  from  the 
changes  in  diet  and  life  which  are  usually  made  when  children  have 
reached  the  latter  half  of  the  second  year.  Most  of  the  cases  seen  in 
private  practice  are  of  a  mild  type  and  recover  without  special  treat- 
ment, often  no  diagnosis  being  made  until  later  in  life,  when  the  bony 
deformities  or  stunted  growth  indicate  the  previous  existence  of  rickets. 
The  first  step  in  treatment  is  to  remove  the  cause,  and  is  therefore  to  be 
directed  to  the  diet  and  hygiene  of  the  patient.  The  results  will  depend 
upon  how  completely  these  causes  can  be  removed. 

Diet. — Carbohydrates,  including  sugars,  proprietary  infant-foods,  and 
all  farinaceous  substances,  should  be  reduced  to  the  minimum,  and  in 
some  cases  prohibited.  So  far  as  possible  the  diet  should  consist  of 
nitrogenous  food  and  fats,  especially  milk,  cream,  eggs,  red  meat  and 
fresh  fruit.  These  articles  are  to  be  given  according  to  the  rules  laid 
down  in  the  chapters  on  Infant  Feeding.  In  addition,  cod-liver  oil — 
which  in  these  cases  may  be  considered  quite  as  much  a  food  as  a  medi- 
cine— should  be  administered  as  soon  as  the  stomach  will  tolerate  it. 

Hygiene. — This  is  the  most  difficult  part  of  the  treatment.  In  large 
cities  it  is  almost  impossible  to  secure  for  rachitic  patients  the  surround- 
ings they  require.  Whenever  possible,  such  children  should  be  sent  to  the 
country  ;  but  where  this  is  out  of  the  question,  much  may  be  accom- 
plished by  frequent  excursions  upon  the  water  or  into  the  country,  by 
keeping  children  as  much  as  possible  in  the  parks  and  open  squares  of  the 
city,  and  securing  plenty  of  fresh  air  in  sleeping  rooms.  Mothers  are 
often  very  much  afraid  of  fresh  air,  on  account  of  the  tendency  of  these 
children  to  take  cold.  If  cold  sponge-baths  are  given  every  morning, 
much  can  be  done  to  lessen  this  susceptibility.  Sunshine,  though  diffi- 
cult to  obtain  in  large  cities,  is  a  most  efficient  therapeutic  agent.  The 
establishment  of  suburban  hospitals  and  homes  for  these  cases  would  do 
more  than  anything  else  to  lessen  the  mortality  from  rickets. 

In  a  disease  which  tends  so  uniformly  to  recovery  when  causal  condi- 
tions are  removed,  it  is  difficult  to  estimate  the  real  value  of  medicinal 
treatment.  No  one  thinks  of  relying  upon  drugs  alone  in  the  treatment 
of  rickets,  and  where  they  are  used  in  conjunction  with  other  means  it 


RICKETS.  269 

is  illogical  to  attribute  all  the  improvement  to  the  drugs  employed. 
Those  most  used  are  cod-liver  oil,  phosphorus,  and  various  prepara- 
tions of  lime.  Eegarding  the  value  of  cod-liver  oil,  there  can  be  no 
question.  While  it  can  not  be  ranked  as  a  specific  in  rickets,  it  should 
be  given  in  every  case  unless  contra-indicated  by  the  condition  of  the 
stomach,  except  possibly  during  very  hot  summer  weather.  Phosphorus 
has  been  popularized  in  the  treatment  of  rickets  by  Kassowitz,  who 
regards  it  as  a  specific  for  the  disease.  I  have  been  unable  to  satisfy 
myself,  after  several  years'  trial,  that  in  the  great  majority  of  the  cases 
it  had  any  decided  influence  upon  the  course  of  the  disease.  The  best 
results  from  phosphorus  are  obtained  in  the  early  cases,  where  there  are 
cranio-tabes  and  marked  nervous  symptoms.  But  even  here  I  have  not 
seen  the  striking  benefit  reported  by  others.  In  the  later  stages  of  rick- 
ets, it  has  been  diflBcult  to  see  any  special  result  from  its  use.  Phos- 
phorus may  be  administered  either  in  the  form  of  the  officinal  oil  of 
phosphorus  diluted  with  olive  oil,  or  as  Thompson's  solution.  The  dose 
is  gr.  Y^ff  three  times  a  day,  given  after  meals ;  it  should  be  continued 
for  several  months.  In  such  doses  I  have  never  seen  it  cause  unpleasant 
symptoms. 

The  absence  of  lime  in  rachitic  bones  has  led  to  the  use  of  various 
preparations  of  lime  as  remedies.  Those  most  employed  are  the  phos- 
phate, the  lactophosphate,  and  the  hypophosphite.  While  these  may  be 
beneficial  as  tonics,  they  are  not  in  any  sense  to  be  classed  as  specifics.  It 
is  probable  that  when  lime  is  given  in  excess  of  the  amount  furnished  by 
ordinary  breast-milk  or  cow's  milk,  this  excess  passes  through  the  bowels 
unabsorbed.  Arsenic  and  iron  are  valuable  in  the  treatment  of  rickets, 
the  special  indication  for  their  use  being  the  presence  of  marked  ana?mia. 
Profuse  sweating  may  be  relieved  by  small  doses  of  atropine — i.  e.,  gr. 
j^^,  three  or  four  times  a  day,  to  a  child  of  six  months. 

Treatment  of  the  rachitic  deformities. — The  deformities  of  the  chest 
are  less  amenable  to  treatment  than  most  of  the  others.  After  the  third 
year  something  can  be  done  by  gymnastics  to  develop  the  chest  muscles 
and  to  increase  the  pulmonary  expansion.  The  employment  of  the  pneu- 
matic cabinet,  in  which  it  is  sought  to  overcome  these  deformities  by  the 
use  of  rarefied  air,  has  never  been  given  the  trial  which  it  deserves.  From 
the  very  meagre  reports  published,  this  appears  to  be  of  considerable  value. 

The  deformity  of  the  spine  (kyphosis)  may  usually  be  overcome  by 
postural  treatment.  The  patient  should  lie  upon  a  hard  bed  ;  no  pillow 
should  be  allowed  under  the  head,  but  in  severe  cases  one  should  be 
placed  beneath  the  back,  so  that  the  head  and  buttocks  are  slightly  lower 
than  the  lumbar  spine.  While  sitting,  the  shoulders  should  be  kept  back 
and  the  trunk  supported.  For  a  few  minutes  each  day  the  child  should 
be  placed  upon  the  face,  and  the  deformity  overcome  by  raising  the  but- 
tocks while  pressure  is  made  upon  the  spine.  In  severe  cases,  an  apparatus 
19 


2Y0 


NUTRITION. 


for  giving  spinal  support,  either  by  a  steel  brace  or  a  plaster-of-Paris 
jacket,  may  be  worn  a  few  hours  each  day  when  the  child  is  sitting  up. 
Other  means  should  be  employed,  especially  friction  and  massage,  to 
develop  the  spinal  muscles. 

In  very  many  cases  slight  deformities  of  the  extremities  are  outgrown 
when  the  general  treatment  can  be  properly  carried  out.  Where  these 
exist,  the  physician  should  take  the  curve  of  the  limbs  by  seating  the 


Fig.  51. — Tracing,  showing  the  curve  in  a  case  of  bow-legs. 

child  upon  a  flat  surface  and  tracing  their  outline  with  a  pencil  held  per- 
pendicularly (see  Fig.  51) .  A  fresh  tracing  should  be  taken  once  a  month. 
If  the  deformity  is  not  very  great  and  no  increase  takes  place,  it  is  safe 
to  continue  with  general  treatment  only.  If  the  deformity  is  marked  or 
if  it  increases  in  spite  of  the  constitutional  treatment,  braces  should  be 
applied.  Something  may  be  done  toward  straightening  the  bones  by 
intelligent  manipulation.  Walking  should  be  discouraged  until  the  bones 
are  quite  firm.  Friction  of  the  extremities,  and  even  the  use  of  electricity, 
will  do  very  much  to  increase  muscular  development.    The  habit  of  sitting 


RICKETS.  271 

cross-legged — a  very  common  one  in  rachitic  children — should  be  pre- 
vented, and  in  fact  any  other  habitual  posture,  on  account  of  the  danger 
of  increasing  certain  deformities.  But  little  is  to  be  expected  from  the 
use  of  apparatus  for  the  correction  of  rachitic  deformities  after  the  child 
is  two  and  a  half  years  old;  since  at  this  time,  and  often  even  at  two 
years,  the  bones  are  so  firm  that  no  amount  of  pressure  from  a  steel 
brace  will  have  any  effect. 

Without  going  fully  into  the  question  of  the  surgical  treatment  of 
rachitic  deformities,  for  which  the  reader  is  referred  to  text-books  of 
general  and  orthopaedic  surgery,  I  will  only  state  that  osteotomy  seems 
to  me  to  offer  decided  advantages  over  the  other  means  of  treating  severe 
deformities.  A  vast  amount  of  time  and  patience  is  wasted  in  the  vain 
attempt  to  overcome  very  marked  deformities  by  apparatus.  The  best 
results  in  osteotomy  are  obtained  when  the  operation  is  delayed  until  the 
fourth  or  fifth  year,  by  which  time  the  bones  are  sufficiently  firm  and 
solid.  Operations  in  the  second  year  are  generally  unsatisfactory,  and 
those  in  the  third  year  often  so,  because  of  the  bending  of  the  bones 
which  takes  place  subsequently.  The  deformities  which  require  opera- 
tion are  bow-legs  and  knock-knees,  less  frequently  the  curvatures  of  the 
femur  or  of  the  bones  of  the  forearm. 


SECTION  III. 
DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

CHAPTEE   I. 

DISEASES  OF  THE  LIPS,    TONGUE,  AMD  MOUTH. 

MALFORMATIONS. 

Harelip. — This  is  one  of  the  most  frequent  congenital  deformities. 
It  is  caused  by  an  incomplete  fusion  of  the  central  process  with  one  or 
both  of  the  lateral  processes  from  which  the  upper  half  of  the  face  is  de- 
veloped. This  deformity  may  be  single  or  double ;  the  fissure  is  never  in 
the  median  line,  but  usually  just  beneath  the  centre  of  the  nostril.  There 
may  be  simply  a  slight  indentation  in  the  lip,  or  the  fissure  may  extend  to 
the  nostril.  Both  single  and  double  harelip — more  frequently  the  latter — 
may  be  complicated  by  fissure  of  the  palate.  Double  harelip  is  usually 
accompanied  by  a  fissure  between  the  intermaxillary  and  the  superior 
maxillary  bone  of  each  side. 

Cleft  Palate. — This  is  second  in  frequency  to  harelip.  It  may  involve 
the  soft  palate  only,  or  the  fissure  may  extend  into  the  hard  palate,  pro- 
ducing a  wide  gap  in  the  roof  of  the  mouth.  The  most  frequent  form 
is  that  in  which  only  the  soft  palate  is  affected. 

For  the  surgical  treatment  of  both  these  deformities  the  reader  is  re- 
ferred to  text-books  upon  surgery.  As  to  the  time  of  operation,  in  cases 
of  harelip  it  is  wisest  to  defer  interference  until  the  child  is  well  started  in 
its  growth — usually  the  second  month — and  in  cleft  palate  during  the 
second  year.  The  medical  treatment  of  these  cases  consists  in  the  care 
of  the  mouth  and  in  the  nutrition  of  the  patient.  The  mouth  in  all  cases 
must  be  kept  scrupulously  clean,  but  the  greatest  care  is  necessary  not 
to  injure  the  epithelium.  A  camel's-hair  brush  and  plain  lukewarm 
water,  or  a  weak  alkaline  solution,  are  to  be  recommended.  Both  these 
deformities  are  exceedingly  likely  to  be  complicated  by  thrush.  This  is 
a  serious  menace  to  the  success  of  any  operation,  and  even  to  the  life  of 
the  patient.  The  nutrition  is  always  a  matter  of  much  difficult}-,  and  a 
very  large  number  of  these  cases  die  of  inanition  or  marasmus.  In  cases 
of  harelip,  if  the  fissure  is  so  great  as  to  interfere  with  nursing,  the  child 
may  be  fed  with  a  spoon  or  a  medicine  dropper  until  the  operation 


DISEASES   OP   THE  TONGUE.  273 

can  be  done.  In  cleft  palate  there  may  be  attached  to  the  rubber  nipple 
of  the  nursing  bottle  a  flap  of  thin  sheet  rubber  in  such  a  way  that  it 
closes  the  fissure  in  the  mouth  when  once  the  nipple  is  in  place.  This 
flap  should  be  shaped  like  a  leaf,  one  extremity  being  sewed  to  the  neck 
of  the  rubber  nipple  and  the  other  end  left  free.  In  many  cases,  both 
before  and  immediately  after  operation,  gavage  (page  62)  may  be  resorted 
to  with  the  greatest  benefit  and  with  very  little  inconvenience. 

Congenital  Hypertrophy  of  the  Tongue. — This  is  usually  due  to  disease 
of  the  lymphatics,  and  is  to  be  regarded  as  a  lymphangioma.  In  a  few 
cases  hypertrophy  of  the  muscular  fibres  has  been  present.  The  tongue 
may  reach  an  enormous  size,  so  that  it  is  impossible  for  it  to  be  contained 
within  the  cavity  of  the  mouth,  and  it  may  thus  interfere  with  nursing, 
deglutition,  and  even  with  respiration.  The  treatment  is  surgical.  Cases 
like  the  above  are  to  be  distinguished  from  those  of  enlargement  of  the 
tongue  seen  in  sporadic  cretinism.  In  this  disease  the  tongue  is  consider- 
ably enlarged  and  may  protrude  slightly  from  the  mouth,  but  it  is  rarely, 
if  ever,  large  enough  to  cause  other  symptoms.  It  diminishes  notably 
under  treatment  with  the  thyroid  extract. 

Bifid  Tongne. — These  cases  are  extremely  rare.  Brothers  has  reported 
to  the  New  York  Pathological  Society  a  case  of  cleft  tongue  in  a  child  of 
one  month.     There  was,  in  addition,  a  fissure  of  the  soft  palate. 

Tongue-Tie. — This  deformity  is  due  to  such  a  shortening  of  the  frenum 
that  it  is  impossible  to  protrude  the  tongue  to  a  normal  extent.  It 
differs  considerably  in  degree  in  different  cases.  In  some,  the  tongue 
can  not  be  advanced  beyond  the  gums.  Tongue-tie  may  interfere  with 
articulation,  and  even  with  sucking.  The  treatment  consists  in  liberating 
the  tongue  by  dividing  the  frenum  with  scissors  and  completing  the  oper- 
ation with  the  finger  nail.  This  should  be  done  in  every  case  unless  the 
child  is  a  bleeder.  In  many  cases  the  mother  may  think  the  tongue  tied 
when  the  frenum  is  of  normal  length. 

Bifid  TJvula. — This  is  not  very  uncommon.  It  usually  occurs  in  con- 
nection with  cleft  palate,  but  is  occasionally  seen  when  there  is  no  other 
deformity  present.  It  may  be  complete  or  partial,  and  it  does  not  of  itself 
require  treatment. 

DISEASES   OP   THE   LIPS. 

Herpes.^ — Herpes  labialis  is  an  exceedingly  common  affection  in  chil- 
dren, occurring  in  acute  febrile  diseases,  particularly  pneumonia,  and 
sometimes  alone.  It  is  the  familiar  "  fever  sore  "  or  "  cold  sore  "  of  do- 
mestic medicine.  The  appearance  is  similar  to  herpes  in  other  parts  of 
the  body.  There  is  first  a  group  of  vesicles,  then  rupture  and  the  forma- 
tion of  crusts.  It  is  often  quite  difficult  to  cure  on  account  of  the  dispo- 
sition of  children  to  pick  the  lip  with  the  fingers.  Although  it  heals  with- 
out treatment,  recovery  is  facilitated  by  the  use  of  some  antiseptic  lotion, 


274  DISEASES   OF   THE   DIGESTIA^E  SYSTEM. 

such  as  dilute  boric  acid,  followed  by  a  dusting  powder  of  zinc  oxide  and 
boric  acid.  This  treatment  is  generally  more  successful  than  the  use  of 
ointments.  Young  children  should  wear  mittens  at  night,  to  prevent 
picking  at  the  crusts. 

Eczema  of  the  Lip. — This  is  an  exceedingly  common  condition,  and 
a  ver}'  troublesome  one.  The  vermilion  border  is  dry  and  rough,  and 
prone  to  deep  cracks  or  fissures.  These  are  usually  seen  at  the  angles  of 
the  mouth  or  in  the  median  line.  When  severe  they  are  exceedingly 
.painful,  bleed  freely,  and  are  the  cause  of  very  great  discomfort,  especial- 
ly in  the  cold  season.  The  lips  should  be  covered  at  night  by  simple  oint- 
ment, and  this  should  be  used  as  much  as  possible  during  the  day. 
Where  deep  fissures  form,  they  should  be  touched  with  burnt  alum,  or 
with  the  solid  stick  of  nitrate  of  silver.  Syphilitic  fissures  are  considered 
with  the  sjonptoms  of  that  disease. 

Perleche  (French,  perUcher  :=  to  licJc). — This  name  was  first  given  by 
Lemaistre,  in  1886,  to  a  form  of  ulceration  occurring  usually  at  the  angle 
of  the  mouth.  It  begins  in  most  cases  as  a  small  fissure,  which,  by  con- 
stant licking  and  irritation,  to  which  there  is  usually  added  infection, 
may  produce  an  intractable  ulcer  of  considerable  size.  It  often  resembles 
the  mucous  patch  of  hereditary  syphilis.  The  ulcer  is  of  a  grayish  colour, 
is  quite  painful,  and  is  associated  with  considerable  swelling  of  the  lip. 
It  lasts  from  two  to  four  weeks.  The  treatment  is  the  same  as  in  simple 
fissure — viz.,  the  use  of  burnt  alum  or  nitrate  of  silver,  and  covering  the 
part  with  bismuth  or  oxide  of  zinc. 

DISEASES  OP  THE  TONGUE. 

Epithelial  Desquamation. — This  is  a  disease  of  the  lingual  epithe- 
lium, which  is  characterized  b}'  the  appearance  upon  the  dorsum  or  mar- 
gin of  the  tongue,  of  circular,  elliptical,  or  erescentic  red  patches,  with 
gray  margins  which  are  slightly  elevated.  It  is  sometimes  improperly 
called  psoriasis  of  the  tongue.     It  is  quite  a  common  condition. 

The  beginning  of  the  disease  is  not  often  seen.  It  is  stated  first  to 
appear  as  a  white  or  gray  patch,  like  thickening  of  the  epithelium.  These 
patches  enlarge  quite  rapidh',  and  are  followed  by  detachment  of  the 
epithelium  and  the  formation  of  bright  red  areas,  which  are  the  parts 
denuded  of  epithelium.  As  usually  seen,  there  exists  upon  the  tongue 
from  two  to  half  a  dozen  of  these  red  patches  surrounded  by  a  gray  bor- 
der, which  is  about  one  twelfth  of  an  inch  wide,  and  slightly  elevated.  The 
outline  of  the  patch  is  nearly  always  erescentic  (see  Fig.  52).  From  day 
to  day  the  configuration  of  the  patches  changes ;  the  gray  lines  advance 
across  the  tongue  from  side  to  side,  or  from  base  to  tip,  disappearing  as 
they  reach  the  border  or  the  extremity.  They  are  followed  by  the  red 
patches,  and  as  the  old  ones  fade  away  new  ones  form  and  run  the  same 
course.    The  white  border  seems  to  be  made  up  entirely  of  epithelium. 


GLOSSITIS. 


275 


The  red  patches  are  of  a  bright  colour  nearest  the  border,  gradually 
shading  oft'  into  the  normal  colour  of  the  tongue.  Only  the  epithelium  is 
involved,  the  deeper  structures  being  unaffected.  The  duration  of  the 
disease  is  indefinite;  it  usually  lasts  for  months,  and  often  for  years. 
Guinon  reports  several  cases  which  recovered  during  an  intercurrent 
attack  of  measles  or  scarlet  fe^er. 

The  cause  is  unknown.  The  condition  occurs  rather  more  frequently 
in  females  than  in  males,  and  Gubler  has  reported  an  instance  of  several 
members  of  the  same  family  being  affected. 
Most  of  the  cases  are  seen  in  infancy  and 
early  childhood.  The  condition  has  been 
thought  to  depend  upon  nearly  every  disease 
of  this  period.  Parrot  believed  that  it  was 
always  syphilitic,  but  this  view  has  been 
effectually  disproved  by  subsequent  observa- 
tion. The  disease  is  not  accompanied  by 
pain,  salivation,  or  by  other  symptoms  of 
stomatitis,  and  it  is  of  little  practical  impor- 
tance. Its  symptoms  are  so  characteristic 
that  it  can  hardly  be  mistaken  for  any  other 
condition.     Treatment  is  unnecessary. 

Two  other  forms  of  epithelial  desquama- 
tion have  been  observed,  both  much  more 
rare  than  that  described.  In  one  of  these 
the  red  denuded  portion  occupies  the  margin  of  the  tongue,  while  the 
centre  is  gray  or  white  ;  the  irregular  wavy  outline  which  separates  the  two 
suggests  strongly  an  outline  map,  and  the  condition  is  sometimes  called 
the  "  geographical  tongue."  In  another  variety  nearly  the  whole  organ 
may  be  uniformly  red,  from  loss  of  the  epithelium,  there  being  no  borders 
or  patches.  Both  these  varieties  are  of  much  shorter  duration  than  the 
more  common  form,  usually  lasting  only  a  few  weeks.* 

Glossitis. — Inflammation  of  the  tongue  is  not  very  common  in  chil- 
dren. It  is  usually  of  traumatic  origin.  The  injury  may  be  due  to  biting 
the  tongue  in  a  fall  or  in  an  epileptic  seizure.  Glossitis  is  sometimes 
excited  by  the  irritation  of  a  sharp  tooth,  causing  a  wound  which  may  be 
the  avenue  of  infection  ;  or  it  may  result  from  taking  into  the  mouth 
irritant  or  caustic  poisons.  In  a  small  number  of  cases  no  cause  can  be 
found.  The  symptoms  are  marked  swelling  of  the  tongue,  so  that  it  may 
protrude  from  the  mouth ;  and  it  may  even  be  so  great  as  to  cause  se- 
vere dyspnoja.     There  are  also  profuse  salivation,  difficulty  in  swallowing 


Fig.  52. — Epithelial  desquamation 
of  the  tongue.     (Guinon.) 


*  For  a  fuller  description  and  literature  of  the  subject,  see  Guinon,  Revue  Men- 
suelle  des  Maladies  de  I'Enfance,  1887,  p.  385 ;  and  Gautier,  Revue  M^dicale  de  la 
Suisse,  Romande,  October  and  November,  1881. 


276  DISEASES  OF   THE  DIGESTIVE  SYSTEM. 

and  in  articulation,  and  often  considerable  local  pain.  There  may  be 
a  rise  of  temperature  to  102°  or  103°  F.  The  treatment  consists  in 
the  use  of  fluid  food,  which  in  severe  cases  may  be  introduced  through 
the  nose  by  means  of  a  catheter.  Ice  may  be  used  externally,  or, 
better  still,  pieces  of  ice  should  be  kept  in  the  mouth  continually.  If 
there  is  obstruction  to  respiration,  and  in  all  severe  cases,  scarifica- 
tion should  be  done  on  the  dorsum  of  the  tongue  along  the  side  of  the 
raphe. 

The  acute  swelling  of  the  tongue  and  lips  occurring  in  some  cases  of 
urticaria  may  be  mentioned  in  this  connection.  This  is  a  rare  condi- 
tion in  children,  but  it  may  develop  rapidly  and  to  such  a  degree  as  to 
cause  alarming  symptoms.  The  treatment  consists  in  the  use  of  ice- 
locally,  free  purgation  by  salines,  and  in  extreme  cases  needle  punc- 
tures to  relieve  the  oedema. 

Tong-ue-swallowing. — This  term  is  used  to  describe  a  rare  condition 
seen  in  infants,  in  which  the  tongue  is  turned  backward  into  the  pharynx, 
so  as  to  obstruct  respiration.  It  may  be  drawn  quite  into  the  oesophagus. 
Several  marked  cases  have  been  collected  by  Hennig.*  While  most  fre- 
quently occurring  with  paroxysms  of  pertussis,  tongiie-swallowing  has 
been  seen  in  other  diseases.  This  should  not  be  forgotten  as  one  of  the 
explanations  of  sudden  asphyxia  in  a  young  infant.  The  conditions 
necessary  to  its  production  are  a  somewhat  relaxed  organ  or  a  long 
frenum.  In  none  of  the  fatal  eases  reported,  however,  had  the  frenum 
been  divided.  In  some  weak  infants,  falling  back  of  the  tongue,  so  that 
its  base  partly  covers  the  epiglottis,  produces  asphyxia,  precisely  as  it 
occurs  in  adult  life  under  full  anaesthesia.  The  recognition  of  the  con- 
dition is  a  very  easy  one,  and  its  treatment  is  to  relieve  the  obstruction 
by  drawing  the  tongue  forward  by  the  finger  or  forceps. 

Ulcer  of  the  Fremim. — The  friction  against  the  sharp  edges  of  the 
lower  central  incisors  frequently  causes  an  ulcer  of  the  frenum  in  in- 
fants. I  have  never  seen  it  in  older  children.  It  usually  occurs  in 
pertussis,  but  is  seen  in  other  conditions.  In  some  it  appears  to  be  pro- 
duced by  friction  of  the  teeth  during  nursing  from  the  breast  or  bottle. 
It  is  more  often  seen  in  children  who  are  delicate  or  cachectic  than  in 
those  who  are  healthy  and  well  nourished.  The  ulcer  may  be  confined 
to  the  frenum,  or  it  may  extend  quite  deeply  into  the  tongue.  It  is 
usually  about  one  fourth  of  an  inch  in  diameter,  and  of  a  yellowish-gray 
colour.  When  not  readily  cured  by  touching  with  alum  or  nitrate  of 
silver,  the  child  may  be  fed  by  gavage  for  several  days,  or  the  teeth  may 
be  covered  by  a  bit  of  absorbent  cotton. 


*  Jahrbuch  fiir  Kinderheilkunde,  xi,  299. 


ALVEOLAR  ABSCESS— DIFFICULT  DENTITION.  277 


ALVEOLAR  ABSCESS. 

This  is  common  in  children,  especially  among  the  class  of  hospital  and 
dispensary  patients,  in  whom  little  or  no  attention  is  given  to  the  care  of 
the  teeth.  It  causes  severe  pain  and  acute  swelling,  which  may  be  limited 
to  the  gum,  or  it  may  involve  to  a  considerable  extent  the  periosteum  of 
the  jaw,  and  even  cause  swelling  of  the  whole  side  of  the  face.  If  there 
is  retention  of  pus,  there  may  be  quite  severe  constitutional  symptoms, 
such  as  a  chill  and  high  temperature  ;  but  in  most  of  the  cases  these  are 
wanting.  The  abscess  usually  opens  spontaneously  into  the  mouth,  but  it 
may  open  externally  if  the  molar  teeth  are  the  ones  affected.  It  may 
even  lead  to  necrosis  of  the  jaw.  If  its  site  is  the  upper  jaw,  the  jnis  may 
find  its  way  into  the  nasal  cavity  or  into  the  maxillary  sinus. 

The  treatment  is,  in  the  first  place,  prophylactic.  This  requires  atten- 
tion to  the  teeth  to  prevent  decay,  and  the  removal  of  old  carious  fangs, 
which  are  a  constant  menace  to  the  health  of  the  child  in  more  ways  than 
one.  The  free  use  of  the  toothbrush  and  some  antiseptic  mouth-wash 
will,  in  the  great  majority  of  cases,  prevent  the  occurrence  of  this  disease. 
It  is  important  that  the  abscess  be  opened  early  and  free  drainage  secured. 
If  there  is  a  carious  tooth  it  should  be  drawn. 

DIFFICULT  DENTITION. 

The  place  of  dentition  as  an  etiological  factor  in  the  diseases  of  infancy 
is  one  which  has  given  rise  to  much  discussion.  From  a  very  early  period 
the  view  has  descended,  that  a  large  number  of  the  diseases  occurring  be- 
tween the  ages  of  six  months  and  two  years  are  due  to  difficult  dentition. 
The  list  of  such  diseases  is  a  long  one,  but  year  by  year  it  has  been  short- 
ened as  one  after  another  has  been  shown  to  depend  upon  other  causes, 
dentition  being  only  a  coincidence. 

At  the  present  time  many  good  observers  deny  that  dentition  is  ever  a 
cause  of  symptoms  in  children ;  some  even  going  so  far  as  to  say  that  the 
growth  of  the  teeth  causes  no  more  symptoms  than  the  growth  of  the 
hair.  Without  doubt  the  usual  mistake  made  in  practice  is  in  overlooking 
serious  disease  of  the  brain,  kidneys,  lungs,  stomach,  and  intestines,  because 
of  the  firm  belief  that  the  child  was  "  only  teething."  The  physician  who 
starts  out  with  the  idea  that  in  infancy  dentition  may  produce  all  symp- 
toms usually  gets  no  further  than  this  in  his  etiological  investigations. 
Although  I  strongly  believe  that  the  importance  of  dentition  as  an  etio- 
logical factor  in  disease  has  been  in  the  past  greatly  exaggerated,  and 
although  I  once  held  the  opinion  that  simple  dentition  never  produced 
symptoms,  I  have  been  compelled  by  clinical  observations  to  change  my 
opinion  upon  this  subject ;  and  I  am  now  willing  to  admit  that,  particu- 
larly in  delicate,  highly  nervous  children,  dentition  may  produce  many 
reflex  symptoms,  some  even  of  quite  an  alarming  character. 


278  DISEASES  OP   THE  DIGESTIVE   SYSTEM. 

Speaking  from  general  impressions,  not  from  statistics,  I  should  say- 
that  in  my  experience  about  one  half  of  the  healthy  children  cut  their 
teeth  without  any  visible  symptoms,  local  or  general ;  in  the  remainder 
some  disturbance  is  usually  seen,  and  though  in  most  cases  it  is  slight 
and  of  short  duration,  it  may  last  for  several  days  or  even  a  week.  The 
sj^mptoms  most  commonly  seen  are  disturbed  sleep,  or  wakefulness  at 
night  and  fretfulness  by  day,  so  that  children  often  sleep  only  one  half 
the  usual  time.  There  is  loss  of  appetite,  and  much  less  food  than  usual 
is  taken.  There  is  often,  but  not  always,  an  increase  in  the  salivary 
secretion,  a  slight  amount  of  catarrhal  stomatitis,  and  a  constant  dispo- 
sition on  the  part  of  the  child  to  stuff  the  fingers  into  the  mouth.  The 
bowels  are  often  constipated  or  there  may  be  slight  diarrhoea.  The  ther- 
mometer may  show  a  slight  elevation  of  temperature  to  100°  to  101  -5° 
F.  The  weight  may  remain  stationary  for  a  week  or  two,  and  there  may 
•even  be  a  loss  of  a  few  ounces.  The  duration  of  these  symptoms  in  most 
€ases  is  but  a  few  days,  and  they  require  no  special  treatment.  If  the 
food  is  forced  beyond  the  child's  inclination,  attacks  of  indigestion  with 
vomiting  and  diarrhoea  are  easily  excited. 

Symptoms  more  severe  than  the  above  are  rare  in  healthy  children, 
but  are  not  infrequent  in  those  who  are  delicate  or  rachitic.  In  such 
susceptible  children,  even  so  slight  a  thing  as  dentition  may  be  the  cause, 
or  at  least  the  exciting  cause,  of  quite  serious  symptoms.  Often  there 
is  some  other  factor  in  the  case,  such  as  bad  feeding  or  feeble  digestion. 
In  delicate  or  rachitic  children  there  may  be  seen  the  symptoms  already 
mentioned  as  occurring  in  healthy  infants,  but  in  greater  severity;  and 
in  addition  there  may  be  severe  attacks  of  acute  indigestion.  Occasion- 
ally there  is  an  elevation  of  temperature  to  102°  or  103°  F.,  lasting  usu- 
ally only  two  or  three  days,  and  accompanied  by  no  symptoms  except 
almost  complete  anorexia.  Convulsions  which  could  fairly  be  attributed 
to  dentition  I  have  seen  but  once;  they  are  more  apt  to  occur  in  rachitic 
■children.  There  are  certain  cases  of  eczema  in  which  the  symptoms 
undergo  a  distinct  exacerbation  with  the  eruption  of  each  group  of 
teeth.  As  regards  almost  all  the  other  diseases  which  are  commonly 
attributed  to  dentition,  I  believe  that  it  is  a  delusion  to  trace  them  to 
this  cause. 

The  physician  should  watch  a  child  carefully,  and  examine  it  fre- 
quently, to  be  sure  that  he  is  not  overlooking  some  serious  local  or  con- 
stitutional disease  before  he  allows  himself  to  make  the  diagnosis  of 
difficult  dentition.  Probably  in  ninety-five  per  cent  of  the  cases  in  which 
symptoms  are  present,  they  are  due  to  some  cause  other  than  denti- 
tion. When,  however,  symptoms  such  as  any  of  those  mentioned  disap- 
pear immediately  when  the  teeth  come  through,  and  when  we  see  them 
repeated  four  or  five  times  in  the  same  child  with  the  eruption  of  each 
group  of  teeth,  and  accompanied  by  red  and  swollen  gums,  I  think  we 


CATARRHAL   STOMATITIS.  279 

can  not  escape  the  conclusion  that  dentition  is  a  factor  in  their  pro- 
duction, though  perhaps  not  the  only  one. 

In  the  treatment  of  this  condition  drugs  occupy  but  a  small  place.  It 
should  be  remembered  that  infants  are  at  this  time  in  a  peculiarly  sus- 
ceptible condition  as  regards  the  digestive  tract,  and  attacks  of  indiges- 
tion, and  even  severe  diarrhcea,  are  readily  excited  from  slight  causes, 
especially  from  overfeeding.  Special  care  should  be  exercised  in  this 
respect.  The  strength  of  the  food  should  be  reduced,  as  well  as  the 
amount  given.  The  poor  appetite  indicates  a  feeble  digestion,  which 
should  not  be  overtaxed.  As  attacks  of  bronchitis  and  acute  nasal  ca- 
tarrh are  readily  induced,  even  slight  exposure  should  be  guarded 
against.  The  nervous  symptoms,  when  severe,  may  be  relieved  by  the 
use  of  moderate  doses  of  the  bromides  and  phenacetine,  better  than  by 
opiates.  All  soothing  syrups  should  be  discountenanced.  All  the  vari- 
ous devices  for  making  dentition  easy  are  a  delusion.  In  a  small  num- 
ber of  cases  lancing  the  gums  is  of  decided  value.  I  have  myself  seen 
marked  and  undoubted  relief  given  by  it.  This  is  likely  to  be  the  case 
where  the  gums  are  tense,  swollen,  and  very  red,  with  the  teeth  just 
beneath  the  mucous  membrane.  To  press  a  tooth  through  the  gum  by 
simply  rubbing  gently  with  the  finger  covered  with  sterile  gauze  is  fre- 
quently much  more  effective  than  an  incision.  It  is  seldom,  however, 
that  the  relief  expected  is  seen  from  any  of  these  measures. 

CATARRHAL   STOMATITIS. 

This  is  characterized  by  redness  and  swelling  of  the  mucous  mem- 
brane, and  by  increased  secretion  of  the  salivary  and  the  muciparous 
glands  of  the  mouth.  It  usually  involves  a  large  part  of  the  mucous 
membrane. 

Etiology. — Catarrhal  stomatitis  may  result  from  traumatism.  This 
injury  may  be  mechanical,  or  due  to  heat  or  any  irritant  accidentally 
taken  into  the  mouth.  It  frequently  occurs  at  the  time  of  the  eruption 
of  a  tooth.  It  complicates  measles,  scarlet  fever,  diphtheria,  influenza, 
and  many  other  infectious  diseases.  In  these  cases,  and  in  many  others, 
the  disease  is  probably  due  to  direct  infection. 

Lesions. — The  lesions  are  essentially  the  same  as  in  catarrhal  inflam- 
mations of  other  mucous  membranes.  There  are  congestion  with  des- 
quamation of  epithelial  cells,  and  sometimes  the  formation  of  superficial 
ulcers.  The  process  may  be  a  very  superficial  one.  or  it  may  extend  to 
the  submucous  tissue. 

Symptoms. — The  mucous  membrane  is  intensely  injected,  all  the 
capillaries  are  dilated,  and  small  haemorrhages  easily  excited.  The  mu- 
cous membrane  is  swollen,  this  being  most  apparent  over  the  gums  or 
about  the  teeth.  There  may  be  some  swelling  of  the  lips.  The  mouth 
seems  hot,  and  the  local  temperature  is  certainly  increased.    There  is  con- 


280  DISEASES   OP   THE  DIGESTIVE   SYSTEM. 

siderable  pain,  as  shown  by  f  retf  ulness,  but  particularly  by  the  disinclination 
to  take  food  :  infants,  though  evidently  hungry,  either  refusing  the  breast 
or  bottle  altogether,  or  dropping  it  after  a  few  moments.  The  increase  in 
secretion  is  sometimes  marked,  so  that  the  saliva  pours  from  the  mouth, 
irritating  the  lips  and  face  and  drenching  the  clothing.  In  other  cases 
the  saliva  is  swallowed.  On  close  inspection  there  may  be  seen  swelling 
of  the  muciparous  follicles,  and  even  the  formation  of  tiny  cysts  from  the 
accumulation  of  secretion  within  them  (Forchheimer).  The  tongue  is 
usually  coated,  the  edges  reddened,  and  the  papillse  prominent.  In  febrile 
diseases,  such  as  typhoid,  etc.,  we  may  get  an  accumulation  of  dead  epi- 
thelium with  the  formation  of  cracks  and  fissures  of  the  tongue,  and  the 
lips  may  present  a  similar  condition.  The  neighbouring  lymphatic  glands 
are  slightly  enlarged  and  tender.  The  constitutional  symptoms  accom- 
panying simple  stomatitis  are  not  severe,  but  some  disturbance  is  almost 
always  present.  There  may  be  derangement  of  digestion  with  vomiting, 
and  even  a  mild  attack  of  diarrhoea.  In  the  majority  of  cases  the  disease 
runs  a  short  course,  recovery  taking  place  in  a  few  days  when  the  primary 
cause  is  removed.  In  very  delicate  children  it  may  be  prolonged,  and 
from  the  interference  with  nutrition  may  even  lead  to  serious  conse- 
quences. 

Treatment. — The  mouth  and  teeth  should  be  kept  clean.  Food  is 
more  acceptable  if  given  cold.  In  very  severe  cases,  where  food  is  refused, 
gavage  may  be  resorted  to  three  or  four  times  daily.  In  all  cases  children 
may  be  given  ice  to  suck.  This  is  refreshing,  both  on  account  of  the  cold 
and  from  the  relief  to  the  thirst.  The  mouth  should  be  kept  clean  with 
a  solution  of  boric  acid,  ten  grains  to  the  ounce,  or  an  alkaline  solution, 
such  as  D obeli's,  diluted  with  an  equal  amount  of  cold  boiled  water ;  or 
simply  water  may  be  used.  In  the  severe  forms,  where  there  is  much 
swelling  and  slight  catarrhal  ulceration,  astringents  are  required.  In  my 
experience  alum  is  the  best ;  this  may  be  applied  in  the  form  of  the  pow- 
dered burnt  alum  mixed  with  an  equal  amount  of  bismuth,  or  in  solution, 
ten  grains  to  the  ounce,  with  a  swab  or  brush.  Where  ulcers  are  slow 
in  healing  and  very  painful,  the  powdered  burnt  alum  may  be  applied 
directly. 

HERPETIC   STOMATITIS. 
Synonyms  :  Aphthous,  vesicular,  follicular  stomatitis. 

In  this  form  of  stomatitis  we  have  the  appearance  first  of  small 
yellowish-white  isolated  spots,  and  subsequently  the  formation  of  super- 
ficial ulcers.  These  ulcers  are  first  discrete,  but  may  coalesce  and  form 
others  of  considerable  size.  It  is  a  self-limited  disease,  usually  running 
its  course  in  from  five  days  to  two  weeks. 

Etiology. — Very  little  is  as  yet  positively  known  regarding  the  cause 
of  herpetic  stomatitis.    It  is  not  common  in  the  first  year,  but  after  that 


HERPETIC   STOMATITIS.  281 

is  very  frequently  seen  throughout  childhood.  It  occurs  in  the  strong  as 
well  as  in  the  delicate.  It  is  often  associated  with  some  disturbance  of 
the  stomach,  and  occasionally  with  dentition.  I  have  adopted  the  term 
herpetic  because  the  condition  is  analogous  to  herpes  of  the  lips  and  face, 
the  difference  in  appearance  being  due  chiefly  to  location.  It  is  appar- 
ently caused  by  something  which  acts  upon  terminal  nerve  filaments. 

Lesions. — The  generally  accepted  opinion  is  that  there  is  first  a  vesi- 
cle, followed  by  a  death  of  epithelial  cells  covering  it,  and  then  a  super- 
ficial ulcer.  The  white  appearance  is  due  to  the  fact  that  the  ulcers, 
being  on  a  mucous  membrane,  are  always  moist.  These  ulcers  may 
extend  superficially,  but  never  deeply;  they  heal  quickly  with  the  for- 
mation of  new  epithelial  cells,  leaving  no  cicatrices.  Herpetic  stoma- 
titis is  always  associated  with  more  or  less  catarrhal  inflammation. 

Symptoms. — The  disease  is  characterized  by  local  and  general  symp- 
toms. The  former  are  quite  indefinite — general  indisposition,  loss  of 
appetite,  and  slight  fever.  The  local  symptoms  consist  in  the  develop- 
ment of  small,  shallow,  circular  ulcers,  usually  coming  in  successive 
crops.  While  most  frequent  at  the  border  of  the  tongue  and  the  inside 
of  the  lips,  they  may  be  found  upon  any  part  of  the  mucous  membrane 
of  the  mouth  or  the  pharynx.  There  may  be  only  half  a  dozen  present, 
or  the  mouth  may  be  filled  with  them.  They  are  first  of  a  ^^ellowish 
colour,  and  on  an  average  about  one-eighth  of  an  inch  in  diameter.  By 
the  coalescence  of  several  smaller  ones  there  may  form  patches  of  con- 
siderable size,  sometimes  nearly  covering  the  lips.  The  older  ulcers  are 
apt  to  have  a  dirty  grayish  colour,  and  in  places  may  look  not  unlike  a 
diphtheritic  membrane.  The  smaller  ones  are  surrounded  by  a  red  areola, 
and  when  healing  the  margin  is  of  a  bright-red  colour.  Their  appear- 
ance is  often  more  like  that  of  an  exudation  upon  the  mucous  membrane 
than  an  excavation  into  it.  The  other  symptoms  are  much  the  same  as 
in  catarrhal  stomatitis,  but  usually  of  greater  severity.  The  pain  is  par- 
ticularly intense,  it  being  often  difficult  to  induce  children  to  take  any- 
thing in  the  form  of  food.  The  tongue  is  frequently  coated,  but  there  is 
never  the  foul  breath  of  ulcerative  stomatitis.  The  duration  of  the  dis- 
ease is  from  one  to  two  weeks,  and,  if  the  child  is  in  good  condition,  com- 
plete recovery  takes  place  even  without  any  special  treatment.  In  badly 
nourished  children  the  disease  may  last  for  two  or  three  weeks ;  relapses 
may  occur,  and  the  condition  may  interfere  very  seriously  with  the  child's 
nutrition. 

Treatment. — This  is  the  same  as  in  catarrhal  stomatitis,  with  the 
addition  that  to  each  one  of  the  ulcers  finely  powdered  burnt  alum  should 
be  applied  with  a  camel's-hair  brush.  If  this  is  not  effective,  the  solid 
stick  of  nitrate  of  silver  may  be  used.  The  ulcers  will  usually  yield  rap- 
idly to  this  treatment.  In  my  experience,  drugs  given  with  the  purpose 
of  affecting  the  lesion  in  the  mouth  have  been  without  Ijenefit. 


282  DISEASES  OF  THE  DIGESTIVE   SYSTEM. 

ULCERATIVE  STOMATITIS. 

Ulcerative  stomatitis  is  believed  to  occur  only  when  teeth  are  pres- 
ent. It  is  characterized  by  an  ulcerative  process,  beginning  at  the  junc- 
tion of  the  teeth  and  the  gum,  and  extending  along  the  teeth;  it  occa- 
sionally involves  other  parts  of  the  mouth,  but  never  spreads  beyond  the 
buccal  cavity. 

Etiology. — A  form  of  ulcerative  stomatitis  is  produced  by  certain 
metallic  poisons,  especially  mercury,  lead,  and  phosphorus ;  but  all  these 
are  now  rare.  Ulcerative  stomatitis  also  occurs  in  scurvy;  and  it  seems 
probable  that  an  allied  disturbance  of  nutrition,  with  spongy,  swollen 
gums,  precedes  some  other  forms  of  ulcerative  stomatitis.  Bad  surround- 
ings and  improper  food  act  as  predisposing  causes;  for  the  disease  is 
quite  common  in  hospital  and  dispensary  patients,  although  rare  in  pri- 
vate practice.  Local  causes  of  some  importance  are  want  of  cleanliness 
of  the  mouth  and  teeth  and  the  presence  of  carious  teeth.  Conditions 
which  produce  a  lowered  vitality  of  the  gums  act  as  a  predisposing  cause, 
and  infection  as  an  exciting  cause  of  the  disease.  The  constant  clinical 
features  of  ulcerative  stomatitis  and  the  occasional  occurrence  of  epi- 
demics indicate  a  specific  cause.* 

Lesions. — The  disease  may  begin  at  any  part  of  the  mouth,  but  most 
frequently  upon  the  outer  surface  of  the  gum  along  the  lower  incisor 
teeth.  From  this  point  it  extends  behind  the  teeth,  and  from  the  in- 
cisors to  the  canines  and  molars,  usually  of  one  side  only;  but  it  may 
involve  the  entire  gum  of  both  jaws.  From  the  gums  the  process  may 
spread  to  the  lips,  affecting  the  fold  of  mucous  membrane  between  the 
gum  and  the  lip,  and  also  to  the  inner  surface  of  the  cheek,  especially 
opposite  the  molar  teeth,  where  large  ulcers  often  form.  In  neglected 
cases  the  disease  may  extend  into  the  alveolar  sockets,  the  teeth  loosen- 
ing and  falling  out.  The  periosteum  of  the  alveolar  process  may  be  in- 
volved, and  even  superficial  necrosis  of  the  jaw  may  occur,  as  has  hap- 
pened in  several  cases  that  came  under  my  observation. 

Ulcers  similar  in  appearance  may  also  be  present  in  other  parts  of 
the  mouth — i.  e.,  on  the  soft  palate  or  the  tonsils,  sometimes  even  when 
the  gums  are  not  involved. 

Symptoms. — The  first  things  noticed  are  the  very  offensive  breath 
and  the  profuse  salivation.    It  is  usually  for  one  of  these  symptoms  that 

*  The  most  important  bacteriological  investigations  of  this  disease  are  those  of 
Bernheim  and  Pospischill  (Jahrbueh  fur  Kinderheilk.,  xlvi,  434).  Of  thirty  cases 
studied,  in  all  but  two,  both  mild  ones,  they  found  two  micro-organisms  associated ; 
sometimes  one  and  sometimes  the  other  predominated.  One  was  a  fusiform  bacillus 
often  bent,  with  sharp  ends,  somewhat  resembling  the  diphtheria  bacillus  but  larger; 
it  was  stained  by  methyl  blue  and  decolourized  by  Gram.  The  other  was  a  spiral 
form.  It  is  interesting  to  note  that  similar  bacteria  were  found  by  Miller  in  carious 
teeth,  and  by  Vincent  in  ulcero-membranous  tonsillitis  (see  page  806). 


ULCERATIVE  STOMATITIS.  283 

the  patient  is  brought  for  treatment.  On  inspection  of  the  mouth,  there 
are  seen  in  the  mild  cases,  swollen,  spongy  gums  of  a  deep-red  or  purplish 
colour,  which  bleed  at  the  slightest  touch.  There  is  a  line  of  ulceration, 
usually  along  the  incisor  teeth,  most  marked  in  front,  which  may  ex- 
tend to  any  or  to  all  of  the  teeth;  sometimes  it  affects  only  the  gum 
along  the  molar  teeth,  the  incisors  escaping.  At  the  junction  of  the 
teeth  and  gum  is  seen  a  dirty,  yellowish  deposit,  on  the  removal  of  which 
free  bleeding  takes  place.  The  diseased  parts  are  very  painful,  and  the 
child  cries  and  resists  any  attempt  at  examination.  In  the  more  severe 
cases  and  in  those  of  longer  duration  the  teeth  are  loosened,  sometimes 
being  so  loose  that  they  can  be  picked  from  the  gum.  There  may  be 
necrosis  of  the  jaw,  and  even  a  loose  sequestrum  may  be  found.  In 
these  cases  the  ulceration  along  the  gums  is  deeper,  and  there  may  be 
ulcers  in  the  cheek  opposite  the  molar  teeth,  or  inside  the  lip.  The 
swelling  may  be  so  great  that  the  teeth  are  almost  covered ;  this  is  seen 
particularly  in  the  scorbutic  form.  The  saliva  pours  from  the  mouth, 
adding  greatly  to  the  discomfort  of  the  patient.  Beneath  the  jaw  are 
felt  the  large,  swollen  lymphatic  glands,  which  are  painful  and  tender  to 
the  touch,  but  show  no  tendency  to  suppurate.  The  tongue  is  somewhat 
swollen,  and  shows  at  the  edges  the  imprint  of  the  teeth ;  it  has  a  thick, 
dirty  coating. 

The  disease  is  attended  by  little  or  no  fever  or  other  constitutional 
symptoms.  The  general  condition  of  these  patients  is  often  poor,  and 
there  may  be  quite  a  marked  cachexia.  Other  forms  of  stomatitis  may  be 
associated,  and  it  should  not  be  forgotten  that  the  gangrenous  form  may 
follow. 

When  not  recognised  or  not  properly  treated,  ulcerative  stomatitis 
may  last  for  months.  When  properly  treated  it  tends  in  all  recent  cases 
to  rapid  recovery,  usually  in  a  few  days.  No  deformity  of  the  mouth 
is  left,  the  only  untoward  results  being  shrinking  of  the  gum,  sometimes 
loss  of  some  of  the  incisor  teeth,  and  more  rarely  a  superficial  necrosis 
of  the  alveolar  process.  All  these  are  quite  uncommon.  Ulcerative 
stomatitis  can  hardly  be  confounded  with  any  other  form,  and  not  only 
should  a  diagnosis  of  the  lesion  be  made,  but  the  condition  upon  which 
it  depends  should,  if  possible,  be  discovered;  scorbutus,  particularly, 
should  not  be  overlooked. 

Treatment. — The  first  thing  to  be  done  is  to  remove  the  cause.  When 
dependent  upon  metallic  poisoning  the  source  should  be  discovered. 
Scorbutic  cases  should  have  the  usual  anti-scorbutic  diet.  Cleanliness  of 
the  mouth  is  of  great  importance,  and  this  may  best  be  accomplished  by 
the  use  of  peroxide  of  hydrogen  diluted  with  from  one  to  four  parts  of 
water.  It  should  be  followed  by  plain  water,  and  repeated  several  times 
a  day.  In  other  cases  an  astringent  solution  of  alum,  five  grains  to  the 
ounce,  or  a  mouth-wash  of  chlorate  of  potash,  three  grains  to  the  ounce. 


284:  DISEASES  OF   THE   DIGESTIVE  SYSTEM. 

may  be  employed.  The  only  objection  to  the  last  mentioned  is  the  pain 
which  it  usually  produces. 

The  specific  remedy  for  ulcerative  stomatitis  is  chlorate  of  potash. 
The  best  method  of  administration  is  to  give  two  grains,  or  one-half  tea- 
spoonful  of  a  saturated  solution,  largely  diluted,  every  hour  during  the 
day  for  the  first  twenty-four  hours  and  subsequently  every  two  hours; 
when  improvement  occurs  the  dose  may  be  still  further  reduced. 
Marked  benefit  is  usually  seen  in  one  or  two  days  even  in  cases  that  have 
lasted  for  several  weeks.  If  the  case  does  not  yield  readily  to  this  treat- 
ment there  is  probably  disease  at  the  roots  of  the  teeth,  and  when  loose 
these  should  be  removed,  and  the  jaw  examined  to  see  if  there  is  necro- 
sis. Occasionally  when  there  is  no  disposition  to  heal,  the  shreds  of 
necrotic  tissue  should  be  carefully  removed,  and  burnt  alum  or  nitrate 
of  silver  applied. 

The  constitutional  and  dietetic  treatment  in  all  these  cases  should 
be  the  same  as  that  employed  in  scurvy — i.  e.,  plenty  of  fruit,  fresh  vege- 
tables, and  sometimes  the  internal  administration  of  mineral  acids,  espe- 
cially aromatic  sulphuric  acid.     Iron  is  indicated  in  most  of  the  cases. 

TJlceration  of  the  Hard  Palate. — This  is  usually  seen  in  the  first  few 
weeks  of  life,  but  may  occur  in  any  child  suffering  from  marasmus.  The 
primary  cause  may  be  the  injury  inflicted  in  cleansing  the  mouth.  In 
other  cases  it  is  due  to  the  friction  of  the  rubber  nipple,  or  something 
else  which  the  child  is  allowed  to  suck.  In  still  others  it  is  apparently 
produced  by  the  habit  of  tongue-sucking  frequently  observed  in  these 
young  infants.  The  appearances  are  quite  characteristic :  there  is  found, 
rather  far  back  upon  the  hard  palate,  usually  in  the  middle  line,  a  super- 
ficial ulcer,  from  a  fourth  to  a  half  inch  in  diameter.  There  are  no  signs 
of  acute  inflammation.  Thrush  may  coexist,  but  it  has  no  relation  to 
the  production  of  the  disease.  Spontaneous  recovery  usually  occurs  in 
from  one  to  three  weeks,  provided  the  cause  can  be  removed.  In  children 
suffering  from  marasmus  these  ulcers  are  very  intractable,  and  in  many 
instances  their  cure  is  practically  impossible.  It  is  therefore  especially 
important  to  prevent,  if  possible,  their  formation  by  care  in  cleansing  the 
mouth,  and  in  avoiding  the  other  causes  referred  to.  Wlien  ulcers  have 
appeared  they  should  be  treated  as  cases  of  herpetic  stomatitis. 

THRUSH. 

Synonyms :  Sprue ;  German,  Soor ;  French,  Miiguet. 

Thrush  is  a  parasitic  form  of  stomatitis  characterized  by  the  appear- 
ance upon  the  mucous  membrane,  usually  of  the  tongue  or  of  the  cheeks, 
of  small  white  flakes  or  larger  patches.  It  is  common  in  infants  of  the 
first  two  or  three  months,  and  in  all  the  protracted  exhausting  diseases 
of  early  life. 


THRUSH. 


285 


Etiology. — The  exact  class  to  which  the  vegetable  parasite  which 
produces  thrush  belongs  has  not  yet  been  definitely  settled.  Eo bin's  opin- 
ion was  long  accepted  that  it  was  the  o'idium  albicans ;  the  view  of  Gra- 
witz,  that  it  is  the  saccharomyces  albicans,  is  now  more  generally  adopted. 
If  a  little  of  the  exudate  from  the  mouth  is  placed  upon  a  slide  and  a 
■drop  of  liquor  potassa3  added,  the  structure  of  the  fungus  is  readily  seen. 
With  the  low  power  of  the  microscope  there  can  be  made  out  fine  threads 
(the  mycelium)  and  small  oval  bodies  (the  spores).  With  a  high  power 
the  threads  can  be  seen  to 

be  made  up  of  a  number  of  /v\^  rT~~\  .i  '""  ll/Zii^ 
shorter  rods,  at  the  ends  of 
which  the  spore  formation 
takes  place  (Fig.  53).  The 
mycelium  is  produced  from 
the  spores.  The  spores  of 
this  fungiis  are  of  very  com- 
mon occurrence  in  the  at- 
mosphere. It  is  difficult  or 
impossible  for  thrush  to  de- 
velop upon  a  healthy  mucous 
membrane.  Its  growth  is 
favoured  by  slight  abrasions, 
such  as  are  often  produced 
by  rough  methods  of  cleans- 
ing the  mouth ;  also  by  catar- 
rhal stomatitis,  a  scanty  salivary  secretion  and  want  of  cleanliness.  The 
fungus  may  grow  in  a  medium  of  any  reaction,  but  best  in  one  which 
is  slightly  alkaline  or  neutral.  The  nature  of  the  process  which  it  pro- 
duces is  in  all  probability  a  sugar  fermentation,  the  acid  reaction  of  the 
mouth  being  the  result  of  the  growth  rather  than  its  cause.  Infection 
may  come  from  another  patient  by  means  of  a  rubber  nipple  or  a  cloth 
which  has  been  used  for  the  infected  mouth,  from  the  nipple  of  the 
nurse,  or  directly  from  the  air.  The  disease  is  an  exceedingly  common 
one  in  foundling  asylums,  in  all  ]ilaees  where  many  young  infants  are 
crowded  together,  and  where  cleanliness  of  mouths,  bottles,  etc.,  is 
neglected.  It  is  especially  frequent  in  children  suffering  from  malnutri- 
tion, marasmus,  or  other  wasting  diseases,  and  in  those  who  have  hare- 
li]).  or  any  deformity  of  the  mouth. 

Lesions. — According  to  Forchheimcr,  flio  spores  lodge  between  the 
epithelial  cells  and  gradually  separate  the  different  layers.  This  occurs 
before  the  fnrmntinn  of  the  white  polliole.  Later  the  disease  spreads  on 
the  surface  oT  the  imicous  iiicinliranc,  and  also  penetrates  the  deeper 
structures.  It  may  invade  the  blood-vessels  and  cause  thrombosis  or 
even  be  carried  to  distant  parts.  Although  the  saccharomyces  albicans 
20 


Fig  53 — Thrush  funsfus  (highlv  m^.rmfied)  a  my 
celium ,  b,  spores,  c,  epithelial  ctlls  from  the 
mouth;  (£,  leucocytes ;  «,  detritus.     (Jaksch.) 


286  DISEASES  OF   THE  DIGESTIVE  SYSTEM. 

is  commonly  found  upon  flat  epithelium,  its  growth  is  not  confined  to  it. 
It  usually  begins  at  many  distinct  points  upon  the  mucous  membrane, 
and  gradually  spreads  until  coalescence  takes  place ;  a  continuous  mem- 
brane may  be  thus  formed.    jSTo  pus  is  produced  by  the  process. 

The  usual  seat  is  the  tongue,  the  inside  of  the  cheeks,  and  the  hard 
palate,  but  not  infrequently  it  involves  the  lips,  the  tonsils,  the  pillars  of 
the  fauces,  and  the  pharynx.  Further  extension  in  the  digestive  tract 
than  this  is  rare,  although  the  stomach,  and  even  the  intestines,  may  be 
invaded.  I  have  seen  it  but  once  or  twice  in  the  oesophagus  and  never 
in  the  stomach,  and  I  know  of  but  two  reported  cases  in  this  country  in 
which  thrush  has  been  found  there.  Cases  involving  the  oesophagus  and 
the  stomach  appear  from  reports  to  be  much  more  common  in  Europe. 
In  three  cases  in  the  Babies'  Hospital  the  saccharomyces  albicans  has 
been  found  in  the  lungs  of  infants  suffering  from  broncho-pneumonia. 

Symptoms. — The  essential  symptoms  of  thrush  are  the  appearance 
upon  the  mucous  membrane  of  the  mouth — usually  beginning  upon  the 
tongue  or  the  inner  surface  of  the  cheek — of  small  white  flakes  which 
resemble  desposits  of  coagulated  milk,  but  which  differ  from  them  in  the 
fact  that  they  can  not  be  wiped  off.  If  forcibly  removed,  they  usually 
leave  a  number  of  bleeding  points.  There  may  be  only  a  few  scattered 
patches,  or  the  mouth  and  pharynx  may  be  covered.  The  mouth  is  gen- 
erally dry,  the  tongue  coated;  food  may  be  refused  on  account  of  pain, 
and  there  may  be  some  difficulty  in  swallowing.  The  other  symptoms 
depend  upon  the  conditions  with  which  the  thrush  is  associated. 

Diagnosis. — This  is  rarely  difficult.  The  deposit  may  be  mistaken  for 
coagulated  milk,  but  is  distinguished  by  the  features  just  mentioned. 
When  existing  upon  the  pharynx  and  fauces  it  has  been  confounded  with 
diphtheria,  although  this  mistake  can  hardly  be  made  if  all  the  facts 
of  the  case  are  taken  into  consideration — the  age  of  the  patient,  the  in- 
volvement of  the  lips  and  tongue,  the  dry  mouth,  the  absence  of  glandu- 
lar enlargement,  etc.  In  any  case  of  doubt  the  examination  of  the  de- 
posit under  the  microscope  at  once  reveals  its  true  nature. 

Prognosis. — Thrush  is  not  in  itself  a  dangerous  disease,  except  in  the 
very  rare  instances  where  it  may  obstruct  the  oesophagus,  and  this  can 
hardly  occur  except  in  a  condition  of  exhaustion  which  is  necessarily 
fatal.  In  a  feeble  and  delicate  infant,  thrush  may  be  a  serious  complica- 
tion by  interfering  with  the  taking  of  sufficient  nourishment.  With 
proper  treatment  most  of  the  cases  involving  only  the  mouth  are  readily 
cured. 

Treatment. — Thrush  may  be  prevented  in  almost  every  case  by  due 
attention  to  cleanliness  of  the  mouth,  rubber  nipples,  bottles,  cloths,  etc. 
All  rubber  nipples  should  be  kept  in  a  solution  of  borax  or  salicylate  of 
soda,  and  the  child's  mouth  should  be  cleansed  several  times  a  day.  On 
no  account  should  a  feeding-bottle  be  passed  from  one  child  to  another. 


GONORRHCEAL  STOMATITIS.  287 

In  the  treatment  of  the  disease  the  essential  things  are  cleanliness, 
and  the  use  of  some  mild  antiseptic  mouth-wash.  The  routine  treat- 
ment which  I  have  followed  for  many  years,  both  in  hospital  and  private 
practice,  is  to  cleanse  the  mouth  carefully  after  every  feeding  or  nursino- 
with  a  solution  of  borax  or  bicarbonate  of  soda,  and  to  apply  four 
times  a  day  a  saturated  solution  of  boric  acid  or  a  3-per-cent  solution 
of  nitrate  of  silver  once  daily  with  a  camel's-hair  pencil.  All  applica- 
tions should  be  carefully  made,  so  as  not  to  injure  the  epithelium.  The 
best  method  of  cleansing  is  by  the  finger  wrapped  in  absorbent  cotton, 
or  b}''  a  swab.  Applications  to  be  specially  avoided  are  those  mixed  with 
honey  or  any  syrup.  In  several  hospital  cases  the  disease  seemed  to  be 
prolonged  by  the  irritation  of  the  rubber  nipple  of  the  feeding-bottle.  In 
such  it  has  been  our  practice  to  feed  by  gavage  for  two  or  three  days,  as 
all  cases  improved  much  more  rapidly  when  this  was  done. 

GOXORRHCEAL  STOMATITIS. 

There  has  been  described  by  Dohrn  and  Rosinski  a  form  of  stomatitis 
in  the  newly  born,  due  to  a  gonorrhoeal  infection.  This  is  not  likely  to 
take  place  unless  the  epithelium  has  been  removed.  The  infection  in  all 
cases  occurred  from  the  mother.  The  lesion  consists  in  the  formation  of 
yellowish-white  patches  upon  the  tongue  or  hard  palate — regions  in 
which  the  epithelium  is  liable  to  be  injured  by  rough  attempts  at  cleans- 
ing the  mouth.  There  may  be  other  evidences  of  gonorrhoeal  infection, 
especially  ophthalmia.  The  diagnosis  rests  upon  the  discovery  of  the 
gonococcus  in  the  exudate.  In  all  the  cases  cited  the  general  health  was 
not  affected,  and  recovery  followed  in  the  course  of  a  week  or  ten  da3'S. 

The  treatment  consists  in  thorough  cleanliness  and  in  the  application 
of  a  saturated  solution  of  boric  acid,  as  in  thrush. 

SYPHILITIC  STOMATITIS. 

The  buccal  symptoms  of  hereditary  syphilis  are  important  both  from 
a  diagnostic  and  therapeutic  standpoint.  The  most  frequent  lesions  are 
fissures,  ulcers,  and  mucous  patches.  Fissures  are  found  upon  the  lips, 
most  frequently  at  the  angle  of  the  mouth,  and  are  usually  multiple. 
They  may  be  quite  deep  and  cause  frequent  htemorrhages.  Mucous 
patches  are  superficial  ulcers  developing  from  papules  which  form  upon 
the  mucous  or  muco-cutaneous  surfaces.  In  cases  of  acquired  syphilis 
in  children  the  primary  sore  may  be  seen  upon  the  tongue,  the  lip,  or  the 
tonsil.  All  these  symptoms  are  more  fully  considered  in  the  chapter  on 
Syphilis. 

DIPHTHERITIC  STOMATITIS. 

In  severe  cases  of  diphtheria  the  membrane  is  found  not  only  upon  the 
pharynx  and  tonsils,  but  it  may  appear  anywhere  upon  the  buccal  mucous 


288  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

membrane  or  the  lips.  It  is  questionable  whether  the  diphtheritic  pro- 
cess ever  begins  in  the  mucous  membrane  of  the  mouth,  or  is  ever 
limited  to  this  part.  In  my  own  experience  diphtheritic  stomatitis  has 
always  been  associated  with  deposits  upon  the  tonsils  and  pharynx.  It 
is  seen  only  in  the  severest  cases,  and  in  those  which,  from  other  con- 
ditions present,  are  almost  necessarily  fatal.  Bearing  in  mind  the  above 
points,  it  can  hardly  be  mistaken  for  any  other  variety  of  stomatitis, 
although  not  infrequently  the  mistake  is  made  of  regarding  as  diph- 
theritic, cases  of  herpetic  stomatitis  in  which  the  ulcers  have  coalesced. 
The  treatment,  so  far  as  the  mouth  is  concerned,  consists  in  cleanliness 
by  frequent  gargling  or  s}'Tinging  with  a  saturated  solution  of  boric  acid. 
Forcible  removal  of  the  membrane  is  not  to  be  advised. 

GANGRENOUS  STOMATITIS— NOMA. 
Synonym :  Cancrum  oris. 

The  term  noma  is  used  to  designate  all  forms  of  spontaneous  gan- 
grene occurring  in  children,  which  involve  mucous  membranes  or  muco- 
cutaneous orifices.  The  most  frequent  situation  being  the  mouth,  noma 
and  gangrenous  stomatitis  are  often  used  synonymously.  Xoma  may, 
however,  affect  the  nose,  external  auditory  canal,  vulva,  prepuce,  or  anus. 
It  is  a  rare  disease,  and  usually  terminates  fatally. 

Etiology. — Xoma  is  seldom  seen  outside  of  institutions  for  children, 
where  small  epidemics  are  not  uncommon.  It  is  usually  secondary  to 
some  of  the  infectious  diseases,  most  frequently  following  measles,  and 
next  to  this  scarlet  fever,  typhoid,  or  whooping-cough.  While  it  may 
occur  at  any  age,  most  of  the  cases  are  in  children  under  five  years,  and 
in  those  of  poor  general  condition.  Xoma  seldom  attacks  parts  previ- 
ously healthy.  In  the  mouth  it  may  be  preceded  by  catarrhal,  or  more 
often  by  ulcerative  stomatitis;  in  the  auditory  canal,  by  a  chronic  otitis 
media.  There  seems  little  doubt  that  the  disease  is  contagious.  In 
1899  I  saw  five  cases  in  a  single  ward,  all  beginning  in  the  auditory 
canal,  which  were  apparently  produced  by  the  use  of  the  same  syringe  to 
clean  the  ears  without  proper  disinfection.  All  these  children  were  suf- 
fering from  whooping-cough  at  the  time. 

The  results  of  bacteriological  studies  of  noma  are  not  uniform,  nor 
as  yet  conclusive.  In  the  gangrenous  tissue  pyogenic  cocci  and  putre- 
factive bacteria  are  usually  abundant.  In  the  border  zone,  and  extend- 
ing into  the  adjacent  healthy  tissue,  bacilli  have  been  found  which  are 
regarded  by  Babes,  Bartels,  Schmidt,  and  others  as  the  specific  organism 
of  the  disease,  although  they  do  not  altogether  agree  in  their  descrip- 
tions. In  eases  reported  by  Freymuth,  Petruschky.  and  in  one  of  my 
own,  bacilli  closely  resembling,  if  not  identical  with,  diphtheria  bacilli 
'were  found.  Others  have  ascribed  the  disease  to  streptococci.  It  is  not 
improbable  that  more  than  one  micro-organism,  or  even  other  agents. 


GANGRENOUS  STOMATITIS— NOMA.  289 

may  under  certain  conditions  have  the  power  of  causing  this  form  of 
gangrene. 

Lesions. — The  process  is  one  of  slowly  spreading  gangrene.  In  most 
of  the  cases  there  are  thrown  out  inflammatory  products  in  quite  large 
amount,  but  there  is  little  or  no  tendency  to  limitation  of  the  disease. 
This  usually  advances  steadily  until  death  occurs.  In  a  small  number  of 
cases  a  line  of  demarcation  finally  forms,  and  the  slough  separates,  leav- 
ing a  large  area  to  be  partially  filled  in  by  granulation  and  cicatrization. 
Other  infectious  processes  are  liable  to  accompany  the  disease,  particu- 
larly broncho-pneumonia. 

Symptoms. — The  constitutional  symptoms  are  not  usually  severe 
until  the  local  disease  has  existed  for  several  days.  Then  those  of 
marked  prostration  and  sepsis  develop,  sometimes  quite  rapidly.  The 
temperature  is  usually  elevated  to  102°  or  103°  F.,  and  sometimes  to 
104°  or  105°  F.  There  are  dulness,  apath}^,  feeble  pulse,  muscular  re- 
laxation, and  very  often  diarrhoea.  Before  death  the  temperature  may 
be  subnormal. 

Of  the  local  symptoms,  often  the  first  to  attract  attention  is  the  odour 
of  the  breath ;  sometimes  it  is  the  dusky  spot  on  the  cheek  or  lip.  On 
examination  of  the  mouth,  there  usually  is  found  upon  the  gum  or  inside 
of  the  cheek  a  dark,  greenish-black  necrotic  mass,  surrounded  by  tissues 
which  are  swollen  and  cedematous,  so  that  the  cheek  or  lips  may  be 
two  or  three  times  their  normal  thickness.  Externally  the  parts  are 
tense  and  brawny  from  the  swelling,  this  infiltration  always  extending 
for  some  distance  beyond  the  gangrenous  part.  As  the  process  extends, 
the  teeth  loosen  and  fall  out ;  there  may  be  necrosis  of  the  alveolar  pro- 
cess of  the  jaw  and  perforation  of  one  or  both  cheeks  or  lower  lip.  Ex- 
tensive sloughing  of  the  face  may  take  place,  usually  upon  one  side, 
sometimes  upon  both,  giving  the  patient  a  horrible  appearance,  as  shown 
in  Fig.  54.  In  this  patient  the  process  began  in  the  right  cheek,  subse- 
Cjuently  involving  the  left;  perforation  occurred  in  both  cheeks,  and 
before  death  a  large  part  of  the  face  was  gangrenous.  The  odour  from 
a  severe  case  is  very  offensive,  and,  in  spite  of  all  efforts  at  disinfection, 
it  may  fill  the  ward  or  even  the  house.  Pain  is  rarely  severe,  and  in  many 
cases  it  is  absent.     Extensive  haemorrhages  are  rare. 

I  have  notes  of  seven  cases  in  which  noma  affected  the  ear,  being 
preceded  l)y  elironic  otitis  media  in  every  instance.  The  disease  began 
in  the  deeper  structures  of  the  canal,  the  first  symptom  noticed  usually 
being  a  nodular  swelling  just  beneath  the  ear,  crowding  the  lobe  upward. 
Shortly  afterward  there  appeared  the  dirty  brown  discharge  with  a  gan- 
grenous odour;  later,  the  gangrenous  circle  surrounding  the  meatus. 
This  gradually  extended,  until  in  some  cases  the  wliolo  side  of  the  face 
and  head  were  involved.  A  probe  could  readily  be  passed  into  tlie  cra- 
nial cavity.    All  these  cases  ended  fatally. 


290  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

The  usual  duration  of  the  disease  is  from  five  to  ten  days.  If  recov- 
ery takes  place,  there  is  first  seen  a  line  of  demarcation ;  then  the  slough 
is  thrown  off,  and  granulation  and  cicatrization  begin,  but  require  a  long 
time,  usually  leaving  an  unsightly  deformity. 

The  prognosis  is  grave,  about  three-fourths  of  the  cases  proving 
fatal.  The  results  depend  not  only  upon  the  disease  itself,  but  upon 
the  condition  of  the  patient  with  which  it  is  associated. 


Fig.  54. — Gangrenous  stomatitis,  following  measles.     (From  a  photogi'aph  lent  by 
Dr.  Henry  Moftat.) 

Gangrenous  stomatitis  can  hardly  be  mistaken  for  any  other  form  of 
disease  occurring  in  the  mouth,  and  early  recognition  is  of  great  impor- 
tance, since  only  early  treatment  is  likely  to  be  successful. 

Treatment. — Much  can  be  done  to  prevent  the  disease  by  careful 
attention  to  all  the  milder  forms  of  stomatitis,  particularly  to  the  ulcera- 
tive variety.  Frequent  and  thorough  cleansing  of  the  mouth  in  all  acute 
infectious  diseases  is  a  part  of  the  treatment  which  is  too  often  neglected. 
This  should  be  a  matter  of  routine  in  every  severe  illness  in  a  young 
child.  Eecognising  the  malignant  nature  of  gangrenous  stomatitis,  its 
treatment  should  be  radical  from  the  very  outset.  Of  the  measures 
which  have  been  proposed,  that  which  seems  to  oifer  the  best  chance  of 
arresting  the  process  is  excision  with  cauterization.  This  should  be 
done  under  anesthesia.  In  excising,  one  should  go  some  distance  into 
tissues  apparently  healthy,  for  the  reason  that  the  process  has  always 


ACUTE  PHARYNGITIS.  291 

advanced  farther  in  the  subcutaneous  tissues  than  in  the  skin.  The 
edges  of  the  wound  should  then  be  thoroughly  cauterized,  best  by  the 
Paquelin  cautery.  Of  the  other  means  employed,  the  use  of  strong  nitric 
acid  is  probably  the  best.  This  is  to  be  used  after  excising,  or  curetting 
the  necrotic  tissue.  Cases  have  been  reported  in  which  the  use  of  anti- 
streptococcus  serum,  and  also  the  diphtheria  antitoxin,  have  appeared  to 
arrest  the  disease.  The  mouth  should  be  kept  as  clean  as  possible  by  the 
use  of  peroxide  of  hydrogen  or  permanganate  of  potash.  The  general 
treatment  should  be  supporting  and  stimulating.  As  the  possibility  of 
contagion  exists,  every  case  should  be  isolated. 


CHAPTER    II. 

DISEASES  OF  THE  PHARYNX. 

ACUTE   PHARYNGITIS. 

Acute  pharyngitis  may  exist  as  a  primary  disease,  or  with  any  of  the 
infectious  diseases,  particularly  scarlet  fever,  measles,  diphtheria,  or 
influenza.  Secondary  pharyngitis  will  be  considered  in  connection  with 
these  different  diseases. 

Certain  children  have  a  constitutional  predisposition  to  attacks  of 
acute  pharyngitis,  and  contract  it  upon  the  slightest  provocation.  In 
some  of  them  there  is  a  strongly  marked  rheumatic  diathesis.  Attacks 
of  acute  pharyngitis  often  follow  exposure.  In  many  cases  they  are 
associated  with  acute  disturbances  of  digestion.  All  of  the  above 
causes  probably  act  by  producing  local  and  general  conditions  favour- 
able to  the  development  of  micro-organisms  already  present  in  the 
mouth.  They  are  cases  of  auto-infection.  The  bacteria  most  frequently 
associated  with  severe  attacks  are  streptococci,  less  frequently  staphylo- 
cocci and  pneumococci. 

In  acute  catarrhal  pharyngitis  the  inflammation  may  involve  the  en- 
tire mucous  membrane  of  the  tonsils,  fauces,  uvula,  posterior  and  lateral 
pharyngeal  walls,  or  any  part  of  it.  It  may  exist  alone,  or  in  connection 
with  a  similar  inflammation  in  the  rhino-pharynx  or  in  the  larynx.  In 
the  beginning  there  is  seen  an  acute  erythematous  blush,  usually  involv- 
ing the  entire  pharynx.  This  may  entirely  subside  after  twenty-four 
hours,  or  it  may  be  followed  by  the  usual  changes  of  acute  catarrhal  in- 
flammation— dryness,  swelling,  and  oedema.  Later  there  is  increased 
secretion  of  mucus,  and  finally  there  may  1)0  muoo-pus.  Occasionally 
slight  haemorrhages  are  present. 

There  is  pain  at  the  angle  of  the  jaws,  whidi  is  increased  by  swallow- 
ing, also  a  sensation  of  dryness  and  roughness  in  the  phar}Tix,  and  often 
iin  irritating  cough.     There  may  be  slight  swelling  of  the  neighbouring 


292  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

lymphatic  glands.  The  constitutional  symptoms  in  yoimg  children  are 
often  severe.  Not  infrequently  there  is  a  sudden  onset  with  vomiting, 
and  a  rise  of  temperature  to  103°  or  even  104°  F.  These  symptoms  are 
usually  of  short  duration,  frequently  less  than  twenty-four  hours,  and  in 
two  or  three  days  the  patient  may  be  entirely  well.  In  other  cases  the 
pharyngitis  may  be  accompanied  or  followed  by  laryngitis. 

Acute  primary  pharyngitis  is  to  be  distinguished  from  scarlet  fever,, 
measles,  and  influenza.  A  positive  diagnosis  from  scarlet  fever  is  im- 
possible until  a  sufficient  time  has  elapsed  for  the  eruption  to  appear,, 
and  the  patient  should  be  closely  watched  for  the  first  sign  of  this. 
If  scarlet  fever  is  prevalent,  a  child  with  the  symptoms  of  severe  phar- 
yngitis should  at  once  be  isolated  while  waiting  for  the  diagnosis  to  be- 
settled.  There  is  commonly  less  difficulty  in  excluding  measles  because 
of  the  presence  of  Koplik's  sign  on  the  buccal  mucous  membrane,  and 
the  accompanying  catarrh  of  the  ej^es  and  nose.  Influenza  is  recognised 
only  by  the  greater  severity  of  the  constitutional  symptoms  and  the  prev- 
alence of  an  epidemic. 

The  first  step  in  the  treatment  of  acute  pharyngitis  is  to  open  the- 
bowels  freely  by  means  of  calomel,  castor  oil,  or  magnesia.  The  child 
should  be  kept  in  bed,  and  the  diet  should  be  fluid,  or,  in  the  case  of 
infants,  the  amount  of  food  should  be  much  reduced.  Pieces  of  ice  may 
be  swallowed  frequently  for  the  relief  of  pain  and  thirst.  Internally 
there  may  be  given  two  grains  of  phenacetine  every  four  hours  to  a  child 
of  three  years.  It  is  important  at  the  outset  to  induce  free  perspira- 
tion. The  disease  is  not  serious,  and  the  indications  are  to  make  the 
child  as  comfortable  as  possible  during  the  short  attack.  I  have  seen 
but  little  benefit  from  the  use  of  aconite,  although  for  years  I  saw  it 
used  as  a  routine  treatment. 

UVULITIS. 

Acute  inflammation  of  the  uvula,  with  swelling  and  oedema,  occurs  as- 
a  part  of  the  lesion  in  acute  pharyngitis.  In  rare  instances  the  uvula 
may  be  the  principal  or  the  only  seat  of  inflammation.  Huber  (N'ew" 
York)  has  reported  two  cases,  one  of  which  is  unique.  An  infant  ten- 
months  old  was  apparently  well  until  two  hours  before  it  was  seen,  when 
there  was  noticed  a  constant  irritating  cough,  accompanied  by  consider- 
able gagging.  A  little  later  there  could  be  seen  in  the  mouth  a  promi- 
nent red  mass,  which  was  the  enlarged  and  elongated  uvula.  It  was 
accompanied  by  paroxysms  of  cough,  which  interfered  both  with  nurs- 
ing and  deglutition.  The  general  symptoms  were  quite  alarming,  and 
the  child  was  in  considerable  distress.  On  examination,  the  uvula  was 
found  to  be  fully  one  inch  long  and  half  an  inch  wide ;  it  was  red  and 
cedematous ;  in  other  respects,  however,  the  throat  was  normal.  The- 
symptoms  were  relieved  by  multiple  needle  punctures  and  the  use  of  ice 
externally  and  internally. 


RETRO-PHARYNGEAL  ABSCESS.  293 

ELONGATED  UVULA. 

Probabh^  this  is  primarily  a  congenital  condition.  It  is  increased  by 
repeated  attacks  of  acute  or  subacute  inflammation.  The  degree  of 
elongation  varies  in  different  cases;  in  some  it  may  reach  an  inch  in 
length.  According  to  Bosworth,  only  the  mucous  membrane  is  involved 
in  the  elongation.  The  symptoms  are  those  of  local  irritation,  espe- 
cially a  cough  upon  lying  down,  and  the  sensation  of  a  foreign  body  in 
the  pharynx.  In  some  cases  it  may  be  a  reflex  cause  of  asthma,  or,  more 
frec|uently,  of  catarrhal  spasm  of  the  larynx.  The  diagnosis  is  very 
easily  made  by  inspecting  the  throat.  The  treatment  consists  in  grasping 
the  tip  of  the  uvula  with  forceps  and  cutting  off  the  excess  with  the 
scissors,  or  a  uvulatome.  Care  should  be  taken  not  to  cut  off  too  much 
of  the  uvula,  or  severe  hgemorrhage  may  occur. 

RETRO-PHARYNGEAL  ABSCESS. 

Two  distinct  varieties  are  seen :  ( 1 )  the  so-called  idiopathic  abscesses 
which  belong  to  infancy,  and  (2)  abscesses  secondary  to  caries  of  the  cer- 
vical vertebrae. 

Eetro-phaeyngeal  Abscess  of  Infancy. — All  of  the  later  investi- 
gations regarding  this  disease  go  to  show  that  primarily  it  is  not  a  cellu- 
litis, but  a  suppurative  inflammation  of  the  lymph  nodes  (lymphatic 
glands)  with  a  surroimding  cellulitis.  Jules  Simon  has  described  the 
retro-pharyngeal  lymph  nodes  as  forming  a  chain  on  either  side  of  the 
median  line  between  the  pharyngeal  and  the  prevertebral  muscles.  These 
nodes  are  said  to  undergo  atrophy  after  the  third  je&T,  and  in  some  cases 
to  disappear  entirely.  Retro-pharyngeal  abscess — or  more  properly  retro- 
pharyngeal lymphadenitis,  since  the  process  does  not  invariably  go  on  to 
suppuration — is  probably  never  primary,  but  secondary  to  infectious 
catarrhs  of  the  pharynx,  and  is  set  up  by  the  entrance  of  pyogenic  bac- 
teria, usually  the  streptococcus.  Its  pathology  is  the  same  as  the  more 
frequent  suppurative  inflammation  of  the  external  cervical  lymph  nodes, 
with  which  it  is  sometimes  associated.  Usually  only  a  single  node  is 
involved,  but  sometimes  two  or  three  are  affected,  and  these  may  be 
situated  upon  opposite  sides.  I  have  seen  retro-pharyngeal  lymph- 
adenitis so  severe  as  to  give  rise  to  marked  local  symptoms,  although  it 
did  not  go  on  to  suppuration.  This  is  rare;  Kormann's  observations, 
however,  show  that  swelling  of  these  glands  in  diseases  of  the  mouth  and 
throat  is  very  much  more  common  than  is  generally  supposed.  Similar 
abscesses  from  suppurative  inflammation  of  other  lymph  nodes  in  the 
neighbourhood  of  the  pharynx  may  occur.  I  have  seen  one  situated  be- 
tween the  epiglottis  and  the  base  of  the  tongue. 

Etiology. — Tbese  cases  almost  invariably  occur  in  infancy.  Fully 
three-fourths  of  those  that  have  come  under  my  observation  have  been  in 


2Q4:  DISEASES  OP   THE  DIGESTIVE  SYSTEM. 

patients  under  one  year.  Bokai  (Buda-Pesth)  reports  that  of  sixty  cases 
observed,  forty-two  occurred  during  the  first  year,  eleven  during  the  sec- 
ond year,  and  only  seven  at  a  later  period.  The  primary  disease  is  usu- 
ally a  severe  rhino-pharyngitis,  or  an  attack  of  epidemic  influenza,  but 
rarely  it  occurs  as  a  sequel  of  scarlet  fever  or  measles.  In  six  hundred 
and  sixty-four  cases  of  scarlet  fever,  Bokai  noted  retro-pharyngeal  ab- 
scess in  seven  cases.  After  measles  it  is  even  more  rare.  Retro-pharyn- 
geal abscess  usually  occurs  in  winter  or  spring,  on  account  of  the  preva- 
lence of  the  diseases  upon  which  it  depends.  It  is  seen  in  children  pre- 
viously robust,  but  more  often  in  those  who  are  delicate  and  who  in  con- 
sequence are  prone  to  severe  catarrhal  affections. 

Symptoms. — The  early  symptoms  in  most  cases  are  merely  those  of  an 
ordinary  rhino-pharyngeal  catarrh.  After  this  has  subsided  the  tem- 
perature may  remain  slightly  elevated,  often  for  a  week  or  more,  before 
local  symptoms  are  noticeable.  Sometimes,  without  any  distinct  history 
of  previous  catarrh,  there  are  seen  quite  high  temperature,  from  102°  to 
104°  F.,  loss  of  flesh,  and  prostration.  A  careful  examination  may  be 
required,  and  sometimes  observation  for  a  day  or  two,  before  the  expla- 
nation of  these  constitutional  symptoms  is  discovered.  In  other  cases 
the  early  constitutional  symptoms  are  so  slight  as  to  escape  notice,  and 
the  physician  is  summoned  on  account  of  the  local  symptoms,  usually 
the  dyspnoea,  which  in  a  short  time  m.ay  assiime  an  alarming  character. 
The  duration  of  the  inflammatory  process  before  abscess  forms  is  gen- 
erally five  or  six  days,  but  it  may  be  two  or  three  weeks.  The  tempera- 
ture is  invariably  elevated,  usually  from  100°  to  103°  '¥.;  occasionally  it 
may  be  104°  or  105°  F.,  with  symptoms  of  prostration  seemingly  out  of 
all  proportion  to  the  local  disease,  but  which  are  to  be  explained  by  the 
tender  age  and  feeble  resistance  of  the  patient. 

The  first  local  symptom  may  be  a  sudden  attack  of  dyspnoea  severe 
enough  to  cause  asphyxia.  This  is  due  to  the  pressure  forward  of  the  ab- 
scess which  encroaches  upon  the  opening  of  the  larynx.  Usually  before 
it  occurs  the  breathing  is  noisy,  especially  during  sleep,  and  on  account 
of  the  obstruction  to  nasal  respiration  the  patient  breathes  with  the 
mouth  open.  The  mouth  may  be  dry,  or  there  may  be  a  copious  secretion 
of  pharyngeal  mucus.  The  dyspnoea  is  in  most  cases  greater  On  inspira- 
tion, and  in  some  it  is  noticed  only  then,  expiration  being  normal.  The 
dyspnoea  is  sometimes  increased  by  attempts  at  swalloAving.  The  degree 
to  which  deglutition  is  interfered  with  depends  upon  the  size  and  the 
position  of  the  tumour.  It  is  more  difficult  when  the  tumour  is  low 
down.  The  child  may  find  it  impossible  to  swallow,  and  in  consequence 
may  refuse  to  nurse ;  or  the  difficulty  in  nursing  may  depend  upon  the 
nasal  obstruction.  Sometimes  there  is  regurgitation  of  food  through  the 
nose  or  mouth.  The  voice  is  usually  nasal.  Generally  there  is  no  hoarse- 
ness, but  a  peculiar  short  cry  which  is  quite  characteristic.    There  may  be 


RETRO-PHARYNGEAL  ABSCESS.  295 

complete  aphonia;  often  there  is  a  short,  dr}^  cough.  In  many  of  the 
cases  a  tumour  is  to  be  seen  externall}'^,  just  below  the  angle  of  the  jaw 
and  in  front  of  the  sterno-mastoid  muscle;  exceptionally  this  may  be 
more  prominent  than  the  internal  swelling.  The  head  is  thrown  back  in 
order  to  relieve  the  pressure  upon  the  larynx,  and  is  held  somewhat  rig- 
idly.   In  one  or  two  cases  I  have  noticed  torticollis  as  an  early  symptom. 

A  positive  diagnosis  is  made  by  an  examination  of  the  throat.  On  in- 
spection there  is  seen  a  distinct  bulging  of  the  lateral  wall  of  the  phar- 
5'nx,  usually  a  little  above  the  base  of  the  tongue.  The  swelling  may  be 
so  great  as  to  crowd  the  uvula  to  one  side  and  nearly  fill  the  pharynx. 
It  is  rarely  if  ever  in  the  median  line.  There  is  usually  redness  of  the 
mucous  membrane  and  oedema  of  the  uvula  and  of  the  adjacent  parts. 
On  digital  examination  the  swelling  is  made  out  even  better  than  by  in- 
spection. It  may  be  situated  so  low  down  as  not  to  be  visible  at  all.  In 
the  early  stage  there  may  be  felt  only  a  localized  induration  or  a  some- 
what diffuse  swelling,  but  by  the  time  the  swelling  is  large  enough  to 
produce  marked  symptoms,  fluctuation  can  generally  be  discovered. 

Prognosis. — When  left  to  itself  the  abscess  may  open  into  the  phar- 
}Tix,  the  pus  being  swallowed  or  expectorated.  The  cavity  may  close  rap- 
idly by  granulation,  and  in  a  few  days  the  patient  be  entirely  well ;  or  the 
abscess  may  refill.  It  is  rare  for  much  burrowing  to  occur.  In  young  or 
very  delicate  infants  the  constitutional  symptoms  may  be  so  severe  that 
the  child  continues  to  fail  even  after  the  evacuation  of  the  abscess,  and, 
graduall}^  sinking,  dies  usually  from  broncho-pneumonia.  In  other  chil- 
dren a  fatal  result  is  generally  due  to  the  fact  that  the  disease  was  not 
recognised. 

Death  may  occur  from  asphyxia  due  to  pressure  upon  the  larynx, 
to  oedema  of  the  glottis,  or  from  rupture  of  the  abscess  into  the  air 
passages,  especially  if  this  occurs  during  sleep.  Carmichael,  Bokai,  and 
others  have  reported  deaths  from  ulceration  into  the  carotid  artery,  or 
one  of  its  large  branches.  Carmichael's  patient  was  only  five  weeks  old. 
The  general  mortality  of  the  disease  is  from  five  to  ten  per  cent;  most  of 
the  deaths  are  owing  to  a  failure  to  make  the  diagnosis.  Gautier  has 
collected  ninety-five  cases,  with  forty-one  deaths.  In  my  own  experience 
a  fatal  termination  has  been  rare;  but  alarming  symptoms  have  often 
been  present. 

Diagnosis. — Retro-pharyngeal  abscess  is  to  be  suspected  if  in  an 
infant  there  is  difficulty  in  swallowing,  noisy  dyspnoea,  mouth-breathing, 
and  the  head  drawn  backward.  A  positive  diagnosis  is  possible  only  by 
a  digital  examination  of  the  pharynx.  The  mistake  most  often  made 
is,  that  the  physician,  called  to  a  young  child  suffering  from  great 
dyspnoea,  has  jumped  at  a  diagnosis  of  laryngeal  stenosis,  and  forth- 
with performed  tracheotomy  or  intubation,  without  taking  the  trouble 
to  get  the  history  or  to  make  a  careful  examination  of  the  pharynx. 


296  DISEASES   OP  THE  DIGESTIVE  SYSTEM. 

Many  such  cases  are  reported  in  which  the  child  has  died  during  the 
operation  or  immediately  afterward^  the  autopsy  first  revealing  the 
nature  of  the  disease.  A  sudden  attack  of  dyspnoea  like  that  caused 
by  the  rupture  of  an  abscess  might  be  produced  by  the  lodgment  of  a 
foreign  body  in  the  pharynx  or  larynx.  A  digital  examination  would 
aid  in  the  diagnosis.  I  once  saw  in  an  infant  a  sarcoma  of  the  pharyn- 
geal lymph  glands  which  gave  an  external  and  internal  tumour  exactly 
like  that  of  a  retro-pharyngeal  abscess. 

Treatment. — Before  the  abscess  has  pointed,  hot  applications  should 
be  made  to  the  throat  to  relieve  the  symptoms  and  to  hasten  the  forma- 
tion of  pus,  since  resolution  is  not  to  be  expected.  Spontaneous  opening 
should  never  be  waited  for,  on  account  of  the  danger  of  the  rapid  devel- 
opment  of  serious  symptoms  from  pressure  or  cedema,  or  of  suffocation 
from  an  opening  into  the  air  passages,  especially  during  sleep. 

As  soon  as  the  diagnosis  is  made  the  case  should  be  carefully  watched, 
and  as  soon  as  well-marked  fluctuation  is  detected,  the  pus  should  be 
evacuated.  External  incision  has  its  advocates,  and  in  a  few  cases,  when 
the  tumour  is  chiefly  external,  it  offers  some  advantages ;  but  as  a 
routine  operation  the  internal  opening  is,  to  my  mind,  much  to  be  pre- 
ferred. In  opening  through  the  mouth  the  patient  should  be  seated  in 
an  upright  position  and  the  head  firmly  held.  The  introduction  of  a 
mouth-gag  may  cause  asphyxia;  but  a  tongue  depressor  may  be  used, 
and  a  bistoury  which  has  been  guarded  to  its  point  plunged  into  the 
abscess  at  its  thinnest  portion  and  the  incision  made  toward  the  median 
line.  The  head  should  then  be  bent  forward,  to  allow  the  pus  to  escape 
through  the  mouth.  It  is  well  to  insert  the  finger  into  the  cavity  and 
break  down  any  septa;  for  after  a  simple  pimcture  the  abscess  may 
refill.  Incision,  although  usually  eas}^,  in  some  cases  may  be  quite  diffi- 
cult on  account  of  the  swelling  and  the  small  pharynx  of  the  infant.  For 
the  past  few  years  I  have  adopted  the  plan  of  opening  these  abscesses 
with  the  finger  nail,  a  procedure  simple,  efficient,  and  free  from  danger. 
While  the  patient  is  held  as  above  described,  the  wall  of  the  abscess  is 
perforated  where  it  points,  by  the  nail  of  the  forefinger  which  has  been 
sharpened  to  a  cutting  point.  I  have  seldom  seen  a  case  in  which  this 
was  difficult.  The  amount  of  pus  evacuated  is  from  one  drachm  to  half 
an  ounce.  In  the  majority  of  cases  no  after-treatment  is  required.  The 
relief  of  the  dyspnoea  and  dysphagia  is  immediate,  and  recovery  rapid. 

Eetro-phakyngeal  Abscess  from  Pott's  Disease. — This  form  is 
rare  in  comparison  with  that  just  described,  and  under  three  years  of  age 
it  is  extremely  so.  These  abscesses  are  usually  larger,  and  the  amount  of 
pus  contained  may  be  from  four  to  eight  ounces.  They  form  very  much 
more  slowly,  often  lasting  for  months,  and  as  with  other  secondary  ab- 
scesses, the  constitutional  symptoms  are  seldom  severe.  The  swelling 
is  frequently  in  the  median  line,  and  is  not  so  circumscribed  as  in  the 


ADEXOID   VEGETATIONS   OF   THE   PHARYNX.  297 

idiopathic  cases.  The  pus  often  burrows  along  the  spine  for  several 
inches. 

The  symptoms  of  Pott's  disease  of  the  cervical  region  are  usually- 
present  for  several  months  before  the  appearance  of  the  abscess.  Some- 
times the  abscess  precedes  the  deformity,  and  it  may  be  the  first  intima- 
tion of  the  existence  of  bone  disease.  The  local  symptoms  resemble 
those  of  the  idiopathic  cases,  but  they  develop  more  slowly,  and  sudden 
attacks  of  fatal  asphyxia  are  very  rare.  External  swelling  is  usually 
seen,  and  it  may  be  quite  large,  extending  almost  from  one  ear  to  the 
other,  forming  a  distinct  collar.  On  digital  exploration  there  may  be 
found  an  irregularity  of  the  anterior  surface  of  the  cervical  vertebrae, 
and  occasionally  a  marked  angular  prominence. 

When  left  to  themselves  these  abscesses  may  open  externally  in  front 
of  the  sterno-mastoid  muscle  just  below  the  jaw,  sometimes  nearly  as  low 
as  the  clavicle ;  they  may  rupture  internally  into  the  pharynx,  the  oesoph- 
agus, or  the  air  passages ;  or  they  may  burrow  a  long  distance  in  front 
of  the  spine.  Death  may  result  from  pressure  upon  the  larynx,  or  from 
rupture  into  the  larynx,  trachea,  or  pleura ;  all  these,  however,  are  rare. 
The  abscesses  not  infrequently  refill  after  they  are  evacuated,  and  occa- 
sionally a  discharging  sinus  is  left  for  many  months. 

Treatment. — These  abscesses  should  be  opened  as  soon  as  they  are 
large  enough  to  give  rise  to  local  symptoms.  The  external  incision  just 
in  front  of  the  sterno-mastoid  muscle  is  generally  to  be  preferred  to 
opening  through  the  mouth,  since  it  gives  better  drainage,  and  the  after- 
treatment  is  more  easily  carried  on;  and  a  sinus  opening  externally  is 
less  objectionable  than  one  opening  into  the  pharynx. 

ADENOID  VEGETATIONS  OF  THE  VAULT  OF  THE  PHARYNX. 

This  is  a  very  common  condition  and  one  much  neglected  by  the 
general  practitioner.  It  is  the  source  of  more  discomfort  and  the  origin 
of  more  minor  ailments  than  almost  any  other  pathological  condition  of 
childhood. 

There  is  a  mass  of  lymphoid  tissue  situated  at  the  vault  of  the  phar- 
ynx which  in  structure  closely  resembles  the  tonsils.  It  is  often  spoken 
of  as  the  "  pharyngeal  tonsil."  Like  the  faucial  tonsils,  this  may  become 
greatly  hypertrophied,  so  as  to  form  a  tumour  large  enough  to  fill  the 
rhino-pharynx  completely.  These  tumors  have  a  broad  attachment 
which  is  sometimes  more  to  the  roof,  and  sometimes  more  to  the  poste- 
rior wall  of  the  pharynx.  The  term  adenoid  vegetations  was  given  to 
them  by  Meyer,  who  first  described  them  in  1868.  In  infancy  these 
growths  are  soft,  vascular,  and  spongy;  in  older  children  they  become 
firm,  dense,  and  more  fibrous.  Their  appearance  is  well  shown  in  Fig. 
55.     Adenoid  vegetations  are  associated  with  hypertrophy  of  the  faucial 


298 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


tonsils  in  about  one-third  the  cases.  Growths  large  enough  to  cause 
decided  nasal  obstruction  may  in  time  produce  changes  in  the  facial 
bones  amounting  to  positive  deformity.  The  bony  palate  is  dome- 
shaped  or  even  acutely  arched;  the  dental  arch  of  the  upper  jaw  be- 


FiG.  55. — Adenoid  vegetations,  natural  size. 

(1)  From  child  eight  months  old;  (2)  from  child  twenty-two  months  old;  (3)  from  child 
two  and  one  half  years  old ;  (4)  from  child  two  and  one  half  years  old ;  (5)  from  child  three 
years  old.     With  the  exception  of  (5)  all  were  removed  with  a  single  sweep  of  the  curette. 

Although  the  growths  represented  are  somewhat  larger  than  the  average  for  the  ages  men- 
tioned, just  such  ones  are  constantly  met  with  in  practice. 


comes  almost  V-shaped.     Deformities  of  the  thorax  also  occur,  which 
will  be  described  with  the  Symptoms. 

Etiology. — The  constitutional  condition  described  elsewhere  as 
"  lymphatism,"  sometimes  called  the  status  lympliaticus,  is  the  one  with 
which  adenoid  growths  are  most  frequently  associated.  Very  often,  how- 
ever, they  are  the  most  marked  manifestation  of  the  condition.  I  have 
frequently  known  every  one  of  a  large  family  of  children  to  be  affected, 
and  often  the  parents  have  suffered  from  the  same  disease.  There  can 
be  no  doubt  regarding  the  influence  of  heredity  in  the  production  of 
adenoids.  In  many  eases  they  are  congenital.  Eachitic  children  are 
somewhat  oftener  aft'eeted  than  others,  but  no  connection  Avith  syphilis 
has  been  traced.  Much  interest  has  lately  been  aAvakened  regarding  tlie 
relation  of  adenoid  growths  to  tuberculosis.     Of  945  cases  collected  by 


ADENOID  VEGETATIONS  OF   THE   PHARYNX.  299 

Lewin  in  which  specimens  of  adenoids  were  examined,  tuberculosis  was 
present  in  5  per  cent.  Though  this  proportion  is  no  doubt  much  higher 
than  will  be  found  in  private  practice,  the  fact  is  an  important  one; 
for  it  is  highly  probable  that  this  is  the  channel  of  infection  in  not  a 
few  cases  of  tuberculous  meningitis.  Adenoids  are  most  common  in 
damp,  changeable  climates.  Their  first  symptoms  often  follow  an  attack 
of  measles,  scarlet  fever,  or  diphtheria.  The  repeated  head  colds  are 
more  often  a  result  than  a  cause  of  the  condition. 

Symptoms. — The  symptoms  of  adenoid  growths  are  usually  first  no- 
ticed when  children  are  from  eighteen  months  to  three  years  old;  but 
they  may  be  present  almost  from  birth.  I  have  in  several  instances  seen 
them  to  a  marked  degree  in  infants  only  a  few  months  old.  The  symp- 
toms generally  increase  in  severity  as  age  advances,  being  always  better  in 
summer  and  worse  in  winter,  until  the  age  of  six  or  seven  is  reached. 
The  chief  symptoms  are  those  which  relate  to  (1)  chronic  rhino-pharjm- 
geal  catarrh,  (2)  mechanical  obstruction,  (3)  deafness,  (4)  general 
malnutrition  and  anaemia,  (5)  reflex  nervous  phenomena. 

The  rhino-pharyngeal  catarrh  shows  itself  by  a  persistent  nasal  dis- 
charge, frequently  recurring  acute  attacks,  or  head  colds,  during  the 
entire  winter  season.  In  susceptible  children  these  attacks  are  often  the 
beginning  of  a  bronchitis,  which  may  keep  a  young  child  indoors  almost 
the  entire  winter. 

The  obstructive  symptoms  are  inability  to  blow  the  nose,  mouth- 
breathing  constantly  or  only  during  sleep,  and  a  nasal  voice.  The 
difficulty  in  breathing  is  increased  when  the  child  lies  upon  the 
back.  In  consequence  of  this,  children  sleep  in  all  sorts  of  positions — 
lying  upon  the  face,  sometimes  upon  the  hands  and  knees,  and  often  toss 
restlessly  about  the  crib  in  the  vain  endeavour  to  find  some  position  in 
which  respiration  is  easy.  The  attacks  of  dyspnoea  at  night  may  amount 
almost  to  asphyxia,  and  are  the  explanation  of  many  of  the  so-called 
night-terrors  from  which  children  sufl'er.  When  the  obstruction  has 
existed  from  infancy  there  are  often  deformities  of  the  chest ;  these  are 
most  marked  in  rachitic  subjects.  The  most  frequent  one  consists  in 
deep  lateral  depressions  of  the  lower  part  of  the  chest,  with  a  promi- 
nence of  the  sternum — the  familiar  pigeon-breast  (Fig.  56).  The  de- 
formity is  due  to  interference  with  pulmonary  expansion. 

Some  impairment  of  hearing  exists  in  a  large  proportion  of  the  cases. 
Blake  (Boston)  found  this  to  be  true  in  39  out  of  47  cases  examined; 
in  35  of  these  marked  improvement  in  the  hearing  followed  removal 
of  the  adenoid  growths.  Deafness  may  bo  due  to  tubal  catarrh  or  to 
otitis.     Often  a  history  is  given  of  several  attacks  of  suppurative  otitis. 

The  reflex  symptoms  associated  with  adenoid  growths  are  many. 
One  of  the  most  important  is  catarrhal  spasm  of  the  larynx,  or  the  famil- 
iar spasmodic  croup.     In  my  experience  the  majority  of  young  children 


300 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


who  are  subject  to  such  attacks  have  adenoids,  the  removal  of  which 
is  frequently  followed  by  their  complete  cessation.  The  crowing  attacks 
of  newly  born  infants  are  believed  by  Eustace  Smith  always  to  depend 
upon  adenoids.  I  have  not  been  able  to  satisfy  myself  upon  this  point. 
Other  respiratory  symptoms  associated  with  adenoids  are  intractable 
coughs,  frequently  of  a  spasmodic  character,  without  bronchial  symptoms 
or  signs;  and  persistent  hoarseness,  lasting  for  months  or  even  years, 
and  recurring  every  cold  season.  Both  these  conditions  are  often  cured 
by  the  removal  of  the  adenoids  after  all  other  treatment  has  been  with- 


\ 


% 


Fig.  56. — Pigeon-breast  due  to  adenoids  of  the  pliarynx. 


out  effect.  To  these  growths  bronchial  asthma  also  is  very  frequently 
due.  Their  relation  to  incontinence  of  urine  is  often  an  intimate  one ; 
the  two  coexist  in  a  large  number  of  patients,  and  in  a  certain  num- 
ber removal  of  the  adenoids  cures  the  incontinence.  Headaches  are  very 
common;  stammering  may  be  present;  chorea  and  even  epileptiform 
seizures  have  been  attributed  to  adenoids,  although  I  have  never  seen 
either. 

The  general  health  of  patients  suffering  from  adenoids  may  be  im- 
paired from  lack  of  oxygen  due  to  obstructed  respiration,  from  loss  of 


ADENOID   VEGETATIONS  OF  THE   PHARYNX.  301 

sleep,  and  from  confinement  to  the  house,  necessitated  b}'  attacks  of 
bronchitis  or  head  colds.  Marked  autemia  is  often  present.  In  old  and 
neglected  cases  of  a  severe  character,  children  may  be  stunted  in  growth, 
and  their  facial  expression  dull  and  stupid.  They  are  languid,  listless, 
often  depressed,  and  this  with  their  deafness  frequently  causes  them  to 
be  regarded  in  schools  as  children  who  are  somewhat  deficient  mentally. 

These  patients  are  always  better  in  summer  and  worse  in  winter. 
The  natural  course  of  the  growths  if  left  to  themselves  is  to  increase  up 
to  a  certain  point,  and  then  to  remain  stationary  until  puberty,  when 
they  usually  undergo  a  certain  amount  of  atrophy.  This,  with  the 
marked  increase  in  the  capacity  of  the  rhino-pharynx  which  occurs  at  this 
time,  results  in  a  disappearance  of  the  most  aggravated  symptoms.  A 
removal  to  an  elevated  region  with  a  dry  atmosphere  will  often  result 
in  a  relief  from  all  the  symptoms,  and  a  diminution  in  the  size  of  the 
growth,  but  unless  such  a  change  in  residence  is  permanent  the  symp- 
toms are  liable  to  return.  Under  ordinary  circumstances  there  is  little 
or  no  tendency  to  spontaneous  recovery.  Children  with  adenoid  growths 
contract  diphtheria  and  tuberculosis  more  easily  than  do  others,  and  in 
them  attacks  of  diphtheria,  scarlet  fever,  measles,  and  whooping-cough 
are  all  likely  to  be  more  severe. 

Diagnosis. — In  a  well-marked  ease  the  condition  is  usually  evident 
.  from  the  history,  and  can  scarcely  be  overlooked.  The  intractable  nasal 
catarrh,  upon  which  no  treatment,  local  or  general,  has  more  than  a  tem- 
porary influence,  the  mouth-breathing,  the  disturbed  sleep,  and  the 
slight  deafness — all  are  characteristic.  In  some  even  of  the  marked 
cases,  attention  may  be  drawn  to  the  larynx,  bronchi,  or  ears  as  the  seat 
of  disease.  At  other  times  the  patients  come  for  treatment  on  account 
of  the  general  symptoms — the  nervous  depression,  the  headaches,  or  the 
anaemia.  In  rare  cases  the  leading  symptom  may  be  epistaxis.  The 
symptoms  do  not  always  depend  upon  the  size  of  the  growth,  for  in  a 
small  throat  quite  a  small  growth  may  cause  very  marked  symptoms. 

Although  the  history  is  in  most  cases  clear,  only  an  examination  can 
make  us  certain  that  an  adenoid  growth  exists.  The  best  method  of  ex- 
amination consists  in  a  digital  exploration  of  the  pharynx;  but  this 
requires  a  little  practice  before  it  is  very  satisfactory.  The  head  is  stead- 
ied by  one  hand,  and  the  forefinger  of  the  other  is  passed  up  behind  the 
palate.  The  growth  is  ordinarily  felt  as  an  irregular,  granular,  soft, 
velvety  mass,  or  sometimes  as  a  firm  tumour  completely  blocking  the 
passage;  and  the  finger,  when  withdrawn,  is  almost  invariably  covered 
with  blood.  By  anterior  rhinoscopy,  after  the  use  of  cocaine,  the  growth 
can  often  be  seen. 

Treatment. — The  disappearance  of  adenoid  growths  by  absorption  is 
possible  only  when  they  are  small.  This  may  be  aided  by  the  prolonged 
use  of  guiaquin,  one  grain  three  times  a  day,  or  the  syrup  of  the  iodide 
21 


302  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

of  iron,  fifteen  drops  three  times  a  day;  but  most  of  all  by  removal  to> 
a  warm,  dry  climate  for  the  winter  season.  All  possible  means  should 
be  employed  to  prevent  these  patients  from  taking  cold,  such  as  proper 
clothing,  cold  sponging,  cod-liver  oil,  etc.  With  the  larger  growths  these 
methods  may  improve  the  catarrhal  symptoms,  but  can  hardly  affect 
the  mechanical  ones.  The  reduction  of  tumours  of  any  considerable 
size  by  local  applications  is,  I  think,  a  delusion;  every  case  that  has 
come  to  my  notice  has  been  relieved  only  by  operation. 

Eemoval  of  adenoid  growths  is  indicated :  ( 1 )  When  the  obstructive 
symptoms — habitual  mouth-breathing,  disturbed  sleep,  nasal  voice, 
chest  deformities,  etc. — are  marked;  (2)  for  a  chronic  nasal  discharge,, 
constantly  recurring  head  colds,  particularly  when  these  tend  to  attacks 
of  bronchitis  or  laryngitis;  (3)  where  there  is  asthma  or  repeated  at- 
tacks of  catarrhal  spasm  of  the  larynx;  (4)  with  deafness,  chronic 
otitis,  or  repeated  attacks  of  acute  otitis;  (5)  for  certain  nervous  symp 
toms — enuresis,  stammering,  chorea,  headaches,  night  terrors,  etc.  Al- 
though striking  improvement  is  not  infrequent,  one  should  be  cautious 
about  promising  too  much  from  operations  where  these  nervous  condi- 
tions exist;  also  in  an  older  child  when  there  is  deafness  or  asthma. 

The  preferable  time  for  operation  is  the  spring  or  early  summer, 
in  order  that  during  the  warm  months  the  mucous  membranes  may  have 
an  opportunity  to  regain  their  normal  condition;  however,  operation 
may  be  done  at  any  time  except  during  attacks  of  acute  catarrh.  Unless 
the  symptoms  are  very  marked,  I  prefer  to  defer  operation  until  a  child 
is  at  least  two  years  old. 

Eemoval  of  adenoids  by  scraping  with  the  finger  nail  is  possible 
only  when  the  growths  are  very  soft;  it  is  at  best  a  very  uncertain 
method,  and  is  not  to  be  advised.  Except  in  the  case  of  children  under 
two  or  two  and  a  half  years  old,  where  the  growths  are  generally  small 
and  the  patients  easily  handled,  I  prefer  to  operate  with  general  anaes- 
thesia :  first,  for  the  sake  of  thoroughness ;  secondly,  to  avoid  the  fright 
and  pain  which  so  bloody  an  operation  is  apt  to  cause  in  those  who  are 
older,  and  especially  in  very  nervous  children.  So  many  deaths  from 
operations  for  adenoids  or  tonsils  under  chloroform  have  now  been  re- 
ported (Hinkel  in  1898  collected  eighteen,  and  a  number  haA^e  since  been 
added),  and  so  many  narrow  escapes  have  occurred  that  have  not  been 
published,  that  chloroform  anaesthesia  should,  I  think,  be  given  up  alto- 
gether. My  preference  is  for  ether ;  in  older  children  it  may  with  advan- 
tage be  preceded  by  nitrous  oxide,  and  sometimes  with  such  patients  the 
nitrous  oxide  alone  may  be  used,  but  this  is  not  to  be  advised  with  very 
young  children.  Deep  anaesthesia  is  not  usually  necessary,  and  if  the 
semi-erect  position  is  assumed  it  increases  the  danger  of  the  entrance  of 
blood  or  portions  of  the  growth  into  the  larynx,  which  might  cause  fatal 
asphyxia. 


ADENOID   VEGETATIONS   OF   THE   PHARYNX.  303 

The  only  instniments  required  are  a  mouth-gag,  like  that  used  for 
intubation,  and  modified  Gottstein's  curettes,  which  should  be  sharp. 
The  physician  should  have  several  sizes  with  different  curves  to  suit  the 
size  and  attachment  of  the  growth  and  the  capacity  of  the  throat.  Many 
of  the  instruments  used  for  young  children  are  too  large,  the  smaller 
ones  being  more  easily  manipulated  and  less  liable  to  do  harm. 

If  no  anaesthetic  is  used,  the  patient's  arms  are  pinioned  to  the  side 
by  two  or  three  turns  of  a  sheet  around  the  body,  the  head  firmly  held 
by  an  assistant,  upon  whose  lap  the  patient  sits,  as  for  the  operation  of 
intubation.  With  anaesthesia  there  is  an  advantage  in  using  the  sheet 
in  the  same  way.  During  operation  I  prefer  to  have  the  patient  raised 
to  a  little  more  than  a  half-reclining  posture  and  the  head  firmly  stead- 
ied. This  position  gives  the  operator  a  decided  advantage  over  the 
low-head  position,  which  is  necessary  when  chloroform  is  used.  After 
the  introduction  of  the  gag,  the  pharynx  should  be  carefully  explored 
with  the  finger  to  determine  the  size  and  position  of  the  growth.  The 
tongue  is  then  depressed  by  the  left  forefinger,  while  with  the  right  hand 
the  curette  is  carefully  passed  high  up  behind  the  soft  palate  until  it 
meets  the  nasal  septum.  The  handle  of  the  curette  is  grasped  as  one 
holds  a  pen.  The  cut  is  made  with  a  downward  movement,  depressing 
the  blade  and  elevating  the  handle  of  the  curette,  it  being  given  a  lever- 
like motion  by  the  action  of  the  wrist.  When  the  curette  is  grasped 
with  the  entire  hand,  and  the  full  arm  used  with  simply  a  downward 
movement,  the  pharyngeal  mucous  membrane  is  often  stripped  down 
for  some  distance  below  the  growth,  but  not  cut  off.  Care  should  be 
taken  to  keep  the  blade  well  against  the  bony  wall  of  the  vault  and  pos- 
terior pharyngeal  wall,  and  the  handle  in  the  median  line,  and  not  to 
employ  too  much  force.  The  majority  of  the  growths  encountered  in 
ordinary  practice,  such  as  Nos.  1,  2,  and  3  in  Fig.  55,  can  be  removed 
with  one  sweep  of  the  curette,  the  mass  usually  coming  away  in  a  single 
piece.  Others  may  require  the  instrument  to  be  used  two  or  three  times. 
The  patient  is  now  turned  face  downward  until  most  of  the  h;vmor- 
rhage  has  ceased.  Then  the  cavity  should  be  explored  with  the  finger 
to  ascertain  whether  the  removal  has  been  complete.  The  forceps  (Low- 
enberg's  and  various  modifications)  are  quite  unnecessary,  and  in  un- 
skilled hands  are  capable  of  doing  much  harm.  One  unfamiliar  with 
their  use  may  easily  tear  away  pieces  of  the  uvula,  soft  palate,  pharyn- 
geal wall,  and  even  portions  of  the  Eustachian  tubes. 

The  entire  operation  consumes  in  most  cases  less  thau  a  minute. 
Hasmorrhage  is  always  abundant,  and  seems  alarming  to  one  who  sees 
it  for  the  first  time.  In  an  average  case  it  amounts  to  one  or  two 
ounces,  but  generally  ceases  in  a  few  minutes.  A  child  should  not  pass 
from  the  physician's  observation  until  all  bleeding  has  stopped.  It  often 
happens  that  the  patient  swallows  the  growth,  a  disappointing  but  not 


304 


DISEASES  OF  THE  DiaESTIVE  SYSTEM. 


a  serious  accident.  The  child  sliould  be  kept  quiet,  preferably  in  bed, 
for  twentj'-f our  hours ;  and  in  the  hoiise  for  five  or  six  days,  unless  the 
weather  is  warm.  Xo  after-treatment  is  necessary,  or  at  most  a  spray 
of  a  weak  antiseptic  solution.  Eecurrences  are  extremely  rare,  except 
after  incomplete  operations,  such  as  those  performed  with  the  finger 
nail,  etc.  The  improvement  is  usually  in  proportion  to  the  severity  of 
the  previous  symptoms.  It  generally  begins  in  a  few  days,  sometimes 
at  once,  though  the  full  benefit  may  not  be  seen  for  a  month.  The 
breathing  becomes  freer,  the  sleep  more  quiet;  the  mouth  may  soon  be 


'*'«/• 


Before  operation.  Three  months  after  operation. 

Figs.  57  and  58. — Adenoid  vegetations  of  the  pharynx;  girl  twelve  years  old.     (Hooper.) 

habitually  closed;  voice  and  hearing  improve,  and  the  benefit  to  the 
general  health  is  soon  apparent.  The  pallor,  listlessness,  and  inattention 
disappear,  and  a  rapid  increase  in  weight  often  follows.  The  entire  ap- 
pearance of  the  child  may  in  a  few  months  be  transformed  (Figs.  57,  58). 
Dangers  and  Accidents  from  Operation. — While  it  is  rare  that  any 
accidents  of  a  serious  nature  are  met  with,  it  should  not  be  forgotten  that 
they  may  occur.  Undue  laceration  of  the  parts  may  result  from  a  bun- 
gling operation  particularly  with  too  large  curettes  or  with  the  forceps. 
Hsemorrhage  may  be  excessive  or  even  fatal.  In  over  two  hundred  oper- 
ations I  have  had  but  one  case  of  serious  hemorrhage.  A  fatal  result  is 
exceedingly  rare.  Xewcomb  in  1893  could  find  but  four  examples. 
Hsemorrhage  may  be  continuous  after  operation,  or  secondary,  in  which 
case  it  almost  invariably  occurs  within  twenty-four  hours.  It  is  impor- 
tant, therefore,  that  the  patient  be  kept  under  observation  for  that 
time.  Bleeding  is  best  controlled  by  injecting  into  the  rhino-pharjux 
through  the  nostrils  one  or  two  drachms  of  hydrogen  peroxide,  full 
strength,  or,  this  failing,  a  solution  of  suprarenal  extract  may  be  used  in 


DISEASES  OF  THE  TONSILS.  305 

the  same  manner.  As  a  last  resource  plugging  of  the  posterior  nares 
may  be  resorted  to.  In  all  eases  the  patient  should  be  kept  absolutely- 
quiet. 

Occasionally  an  acute  attack  of  bronchitis  or  otitis  occurs  after  oper- 
ation ;  and  in  a  few  recorded  instances  acute  meningitis,  simple  or  tuber- 
culous, has  followed.  The  danger  of  asphyxia  from  the  entrance  of  blood 
or  the  tumour  into  the  larynx  has  already  been  mentioned. 

The  danger  from  chloroform  anaesthesia  is  due  not  so  much  to  the 
nature  of  the  operation  as  to  the  condition  of  the  patient.  It  is  now 
well  established  that  all  children  in  whom  the  condition  known  as  lym- 
phatism  is  marked,  bear  chloroform  very  badly. 


CHAPTER    III. 
DISEASES  OF  THE  TONSILS. 

The  tonsils  *  are  lymphoid  structures  closely  resembling  Peyer  s 
patches,  but,  instead  of  having  a  flattened  surface,  the  lymphoid  tissue  in 
the  tonsil  is  folded  upon  itself,  forming  quite  deep  depressions — the  ton- 
sillar crypts.  These  crypts,  like  the  surface  of  the  tonsils,  are  lined  by 
epithelial  cells.  They  contain  lymphoid  cells,  desquamated  epithelium, 
particles  of  food,  and  bacteria.  Under  normal  conditions  the  tonsils 
take  no  part  in  absorption  from  the  mouth.  When,  however,  their  epi- 
thelium is  rarefied  or  removed,  the  tonsils  absorb  with  very  great  facility 
every  sort  of  poison  which  the  mouth  may  contain.  Such  poisons  are 
taken  up  by  the  lymphatics,  and  through  them  reach  the  general  circu- 
lation. 

Acute  inflammation  of  the  tonsils,  like  that  of  the  pharynx,  occurs 
regularly  in  diphtheria,  scarlet  fever,  and  measles,  less  frequently  in  the 
other  infectious  diseases.  The  secondary  forms  will  be  considered  with 
the  diseases  with  which  they  are  associated. 

Acute  catarrhal  tonsillitis,  or  inflammation  of  the  mucous  membrane 
covering  the  tonsils,  occurs  as  part  of  the  lesion  in  acute  pharyngitis, 
but  very  rarely  is  seen  alone. 

Croupous  Tonsillitis. — This  is  a  more  severe  form  of  inflammation 
than  catarrhal  tonsillitis.  It  involves  the  mucous  membrane  of  the  ton- 
sils, the  tonsillar  crypts,  and  to  a  greater  or  less  degree  the  whole  struc- 
ture of  the  tonsil.  Fibrin  is  poured  out  upon  the  surface  in  sufficient 
quantity  to  form  a  distinct  pseudo-moiii1)ran(',  which  usually  covers  tlie 

*  See  Ilodenpyl,  American  Journal  of  the  Medical  Sciences,  March,  1891,  on  Anat- 
omy and  Physiology;  Packard,  Philadelphia  Medical  Journal,  April  21,  1900,  on  In- 
fection through  the  Tonsils. 


306  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

tonsils,  but  in  primary  cases  it  does  not  extend  beyond  them.  In  most 
cases  both  sides  are  affected.  The  exudation  sometimes  begins  in  iso- 
lated dots,  like  a  follicular  tonsillitis,  which  afterward  coalesce  to  form 
a  continuous  patch.  The  membrane  is  usually  of  a  yellowish  gray  col- 
our. It  can  often  be  completely  removed  with  the  swab.  The  constitu- 
tional symptoms  are  generally  marked  and  resemble  those  of  follicular 
tonsillitis. 

The  disease  is  differentiated  with  certainty  from  diphtheria  only  by 
means  of  cultures,  which  should  be  made  in  every  case.  (See  Diagnosis 
of  Diphtheria.)  Croupous  tonsillitis  is  nearly  always  due  to  the  strep- 
tococcus. Though  never  severe  when  it  occurs  as  a  primary  affection, 
it  may  be  very  serious  when  it  is  secondary  to  measles  or  scarlet  fever. 
Its  clinical  features  are  more  fully  considered  under  the  head  of  Pseudo- 
diphtheria. 

Ulcero-membranous  Tonsillitis. — This  is  an  inflammation  somewhat 
resembling  croupous  tonsillitis,  but  it  is  often  unilateral  and  associated 
with  superficial  ulceration.  The  tonsil  is  covered  with  a  dirty  yellowish 
exudation,  which  may  be  mistaken  for  diphtheria.  There  is  superficial 
necrosis,  and  when  this  tissue  is  wiped  away  with  a  swab,  bleeding  occurs. 
The  disease  is  further  distinguished  by  the  swollen  lymph  nodes  at  the 
angle  of  the  jaw,  and  by  the  fact  that  the  constitutional  symptoms  which 
accompany  other  forms  of  tonsillitis  are  either  very  slight  or  absent  alto- 
gether. The  pathological  process  is  similar  to,  if  not  identical  with, 
ulcerative  stomatitis  (see  page  282),  with  which  it  is  sometimes  asso- 
ciated. At  such  times  the  breath  is  foul  and  there  is  often  profuse  sali- 
vation. 

Ulcero-membranous  tonsillitis  was  first  described  by  Yincent,*  and 
by  him  attributed  to  a  fusiform  bacillus,  which  he  described,  although  a 
spirillum  was  found  associated  with  it.  Vincent's  observations  have 
since  been  confirmed  by  a  number  of  writers. f 

The  chief  interest  in  ulcero-membranous  tonsillitis  lies  in  the  diag- 
nosis, although  it  is  not  an  infreqiient  disease.    It  is  to  be  treated,  like 

*  La  Presse  Medicale,  March  12,  1896. 

\  See  Sobel  and  Herrmann,  New  York  Medical  Journal,  December  7,  1901,  for 
recent  literature. 

Vincent's  bacillus  is  described  as  about  twice  as  long  as  the  Klebs-Loeflfler  bacillus. 
It  is  thin,  with  pointed  ends,  and  sometimes  bent ;  it  is  negative  to  Gram,  and  has  not 
yet  been  isolated  in  pure  culture,  although  Vincent  was  able  to  make  it  grow  in 
bouillon  with  other  organisms  from  the  mouth.  It  is  not  yet  determined  whether  the 
disease  is  due  to  the  fusiform  bacillus  alone,  or  that  the  spirillum  plays  any  part ;  the 
spirillum  may  possibly  be  merely  a  morphological  variation  of  the  bacillus.  The 
fusiform  bacillus  is  occasionally  found  alono  ;  the  spirillum,  never  alone.  The  bacillus 
is  found  in  smears  from  an  affected  tonsil,  in  making  which  it  is  recommended  to  go 
deeply  into  the  necrotic  tissue,  since  the  superficial  parts  are  crowded  with  other 
bacteria. 


FOLLICULAR  TONSILLITIS.  307 

ulcerative  stomatitis,  by  the  internal  administration  of  chlorate  of  pot- 
ash, combined  with  the  local  use  of  some  antiseptic,  such  as  peroxide  of 

hydrogen  or  nitrate  of  silver. 

FOLLICULAR  TONSILLITIS. 

This  is  the  most  frequent  and  most  characteristic  form  of  inflamma- 
tion of  the  tonsil.  It  is  essentiall}^  an  inflammation  of  the  tonsillar 
crypts,  and  secondarily  of  the  whole  glandular  structure. 

Etiology. — There  is  seen  in  certain  children  a  predisposition  to  at- 
tacks of  tonsillitis,  so  that  from  very  slight  exciting  causes  these  occur — 
sometimes  from  exposure,  sometimes  from  derangement  of  the  stomach, 
and  sometimes  without  any  evident  reason.  Children  with  a  rheu- 
matic inheritance  appear  to  be  more  susceptible  than  others.  One  at- 
tack predisposes  to  a  second.  Patients  suffering  from  chronic  hyper- 
trophy of  the  tonsils  are  exceedingly  prone  to  acute  tonsillitis.  It  is  not 
very  common  in  infancy,  but  after  this  period  it  is  very  frequent  through- 
out childhood.  The  disease,  in  all  probability,  begins  as  an  infectious 
inflammation  at  the  bottom  of  the  crj^pts,  due  to  the  presence  of  strep- 
tococci or  staphylococci,  which  readily  enter  from  the  mouth,  and  excite 
an  attack  whenever  favourable  conditions  are  present. 

Lesions. — As  a  result  of  the  inflammation,  the  tonsillar  crypts  are 
filled  with  epithelial  cells,  pus  cells,  mucus,  and  bacteria.  These  form 
masses  which  appear  at  the  mouth  of  the  crypts  as  small  yellow  dots, 
often  miscalled  ulcers.  Sometimes,  in  addition,  fibrin  is  poured  out,  and 
forms,  with  the  other  inflammatory  products,  little  plugs  which  project 
somewhat  from  the  surface  of  the  mucous  membrane,  and  which  can 
•easily  be  pressed  out.  Accompanying  the  changes  in  the  mucous  mem- 
brane above  mentioned,  there  are  acute  congestion  and  swelling  of  the 
whole  tonsil,  with  more  or  less  proliferation  of  the  lymphoid  tissue.  Fol- 
licular tonsillitis  is  always  bilateral.  Although  the  pathological  process 
is  generally  limited  to  the  tonsils,  there  may  be  more  or  less  pharyngitis 
associated. 

Symptoms. — The  general  symptoms  usually  appear  before  the  local 
ones,  and  are  often  quite  severe.  The  onset  is  abrupt,  with  chilly  sensa- 
tions, occasionally  a  distinct  rigour.  In  infants  there  is  often  vomiting, 
and  sometimes  diarrhoea.  There  is  pain  in  tlic  l)a('k,  in  the  muscles  of 
the  extremities,  and  in  the  head.  Sometimes  there  is  pain  in  the  lateral 
cervical  muscles.  The  temperature  rises  rapidly  to  102°  or  103°  F. ; 
often  it  touches  104°  or  105°  F. 

The  first  local  symptoms  are  some  swelling  of  the  tonsils  and  the  ap- 
pearance of  isolated  yellow  spots  a  little  larger  than  a  pin's  head.  Often 
these  can  be  wiped  off  with  a  swab,  or  the  little  plugs  can  be  squeezed 
out,  leaving  slight  depressions.  Later  there  is  acute  congestion  of  the 
tonsil,  with  more  swelling.    Even  when  the  disease  is  at  its  height  the 


308  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

local  pain  and  discomfort  are  only  moderate,  and  in  manj^  eases  scarcely 
noticeable.  The  swelling  and  tenderness  of  the  lymph  glands  behind  the 
angle  of  the  jaw  are  not  great,  and  may  be  absent. 

The  constitutional  symptoms,  as  a  rule,  last  three  days,  and  are  most 
severe  upon  the  first  day.  The  local  symptoms  last  somewhat  longer,  but 
usually  by  the  end  of  the  fourth  day  the  exudate  has  disappeared,  although 
enlargement  of  the  tonsil  may  persist  for  a  week  or  even  longer.  On  ac- 
count of  the  connection  of  tonsillitis  with  rheumatism,  the  heart  should 
be  watched  during  attacks,  especially  in  those  who  are  subject  to  them. 

Diagnosis. — Tonsillitis  may  be  confounded  at  its  onset  with  scarlet 
fever.  Its  constitutional  symptoms  in  the  beginning  closely  resemble 
malaria,  influenza,  or  pneumonia.  The  great  f requeue}^  of  tonsillitis 
makes  inspection  of  the  throat  imperative  in  every  case  of  acute  illness 
in  children.  The  diagnosis  from  diphtheria  is  considered  in  connection 
with  that  disease. 

Treatment. — Follicular  tonsillitis  is  a  mild  disease  without  danger  to 
life,  and  one  which  runs  a  short,  self-limited  course.  The  indications 
are,  therefore,  to  make  the  patient  as  comfortable  as  possible  by  the  relief 
of  individual  symptoms.  Older  children,  particularly  those  who  are 
rheumatic,  should  be  treated  with  sodium  salicjdate,  four  grains  every 
three  hours  being  given  for  the  first  twenty-four  hours,  and  later  less 
frequently.  In  infants  this  drug  must  be  given  in  smaller  doses  and 
with  care,  lest  it  upset  the  stomach.  The  general  muscular  pains  of  the 
first  day  are  best  relieved  by  phenacetine,  two  grains  every  four  hours 
to  a  child  three  years  old.  Later  it  may  be  used  in  smaller  doses,  but 
enough  should  be  given  to  make  the  patient  comfortable. 

Local  treatment  is  not  absolutely  necessary,  and  in  infants  may  be 
omitted.  Older  children  may  use  a  gargle  of  boric  acid  or  a  weak  bichlo- 
ride solution — i.  e.,  1  to  10,000.  In  all  doubtful  cases  the  patient  should 
be  isolated,  and  until  all  doubt  is  removed  the  same  treatment  adopted 
as  in  a  case  of  diphtheria. 

PHLEGMONOUS  TONSILLITIS— PERITONSILLAR  ABSCESS— QUINSY. 

This  is  an  inflammation  of  the  cellular  tissue  surrounding  the  tonsil, 
sometimes  invading  the  tonsil  itself.  It  may  terminate  in  resolution,  but 
usually  goes  on  to  the  formation  of  an  abscess.  Phlegmonous  tonsillitis 
is  much  less  common  in  children  than  in  adults,  and,  compared  with  the 
other  forms,  it  is  a  rare  disease  in  early  life.  It  is  the  only  variety  which 
is  regularly  unilateral.  In  most  cases  the  inflammatory  process  is  cir- 
cumscribed, but  in  rare  instances  there  is  seen  a  diffuse  phlegmonous  in- 
flammation of  the  pharynx. 

In  certain  patients  there  exists  a  constitutional  predisposition  to  the 
disease,  which  is  often  associated  with  rheumatism.  The  exciting  cause 
may  be  exposure,  or  anything  which  may  reduce  the  patient's  general 


PHLEGMONOUS  TONSILLITIS.  309 

health,  to  which  there  is  added  local  infection.  Catarrhal  pharjugitis 
predisposes  to  this  disease. 

Symptoms. — The  onset  resembles  that  of  follicular  tonsillitis,  except 
that  the  general  symptoms  are  usually  less  marked,  the  temperature  is 
commonly  not  so  high,  and  the  muscular  pains  and  prostration  less  se- 
vere. The  local  symptoms,  however,  are  more  striking.  There  is  very  se- 
vere pain  in  the  throat,  which  is  increased  by  deglutition,  and  finally  may 
be  so  great  that  swallowing  is  almost  impossible.  It  is  difficult  to  open 
the  mouth.  There  is  pain  in  the  lateral  muscles  of  the  neck,  and  often 
tenderness.  In  the  beginning  but  little  can  be  seen  on  inspection,  even 
though  the  patient  complains  of  a  very  sore  throat.  This  is  always  a 
suspicious  circumstance,  and  should  lead  one  to  look  out  for  quinsy.  It 
is  due  to  the  fact  that  the  inflammation  begins  in  the  deeper  tissues, 
and  that  the  mucous  membrane  is  affected  later.  After  twenty-four  or 
forty-eight  hours  there  is  usually  quite  marked  swelling,  which  is  rather 
more  behind  the  tonsil  than  elsewhere,  pushing  it  upward  and  forward; 
sometimes  it  is  more  in  front  of  the  tonsil.  A  little  later  there  is  in- 
tense inflammation  of  the  mucous  membrane  covering  the  tonsil,  fauces, 
and  uvula,  with  marked  congestion  and  oedema;  the  uvula  may  be  pushed 
to  one  side,  and  the  isthmus  of  the  fauces  diminished  to  less  than  one 
half  its  natural  size.  In  one  of  my  own  cases  marked  torticollis  was 
present,  and  existed  for  two  or  three  days  before  the  diagnosis  of  quinsy 
could  be  made  by  the  other  symptoms. 

In  most  cases  the  recognition  of  quinsy  is  quite  easy  by  attention  to  the 
symptoms  above  mentioned.  By  inspection  of  the  throat,  less  information 
is  sometimies  obtained  than  by  palpation  ;  by  this  means  a  fulness,  and 
later  a  point  of  fluctuation,  can  readily  be  made  out.  Acute  phlegmonous 
tonsillitis  generally  involves  no  danger  to  life.  In  very  young  infants 
serious  results  may  follow  spontaneous  rupture  during  sleep  ;  and  in 
older  children  occasionally  there  may  be  oedema  of  the  glottis.  If  not 
treated,  abscess  usually  forms  in  from  five  to  seven  days,  and  opens  spon- 
taneously. 

Treatment. — If  an  early  diagnosis  is  made  an  attack  of  quinsy  may 
occasionally  be  aborted.  For  this  many  drugs  have  been  advocated,  but 
to  my  mind  the  best  is  salol,  which  should  be  given  in  doses  of  two 
grains  every  two  hours  to  a  child  of  five  years.  In  some  patients  larger 
doses  may  be  used.  This  may  be  combined,  with  small  doses  (gr.  ^)  of 
Dover's  powder.  Relief  may  be  afforded  by  very  hot  or  cold  applications, 
according  to  the  sensations  of  the  patient.  The  holding  of  ice  in  tlie 
mouth  and  the  application  of  an  ice-bag  externally,  often  give  great  com- 
fort. In  other  cases,  gargling  with  very  hot  water  and  the  application  of 
hot  flaxseed  poultices  externally,  will  be  preferred.  As  soon  as  fluctuation 
is  detected  an  incision  should  be  made  with  a  guarded  bistoury.  If  made 
too  early,  only  a  small  amount  of  pus  is  evacuated  and  the  abscess  may 


310  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

refill.     After  spontaneous  rupture  the  relief  to  symptoms  is  usually  im- 
mediate. 

CHRONIC  HYPERTROPHY  OP  THE  TONSILS.— CHRONIC   TONSILLITIS. 

The  condition  known  as  chronic  hypertrophy,  is  a  permanent  enlarge- 
ment due  to  a  proliferation  of  the  lymphoid  tissue  of  the  tonsils,  and  an 
increase  in  the  connective-tissue  stroma.  If  the  increase  in  the  connective 
tissue  is  slight,  the  tonsil  is  soft ;  if  it  is  great,  the  tonsil  is  firm  and  hard, 
almost  like  a  fibrous  tumour.  All  degrees  are  found.  Associated  with 
hypertrophy  of  the  tonsils  there  are  frequently  found  adenoid  growths  of 
the  pharynx,  both  of  these  depending  upon  similar  local  and  constitu- 
tional conditions.  There  is  in  nearly  all  marked  cases  a  chronic  pharyn- 
geal catarrh  which  may  involve  the  Eustachian  tubes. 

Etiology. — Hypertrophy  of  the  tonsils  is  an  exceedingly  common  con- 
dition in  the  cities  of  the  seacoast  and  lake  districts  of  the  temperate 
zone.  In  a  routine  examination  of  2,000  New  York  school  children, 
Chappell  found  enlargement  of  the  tonsils  sufficiently  marked  to  be  con- 
sidered pathological,  in  370  cases.  The  causes'  are  constitutional  and  local. 
The  constitutional  causes  relate  to  the  conditions  described  in  the  chapter 
upon  Lymphatism.  This  is  often  found  in  certain  families  for  several 
generations.  The  condition  is  not  connected  with  tuberculosis.  It  oc- 
curs in  children  who  are  in  other  respects  healthy.  Hypertrophy  of  the 
tonsils  is  often  a  congenital  condition,  increasing  slowly  during  infancy, 
so  as  to  produce  marked  symptoms  by  the  time  the  child  is  two  years  old. 
The  most  important  of  the  local  causes  are  attacks  of  acute  or  subacute 
pharyngitis.  While  it  is  true  that  attacks  of  acute  inflammation  are  often 
the  cause  of  hypertrophy,  it  is  also  true  that  hypertrophy  is  one  of  the 
most  frequent  predisposing  causes  of  acute  attacks,  and  that  it  may  be 
seen  in  children  who  have  never  had  tonsillitis. 

Symptoms. — Hypertrophy  of  the  tonsils  is  rarely  marked  enough  to 
cause  any  decided  symptoms  before  the  end  of  the  second  year,  although 
I  once  saw  in  a  younger  child  enlargement  sufficient  to  bring  the  two  ton- 
sils into  contact.  The  most  important  local  symptoms,  formerly  ascribed 
to  hypertrophied  tonsils,  are  now  known  to  depend  upon  adenoid  growths 
of  the  pharynx.  As  these  conditions  are  so  frequently  associated,  it  is 
somewhat  difficult  to  determine  which  symptoms  are  due  to  the  tonsils 
alone.  In  a  marked  case,  the  most  prominent  symptoms  are  mouth- 
breathing,  disturbed  sleep  accompanied  by  snoring,  and  nasal  voice — the 
patient  in  some  cases  talking  as  though  he  had  food  in  his  mouth.  There 
may  be  some  difficulty  in  swallowing  solid  food.  Enlarged  tonsils  may 
often  be  felt  externally.  As  a  consequence  of  the  obstruction  of  the 
Eustachian  tubes  there  may  be  deafness.  Deformities  of  the  chest,  such 
as  pigeon-breast,  are  occasionally  seen,  but  probably  depend  more  upon 
obstructed  respiration  by  adenoids  than  by  the  tonsils. 


CHRONIC   HYPERTROPHY  OF  THE  TONSILS.  311 

The  soft  tonsils  may  diminish  somewhat  in  size  spontaneously.  They 
sometimes  shrink  very  decidedly  after  an  attack  of  acute  tonsillitis,  scar- 
let fever,  or  diphtheria.  As  a  rule  the  tonsils  become  firmer  and  harder 
as  time  passes.  They  usually  increase  in  size  up  to  a  certain  point,  and 
then  remain  nearly  stationary  until  about  puberty,  when  they  may 
diminish  considerably.  During  intercurrent  attacks  of  inflammation,  the 
swelling  is  much  increased,  and  the  symptoms  are  proportionately  aggra- 
vated. In  cases  of  marked  enlargement  very  little  spontaneous  improve- 
ment is  to  be  looked  for  during  childhood. 

Treatment. — Very  large  tonsils  are  a  source  of  continued  danger  to 
the  patient,  and  in  every  case  of  marked  hypertrophy  treatment  should 
be  advised.  The  danger  may  be  from  Eustachian  catarrh  and  deafness, 
or  from  repeated  attacks  of  acute  tonsillitis.  But  quite  as  important  as 
these  is  the  fact  that  they  increase  the  liability  to  contract  diphtheria, 
and  add  to  the  dangers  both  from  diphtheria  and  scarlet  fever.  If  the 
patient  is  removed  from  the  locality  in  which  acute  tonsillitis  is  liable  to 
occur,  to  a  dry  climate,  considerable  improvement  is  likely  to  result  in 
a  young  child  in  whom  the  tonsils  are  soft,  but  not  much  is  to  be  ex- 
pected in  older  children  with  hard,  fibrous  tonsils,  except,  perhaps,  a 
■cure  of  the  accompanying  pharyngeal  catarrh. 

The  only  internal  remedy  offering  much  chance  of  benefit  is,  in  my 
■experience,  the  syrup  of  the  iodide  of  iron,  which  must  be  given  in  quite 
large  doses  (twenty  drops  three  times  a  day  to  a  child  of  five  years),  and 
continued  for  several  months.  In  a  small  number  of  cases  marked  im- 
provement is  seen  from  this  treatment,  but  in  the  majority  but  little 
change  occurs.  Astringent  applications  may  accomplish  something  in 
recent,  but  practically  nothing  in  old  cases.  In  a  marked  case,  operation 
Is  the  only  thing  which  can  be  relied  upon  to  effect  a  cure.  In  those  in 
which  it  is  decided  not  to  operate,  or  in  which  operation  is  refused,  a 
faithful  trial  may  be  made  with  the  other  measures  referred  to.  The 
question  to  be  decided  always  is  whether  or  not  operation  shall  be  done. 
For  convenience  of  consideration,  the  cases  may  be  divided  into  three 
groups:  (1)  those  in  which  the  tonsils  are  nearly  or  quite  in  contact;  (2) 
those  in  which  tliey  project  not  more  than  one  fourth  of  an  inch  beyond 
the  faucial  pillars;  (3)  the  intermediate  cases.  All  of  the  first  group 
should  unquestionably  be  operated  upon,  unless  the  patient's  general  con- 
dition is  such  as  to  forbid  operation  of  any  kind.  Of  the  second  group, 
few  if  any  require  operation.  "Whether  an  operation  is  done  in  the  third 
group  will  depend  u])on  llio  individual  case.  If  there  are  frequent  attacks 
of  acute  tonsillitis,  and  some  deafness,  an  operation  should  be  performed. 
If  little  or  no  local  discomfort  is  experienced  it  may  be  postponed. 

Of  the  various  operations  proposed,  excision  with  the  guillotine  is  the 
■one  which  has  in  children  superseded  all  others  in  the  practice  of  New 
York  physicians.     The  risk  of  hemorrhage  at  this  age  is  very  slight. 


312  DISEASES  OP   THE  DIGESTIVE  SYSTEM. 

The  child  is  held  as  for  the  operation  of  intubation,  except  that  the  head 
is  thrown  backward.  No  after-treatment  is  required,  excepting  fluid  diet 
and  confinement  to  the  house  for  two  or  three  days.  Excessive  hgemor- 
rhage  may  be  controlled  by  digital  pressure,  or  by  the  application  of 
styptic  cotton  upon  a  swab ;  in  extreme  cases,  by  transfixing  the  tonsil 
stump  with  a  hare-lip  pin  and  the  application  of  a  ligature.  I  have  more 
than  once  seen  physicians  greatly  alarmed  at  the  gray  wound  on  the  day 
following  tonsillotomy,  the  appearance  being  such  as  to  lead  in  several 
cases  to  the  diagnosis  of  diphtheria.  This  mistake  will  not  be  made  if 
the  possibility  of  it  is  borne  in  mind.  It  is  seldom  that  any  but  good 
results  follow  the  operation  of  tonsillotomy  if  properly  performed.  It  is 
too  often  neglected.  Where  adenoids  of  the  pharynx  are  also  present,  the 
symptoms  may  depend  more  upon  them  than  upon  the  enlarged  tonsils,. 
and  little  benefit  is  seen  until  the  adenoid  growths  also  are  removed. 
Both  may  be  operated  upon  at  a  single  sitting,  or  at  two  sittings  if  pre- 
ferred. 

It  is  not  usually  necessary  to  remove  the  tonsil  to  a  point  even  with  the- 
faucial  pillars,  but  the  more  nearly  we  can  come  to  this  the  better.  The- 
amount  of  shrinkage  from  cicatrization  after  operation  has  been,  in  my 
experience,  generally  less  than  was  expected.  As  a  rule,  enlargement 
of  the  tonsil  subsequent  to  an  operation  is  not  seen  ;  but  one  should  be 
careful  about  promising  parents  that  it  will  not  occur.  I  have  seen  it  in 
two  or  three  instances  to  a  striking  degree,  and  think  it  more  likely  to- 
occur  if  children  operated  on  are  very  young — i.  e.,  under  three  years. 


CHAPTER   IV. 
DISEASES  OF  THE  (ESOPHAGUS. 

MALFORMATIONS. 

Congenital  anomalies  of  the  oesophagus  are  much  less  frequent  than: 
those  of  the  lower  part  of  the  respiratory  tract,  with  which,  however,  they 
are  often  associated. 

There  may  be,  (1)  Congenital  fistula  of  the  neck,  due  to  a  want  of 
closure  between  the  second  and  third  branchial  arches.  This  gives  an 
external  opening  just  above  and  to  the  outside  of  the  sterno-clavicular 
articulation,  which  communicates  with  the  upper  part  of  the  oesophagus 
or  the  lower  part  of  the  pharynx.  (2)  The  oesophagus  may  be  absent, 
the  pharynx  ending  in  a  blind  pouch.  (3)  The  oesophagus  may  be  oblit- 
erated in  certain  portions,  being  represented  only  by  a  fibrous  cord.  (4) 
There  may  be  stenosis  and  dilatation  or  diverticula.     (5)  There  may  be  a 


ACUTE   CESOPHAGITIS.  3I3 

fistulous  communication  with  the  trachea,  existing  either  alone  or  asso- 
ciated with  some  of  the  other  deformities  mentioned. 

Congenital  narrowing  of  the  (esophagus  and  fistula  of  the  neck  are 
amenable  to  surgical  treatment.  The  cases  of  complete  obstruction  in  the 
oesophagus  are  almost  of  necessity  fatal,  the  patients  dying  from  inanition 
two  or  three  days  after  birth. 

The  symptoms  of  oesophageal  obstruction  are  regurgitation  on  attempts 
at  swallowing  and  the  impossibility  of  passing  the  stomach  tube. 

ACUTE  CESOPHAGITIS. 

It  is  quite  remarkable,  considering  the  frequency  of  pathological  pro- 
cesses in  the  pharynx,  that  these  so  rarely  extend  to  the  oesophagus. 
Thrush,  when  very  extensive  in  the  pharynx,  may  involve  the  upper  part 
of  the  oesophagus  ;  but  there  it  gives  rise  to  new  symptoms.  Diphtheria 
and  pseudo-diphtheria  of  the  pharynx  may  invade  the  oesophagus,  but 
this  is  seen  only  in  very  rare  instances.  In  about  seventy-five  autopsies 
which  I  have  seen  in  cases  of  diphtheria,  the  oesophagus  was  involved  in 
but  one,  and  in  this  case  for  three  or  four  inches  only.  Diphtheria  of 
the  oesophagus  produces  no  symptoms,  and  can  not  be  diagnosticated  dur- 
ing life. 

Catarrhal  (Esophagitis  is  very  rarely  met  with.  It  may  be  caused  by 
lacerations  due  to  swallowing  a  foreign  body,  which  may  excite  a  simple 
catarrhal  inflammation,  or,  if  the  foreign  body  is  sharp  and  angular, 
lacerations  may  be  produced  which  result  in  ulcerations  of  variable  depth. 
The  chief  symptoms  of  catarrhal  oesophagitis  are  soreness  and  pain  on 
swallowing.  These  lacerations,  when  slight,  are  healed  in  a  few  days,  and 
are  rarely  followed  by  any  after-effects. 

Corrosive  (Esophagitis. — This  is  altogether  the  most  frequent  form, 
and  the  only  one  which  is  of  clinical  importance.  The  usual  causes  are 
the  same  as  of  corrosive  gastritis,  viz.,  the  swallowing  of  caustic  alkalies  or 
strong  acids.  It  is  often  in  the  oesophagus  that  the  most  extensive  injury 
is  done.  The  effects  are  superficial  or  deep,  according  to  the  amount 
of  the  irritant  swallowed  and  its  degree  of  concentration.  There  may 
be  simply  a  destruction  of  the  epithelial  layer,  which  is  followed  by  no 
serious  consequences,  or  the  mucous  membrane  may  be  destroyed  and  the 
submucous  coat  invaded  ;  rarely,  however,  does  the  injury  extend  to  the 
muscular  layer.  If  the  patient  survives  the  dangers  incident  to  the 
irritant  poisoning  and  the  acute  inflammation  which  follows,  healing  by 
granulation  and  cicatrization  takes  place,  the  contraction  of  the  cicatrix 
gradually  narrowing  the  lumen  of  the  oesophagus  until  stricture  is  pro- 
duced. 

The  early  symptoms  of  corrosive  oesophagitis  are  mingled  with  those 
of  inflammation  of  the  moutli,  pharynx,  and  stomach.  There  is  a  burn- 
ing pain  in  the  parts,  great  thirst,  spasm  of  the  oesophagus  on  attempts  at 


314  DISEASES   OF  THE   DIGESTIVE   SYSTEM. 

swallowing,  so  that  deglutition  may  be  almost  impossible.  There  follows 
a  period  of  acute  inflammation  of  several  days'  duration,  in  which  the 
chief  local  symptoms  are  dysphagia  and  pain,  and  in  which  the  prin- 
cipal danger  is  that  of  suffocation  from  oedema  of  the  glottis.  After  this 
period  has  passed,  the  patient  may  be  comparatively  well  until  the  symp- 
toms of  stricture  begin,  usually  in  from  three  to  six  months  after  the 
injury. 

The  indications  for  treatment  in  the  early  stage,  are  to  neutralize  the 
caustic  in  order  to  prevent  if  possible  its  deep  action,  and  in  all  cases  to 
give  oils,  demulcent  drinks,  and  ice  for  the  local  effect,  and  morphine  for 
the  pain. 

The  treatment  of  oesophageal  stricture  is  purely  surgical,  and  for  this 
the  reader  is  referred  to  surgical  text-books. 

RETRO-CESOPHAGEAL  ABSCESS. 

Retro-oesophageal  abscess  may  result  from  the  breaking  down  of 
tuberculous  lymph  nodes  in  the  posterior  mediastinum,  and  may  give  rise 
to  symptoms  like  those  which  result  from  an  abscess  due  to  Pott's  disease, 
from  which  it  can  not  be  diagnosticated.  Retro-oesophageal  abscess  or 
peri- oesophagitis  may  occur  in  children  after  measles,  scarlet  fever,  influ- 
enza, or  with  syphilis.  Here  its  pathology  is  the  same  as  retro-pharyngeal 
abscess,  differing  only  in  location.  Eetro-oesophageal  adenitis,  or  enlarge- 
ment of  the  lymph  nodes  in  the  posterior  wall  of  the  oesophagus,  not 
going  on  to  suppuration,  is  a  rare  condition.  I  have  recently  met  with  a 
case  in  which  a  tumour  nearly  an  inch  in  diameter  was  formed  at  the 
upper  part  of  the  oesophagus,  and  which  caused  pressure  symptoms,  neces- 
sitating tracheotomy.  The  growth  was  at  first  believed  to  be  of  a  malig- 
nant character,  but  it  completely  disappeared  after  four  or  five  months  of 
general  treatment,  including  a  summer  in  the  country. 

Perforation  of  the  oesophagus,  and  a  food-fistula  connecting  the  ceso- 
phagus  and  the  trachea,  may  result  from  ulceration  caused  by  a  tracheal 
canula  or  by  a  foreign  body.     This  may  be  accompanied  by  abscess. 

The  most  common  variety  of  retro-oesophageal  abscess  is  that  due  to 
Pott's  disease  of  the  lower  cervical  or  upper  dorsal  region.  The  symptoms 
are  obscure,  and  an  exact  diagnosis  is  not  often  made  during  life.  Death 
may  occur  quite  suddenly  where  the  previous  symptoms  have  been  so 
slight  as  to  be  easily  overlooked.  The  following  is  a  fair  example  of  such 
a  case  : 

A  little  girl  two  years  old,  of  a  tuberculous  family,  was  admitted  to  the 
Babies'  Hospital  in  December,  1892,  with  spinal  caries  of  the  upper 
dorsal  region.  The  symptoms  were  of  two  months'  duration,  and  already 
there  was  a  spinal  deformity  consisting  of  a  small  knuckle.  The  patient 
was  kept  in  bed  and  a  plaster-of-Paris  jacket  applied.  A  slight  febrile 
action  of  irregular  type  was  present.     About  a  month  after  admission 


RETRO-GESOPHAGEAL  ABSCESS.  31 5 

dyspnoea  was  first  observed  ;  this  was  at  times  quite  intense,  and  again 
almost  absent.  It  was  always  on  inspiration,  expiration  being  easy.  No 
explanation  for  this  was  found  in  the  lungs.  There  was  no  difficulty  in 
swallowing,  and  very  little  cough.  After  these  symptoms  had  lasted  for 
about  a  week,  the  child  while  eating  was  suddenly  seized  with  violent 
dyspnoea,  and  in  a  few  moments  became  completely  asphyxiated.  Trache- 
otomy was  immediately  done,  and  by  means  of  artificial  respiration  the 
patient  was  restored  to  comparative  comfort.  About  two  hours  later  a 
second  attack  occurred,  and  the  patient  died  in  an  hour.  At  the  autopsy 
there  was  found  an  abscess  a  little  larger  than  a  hen's  egg,  containing 
about  two  ounces  of  curdy  pus,  overlying  the  bodies  of  the  first  three 
dorsal  vertebras  and  communicating  with  them.  These  vertebrae  were 
carious.  The  right  pneumogastric  nerve,  an  inch  and  a  half  above  the 
bifurcation  of  the  trachea,  was  compressed  between  the  abscess  and  a 
large  tuberculous  lymph  node,  with  the  capsule  of  which  it  was  blended. 
In  the  lungs  were  a  few  small  tuberculous  deposits  and  the  usual  condi- 
tions found  in  death  by  asphyxia.  The  dyspnoea  seems  to  have  been  of 
nervous  and  not  of  mechanical  origin,  and  caused  by  irritation  of  the 
pneumogastric.  The  fatal  issue  was  apparently  from  an  increase  of  the 
pressure  upon  the  nerve. 

I  have  seen  but  one  other  case,  and  this  closely  resembled  the  one 
reported.  Griffith  has  collected  (Archives  of  Paediatrics,  January,  1898) 
twelve  cases  from  the  literature,  and  added  one  of  his  own.  The  symp- 
toms in  all  were  much  alike.  Dyspnoea,  usually  of  a  spasmodic  character, 
was  prominent  in  nearly  all,  and  generally  it  was  the  most  marked  symp- 
tom. It  was  more  marked  on  inspiration,  and  often  accompanied  by  a 
spasmodic  cough,  suggesting  laryngeal  stenosis.  The  voice  was  affected 
in  but  two  cases,  in  one  complete  aphonia  being  present.  It  is  striking 
that  in  no  case  was  there  any  difficulty  in  swallowing,  in  marked  contrast 
to  retro-pharyngeal  abscess.  Swelling  in  the  neck  was  noted  in  but  three 
cases.  Spinal  caries  was  stated  to  be  present  in  seven  cases  and  absent  in 
two.  The  final  attack  of  asphyxia  sometimes  came  without  warning, 
sometimes  was  preceded  for  several  days  or  longer  by  milder  attacks. 

The  diagnosis  of  this  condition  is  very  difficult,  and  a  positive  diag- 
nosis almost  impossible.  It  may  be  suspected  in  cases  of  Pott's  disease  of 
the  lower  cervical  or  upper  dorsal  regions,  when  there  is  spasmodic  inspir- 
atory dyspnoea,  especially  if  accompanied  by  irritative  cough.  It  should, 
however,  be  remembered  that  precisely  similar  symptoms  may  depend 
upon  the  irritation  of  a  tuberculous  node,  and  that  the  sudden  asphyxia  i& 
exactly  like  that  caused  by  the  ulceration  of  such  a  node  into  the  trachea 
or  a  large  bronchus.  The  latter,  however,  may  occur  without  the  pres- 
ence of  Pott's  disease.  If  the  abscess  is  higher  up,  there  may  be  a  lateral 
swelling  on  either  side  of  the  neck,  just  above  the  clavicle.  In  most  of 
the  cases  there  are  no  external  signs  of  disease.    Such  abscesses  are  too 


316  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

low  to  be  reached  by  digital  examination  of  the  pharynx.  The  attack 
of  asphyxia  may  also  be  confounded  with  that  due  to  the  presence  of  a 
foreign  body  in  the  larynx. 

The  prognosis  in  cases  of  retro-oesophageal  abscess  is  exceedingly  bad. 
Death  usually  results  from  pressure  upon  the  pneumogastric,  as  in  the 
cases  reported.  The  abscess  may  rupture  into  the  oesophagus  and  recov- 
ery follow.  This  termination  is  very  rare,  but  such  a  case  has  been  re- 
ported by  Knight.  A  fatal  one  is  reported  by  Loschner  and  Lambl.  The 
abscess  may  burrow  along  the  oesophagus  into  the  abdominal  cavity  and 
excite  peritonitis ;  finally,  it  may  open  externally. 

But  little  is  to  be  said  under  the  head  of  Treatment.  The  symptoms 
are  rarely  definite  enough  to  justify  a  radical  surgical  operation.  Trache- 
otomy gives  but  temporary  relief  to  the  asphyxia.  This  operation  should 
be  performed,  however,  in  every  case,  because  of  the  impossibility  of 
making  a  diagnosis  of  retro-oesophageal  abscess  from  other  conditions 
in  which  the  operation  might  be  curative. 


CHAPTEE    V. 
DISEASES  OF  TEE  STOMACH. 

It  is  difficult  wholly  to  separate  diseases  of  the  stomach  from  those 
of  the  intestines.  Although  in  older  children  they  are  often  quite  dis- 
tinct, in  infancy  they  are  more  frequently  associated:  but  at  one  time 
the  gastric  symptoms  may  be  prominent,  and  at  another  the  intestinal 
symptoms.  Functional  disorders  particularly  are  likely  to  involve  the 
whole  tract.  Serious  organic  lesions  are  more  frequently  limited  in 
their  extent  either  to  the  stomach  or  to  the  intestine.  The  former  are 
rare,  while  the  latter  are  very  common.  The  diseases  in  which  the  stom- 
ach is  alone  or  chiefly  involved  will  be  considered  by  themselves.  Those 
in  which  both  the  stomach  and  intestine  are  involved  are  classed  with 
the  intestinal  diseases,  as  the  intestinal  symptoms  usually  predominate. 

DIGESTION   IX   INFANCY. 

The  first  step  in  the  process  of  digestion  in  the  newly-born  infant  is 
sucking.  During  this  act  the  nipple  is  grasped  between  the  lower  lip  and 
tongue  below,  and  the  upper  lip  and  jaw  above.  The  back  of  the  mouth 
is  closed  by  the  fall  of  the  palate.  A  strong  downward  movement  of  the 
lower  jaw  rarefies  the  air  in  the  mouth,  and  produces  the  suction  force 
which  causes  the  milk  to  flow.  Sucking  can  be  carried  on  only  when  the 
nose  is  free  for  respiration  and  the  palate  and  upper  jaw  intact.  Children 
with  deformities  of  the  mouth,  like  cleft  palate  and  harelip,  suck  only 


The  Stomach  at  the  Different  Periods  < 
Life  size,  from  photographs. 


DIGESTION    IN   INFANCY. 


3i: 


with  the  greatest  difficulty,  and  complete  nasal  obstruction  prevents 
nursing. 

The  Saliva. — This  is  present  at  birth  only  in  very  small  quantity,  and 
the  part  which  it  plays  in  digestion  in  early  infancy  is  an  insignifi- 
cant one.  During  the  third  and  fourth  months  it  increases  markedly  in 
amount,  and  at  this  time  it  possesses  quite  actively  the  power  of  trans- 
forming starch  into  sugar.  This  property  is  present  only  to  a  very  slight 
degree  during  the  first  eight  or  ten  weeks.  With  the  advent  of  the  teeth 
there  is  a  further  increase  in  the  amount  of  saliva  secreted,  indicating  a 
change  in  the  digestion  of  the  infant. 

The  Stomach, — The  position  of  the  stomach  in  the  foetus  is  nearly 
vertical.  In  the  newly-born  child  it  lies  obliquely  in  the  abdomen,  and 
at  the  end  of  infancy  has  almost  reached  the  transverse  position.  The 
stomach  at  birth  is  nearly  cylindrical,  but  the  fundus  increases  in  size 
very  rapidly  during  the  first  year,  although  it  does  not  reach  its  full  de- 
velopment until  quite  late  in  childhood.  In  Plate  VII  are  shown  the 
actual  size  and  shape  of  the  stomach  at  the  various  periods  of  infancy. 
In  the  following  table  are  given  the  results  of  post-mortem  measure- 
ments of  the  stomach,  which  I  have  personally  made  in  ninety-one  in- 
fants under  fourteen  months  of  age : 


The  Capacity  o 

/  the  Stomach. 

Age. 

Number 
of  cases. 

Average 
capacity. 

1 

Age. 

Number 
of  cases. 

Average 
capacity. 

Birth 

5 

7 

4 

11 

t 

1-20OZ. 
1-50  " 
2-00  " 
2-27  " 
3-37  '• 
4-25  " 

! 

12  weeks 

14  to  18  weeks  . .  . 
5  to  6  months. . . 
7  to  8        "       ... 
10  to  11      "       ... 
12  to  14     "      ... 

6 

12 

14 

9 

7 

10 

4-50  oz. 

2  weeks 

5-00    " 

4      "     

5-75    " 

6      "     

6-88    " 

8      "     

8-14   " 

10    "     

8-90   " 

In  brief,  the  average  capacity  was,  at  birth,  one  and  one  fifth  ounce ; 
at  three  months,  four  and  a  half  ounces;  at  six  months,  six  ounces;  at 
twelve  months,  nine  ounces. 

Gastric  digestion. — The  part  taken  by  the  stomach  in  digestion  is 
smaller  than  was  formerly  supposed,  and  not  so  important  in  infants  as  in 
adults.  The  food  leaves  the  stomach  so  rapidly  that  a  large  part  of  the 
casein  must  pass  into  the  intestine  before  it  is  converted  into  peptones. 
The  opinion  has  been  steadily  gaining  ground  that  the  function  of  the 
stomach  is  largely  that  of  a  reservoir,  into  which  the  milk  is  received  and 
from  which  it  is  allowed  to  pass  gradually  into  the  intestine;  and  that  the 
gastric  process  is  only  a  preliminary  and  partial  one,  even  in  the  digestion 
of  proteids,  this  being. completed  in  the  intestine. 

The  only  part  of  the  food  acted  on  in  the  stomach  is  the  proteids, 
which  are  transformed  successively  into  acid-albumin,  albumoses,  and 
peptones.     This  is  accomplished  by  the  agency  of  the  pepsin  and. the  acid 


318  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

of  the  gastric  juice — generally  hydrochloric  acid,  although  lactic  acid 
may  take  its  place.  Pepsin  is  found  in  the  stomach  at  birth,  and  even  in 
the  embryo  as  early  as  the  fourth  month  (Krliger).  The  reaction  of  the 
stomach  contents  in  fasting  is  acid,  and  at  this  time  usually  free  hydro- 
chloric acid  can  be  demonstrated ;  soon  after  a  meal  of  human  milk  it  is 
alkaline  or  neutral ;  after  one  of  cow's  milk  it  is  acid  or  neutral.  In  fif- 
teen minutes  after  feeding  the  reaction  is  always  acid  (Leo).  Free 
hydrochloric  acid  can  not  usually  be  demonstrated  until  about  an  hour 
after  feeding,  then  only  in  small  quantities,  and  in  very  many  cases  not 
at  all.  Some  good  observers  go  so  far  as  to  say  that  in  health  free  acid 
is  never  found  during  digestion.  The  reason  for  this  apparently  is,  that 
the  acid  combines  with  the  casein  of  the  milk,  that  of  cow's  milk  in  par- 
ticular having  a  very  great  power  of  combining  with  hydrochloric  acid. 

Lactic  acid  is  feebler  in  its  digestive  power'  than  hydrochloric  acid. 
It  is  more  abundant  early  in  infancy  than  later;  it  is  derived  from  the 
milk  sugar.  It  is  rarely  found  as  free  acid;  never  in  health,  according 
to  many  observers. 

The  coagulation  of  milk  in  the  stomach  is  accomplished  through  the 
agency  of  the  rennet  ferment  (the  lab-ferment  of  Hammarsten) .  This  is 
independent  of  both  the  pepsin  and  the  acid  of  the  stomach.  It  acts  in 
acid,  alkaline,  and  neutral  media.  Coagulation  is  the  first  change  in  the 
milk  in  the  stomach.  Human  milk  coagulates  in  loose  flocculi  and  quite 
imperfectly,  more  firmly  if  the  stomach  is  very  acid.  Cow's  milk,  unless 
diluted,  coagulates  in  firm,  compact  masses.  L^'nder  the  influence  of  pep- 
sin and  hydrochloric  acid,  solution  of  this  coagulum  now  begins ;  but  this 
is  only  partially  accomplished  in  the  stomach.  It  goes  forward  much 
more  rapidly  in  the  case  of  human  milk,  becaiise  the  amount  of  casein 
is  less  and  because  of  the  smaller  curds.  The  milk  begins  to  leave  the 
stomach  very  soon  after  the  meal,  and  even  during  the  first  half  hour 
a  considerable  part  passes  into  the  intestine.  At  the  end  of  an  hour 
the  stomach  in  a  young  infant  is  often  empty.  In  the  case  of  cow's  milk, 
not  only  are  the  coagula  firmer,  but  the  amount  of  casein  present  is 
much  larger,  and  hence  the  milk  is  detained  in  the  stomach  a  longer 
time ;  even  then  a  considerable  portion  of  it  must  pass  but  little  changed 
into  the  intestine. 

The  duration  of  gastric  digestion  varies  with  the  age  of  the  infant 
and  with  the  food.  During  the  first  month  the  stomach  of  healthy 
nursing  infants  is  usually  found  empty  in  an  hour  and  a  half  after  feed- 
ing; often  in  one  hour.  In  those  taking  cow's  milk  the  average  is  at 
least  half  an  hour  longer.  In  infants  from  two  to  eight  months  old 
the  average  is  two  hours  for  those  receiving  breast-milk,  and  two  and  a 
half  to  three  hours  for  those  fed  upon  cow's  milk.  This  is  influenced  by 
the  size  of  the  meal  taken.  This  period  is  very  much  longer  in  all  cases- 
of  disordered  digestion. 


DIGESTION   IN  INFANCY.  319 

The  bacteria  of  the  stomach  are  very  few  as  compared  with  those  of 
the  intestine,  and  no  varieties  are  constantly  present  (Booker). 

The  Intestines. — The  length  of  the  small  intestine  at  birth  is  about 
nine  feet ;  that  of  the  large  intestine  about  eighteen  inches.  The  great 
length  of  the  sigmoid  flexure  is  the  most  striking  peculiarity,  this  being 
nearly  one  half  the  length  of  the  large  intestine.     (See  page  6-i.) 

Intestinal  digestion. — All  the  important  elements  of  food — proteids, 
carbohydrates,  and  fats — are  acted  upon  by  the  pancreatic  juice.  The 
proteids  are  converted  into  peptones  by  the  trypsin,  which  is  active  only 
in  an  alkaline  medium.  How  much  of  the  proteids  of  the  milk  is  left 
for  intestinal  digestion,  depends  upon  how  well  the  stomach  has  done  its 
part.  In  every  case  something  is  left ;  in  most  cases  a  large  part  of  the 
proteids  passes  but  little  changed  into  the  intestine.  The  amylolytic  fer- 
ment of  the  pancreas  has  the  power  of  converting  starch  into  sugar. 
This  action  is  feeble  during  the  first  five  or  six  months,  but  we  can  not 
accept  the  statements  of  Koronin  and  Zweifel,  that  it  is  entirely  absent 
in  early  infancy.  Fats  are  partly  emulsified  and  partly  saponified  by 
the  pancreatic"  juice,  in  connection  with  bile,  which  probably  furnishes 
the  needed  alkali.  The  pancreatic  juice  actively  emulsifies  fat,  even  at 
birth. 

The  very  large  size  of  the  liver  in  the  newly  born  indicates  how  im- 
portant are  its  functions  in  digestion.  The  biliary  secretion  is  present  as 
early  as  the  third  month  of  foetal  life  (Zweifel).  Bile  assists  in  the  diges- 
tion and  absorption  of  fats,  as  has  already  been  mentioned.  In  addition 
it  is  a  stimulus  to  peristalsis,  and  in  this  way  aids  in  the  absorption  of  all 
kinds  of  food.  Its  antiseptic  effect  is  very  doubtful.  It  has  a  feeble 
diastatic  action  upon  starch.  The  greater  part  of  the  bile  is  reabsorbed 
from  the  intestine. 

Milk  sugar  is  changed  into  galactose  (Biedert),  cane  sugar  into  dex- 
trose and  levulose,  all  three  being  closely  allied  substances.  Through 
what  agency  these  changes  are  accomplished  is  not  now  positively  kuown^ 
but  it  is  probably  the  pancreatic  juice. 

The  action  of  the  intestinal  juice  is  not  perfectly  understood ;  its  chief 
function  is  thought  to  be  diastatic.  It  is  alkaline  in  reaction,  and  prob- 
ably facilitates  the  action  of  the  trypsin,  the  diastatic  ferment,  and  the 
absorption  of  fats. 

Absorption. — From  the  stomach,  absorption  of  water,  salts,  sugar,  and 
peptones  may  take  place  directly  into  the  blood.  From  the  small  intestine, 
in  addition  to  the  above  elements,  fat  is  absorbed  especially  by  the  villi. 
Absorption  is  less  active  than  secretion  in  the  small  intestine,  except  in 
the  duodenum.  It  is  accomplished  through  the  agency  of  the  villi  and 
the  simple  follicles  of  the  mucous  membrane.  It  is  perhaps  partly  by 
filtration  and  endosmosis,  but  chiefly  through  the  activity  of  the  epithelial 
cells  themselves  (Hoppe-Seyler,  Haidenhain).     Absorption  from  the  large 


320  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

intestine  is  quite  imperfect.  There  are  no  villi,  and  hence  fat  absorption 
is  very  slight.  Sugar,  salts,  and  peptones,  however,  may  be  absorbed  with 
moderate  facility.  Since  there  is  little  or  no  digestive  activity  in  the 
large  intestine,  if  this  is  used  as  a  means  of  nutrition,  the  food  must  be 
given  in  a  condition  in  which  it  is  ready  for  absorption. 

Even  in  healthy  nursing  infants  complete  absorption  is  possible  only 
in  the  case  of  milk  sugar.  From  two  to  five  per  cent  of  the  proteids  and 
fats  taken  pass  through  the  intestinal  canal.  In  infants  taking  cow's 
milk  the  fat-residue  is  from  one  to  three  per  cent  greater  than  in  those 
who  are  breast-fed  (Ulfelmann).  Even  when  the  amount  of  fat  given  is 
considerably  greater  than  that  usually  present  in  cow's  milk,  it  may  be 
almost  entirely  absorbed.  In  infants  taking  cow's  milk  the  proteid  resi- 
due is  relatively  much  greater  than  that  of  the  fat. 

In  cases  of  indigestion  the  increase  in  the  food-residue  in  most  cases 
is  first  in  the  proteids,  next  in  the  fat,  and  least  in  the  sugar.  In  some 
of  the  chronic  cases  the  principal  increase  may  be  in  the  fat. 

Intestinal  Bacteria. — For  the  fundamental  work  upon  this  subject  we 
are  indebted  to  the  researches  of  Escherich.  Bacteria  are  absent  from 
the  entire  gastro-enteric  tract  at  birth.  They  quickly  enter  by  the  mouth, 
and  by  the  end  of  twenty-four  hours  they  are  usually  found  in  all  parts  of 
the  intestinal  tract.  The  meconium-bacteria  are  derived  from  the  in- 
spired air,  and  hence  vary  somewhat  with  surroundings.  As  soon  as  the 
ingestion  of  milk  begins  these  varieties  are  displaced,  and  throughout  the 
period  in  which  the  infant  has  this  food  exclusively,  there  have  been 
found  in  healthy  conditions  but  two  varieties  which  are  constantly  pres- 
ent. These  are  the  bacterium  lactis  aerogenes  and  the  bacterium  coli 
commune.  The  first  is  found  most  abundantly  in  the  upper  part  of  the 
small  intestine,  diminishing  as  we  descend,  in  small  numbers  only  in  the 
colon,  and  usually  none  are  in  the  faeces.  It  seems  to  require  for  its 
growth  the  presence  of  milk  sugar,  hence  its  absence  from  that  part  of 
the  intestine  where  milk  sugar  is  not  found.  Milk  sugar  is  decomposed 
by  it  with  the  formation  of  lactic  acid  (acetic,  according  to  Baginsky), 
carbon  dioxide,  hydrogen,  and  methane.  This  action  is  not  hindered  by 
the  bile.  The  b.  lactis  has  no  action  of  importance  on  either  the  fat  or 
casein  of  the  milk. 

The  b.  coli  commune  is  found  in  but  small  numbers  in  the  upper 
small  intestine,  becoming  more  abundant  as  we  descend.  In  the  colon 
and  in  the  faeces  it  is  present  in  immense  numbers,  and  in  the  fasces  is 
sometimes  almost  the  only  variety.  The  activity  of  the  b.  coli  commune 
apparently  begins  where  that  of  the  b.  lactis  ends,  viz.,  in  the  lower  part 
of  the  small  intestine.  It  does  not  seem  to  depend  for  its  growth  upon 
any  part  of  the  food,  but  upon  the  intestinal  secretions.  A  change  from 
a  milk  diet  to  a  mixed  diet  of  meat  and  farinaceous  food,  produces  a  con- 
stant change  in  the  bacteria  of  the  intestine.    The  b.  lactis  disappears; 


DIGESTION   IN   INFANCY.  321 

the  h.  coll  commune,  however,  continues  to  he  found  as  the  principal 
form  in  the  colon. 

Eegarding  the  action  of  these  bacteria  but  little  is  as  yet  kno^Ti. 
The  &.  lactis  is  believed  not  to  be  pathogenic.  There  seems  to  be  abun- 
dant evidence  to  show  that  the  &.  coli  commune,  though  not  ordinarily 
pathogenic,  may  under  a  great  many  conditions  become  so. 

Faeces, — The  first  discharges  after  birth  are  called  meconium ;  this  is 
of  a  darlv  brownish-green  colour,  semi-solid,  and  usually  passed  from 
four  to  six  times  daily  during  the  first  two  or  three  days.  On  the  third 
day  the  stools  begin  to  change  in  character,  and  by  the  fourth  or  fifth 
day  they  have  usually  assumed  the  appearance  of  healthy  milk-fgeces. 
Under  many  abnormal  conditions  the  stools  may  continue  to  have  the 
character  of  meconium  for  a  week  or  more.  The  composition  of  meco- 
nium, according  to  Forster,  is  intestinal  mucus,  bile,  the  vernix  caseosa, 
epithelial  cells  from  the  epidermis,  hairs,  fat-globules,  and  cholesterin 
crystals.  For  its  formation  there  are  necessary  the  secretions  of  the  in- 
testine and  the  liver  and  the  swallowing  of  a  considerable  amount  of 
amniotic  fluid. 

MilJc-fceces. — The  normal  amount  of  faeces  discharged  daily  by  a 
healthy  nursing  infant  is  from  two  to  three  ounces.  Such  stools  have  the 
colour  of  the  yolk  of  egg.  They  are  smooth,  homogeneous,  of  a  soft,  but- 
ter-like consistency,  with  an  acid  reaction,  and  a  slightly  acid  but  not 
unpleasant  odour.  The  reaction  is  due  to  the  presence  of  fatty  acids 
(Biedert)  or  lactic  acid  (Uffelmann).  The  colour  depends  upon  biliru- 
bin. The  stools  of  an  infant  fed  upon  properly  modified  cow's  milk  may 
differ  in  no  respect  from  those  described ;  they  are,  however,  commonly 
firmer,  paler,  and  may  be  neutral  or  even  alkaline  in  reaction,  depending 
upon  the  decomposition  of  casein.  In  fact,  all  these  differences  depend 
chiefly  upon  the  presence  of  undigested  casein. 

The  only  gases  present  are  hydrogen  and  carbon  dioxide  (Escherich). 
Sulphuretted  hydrogen  and  marsh  gas,  to  which  the  odour  of  adult  stools 
is  largely  due,  are  not  present.  The  following  is  the  chemical  composi- 
tion as  given  by  Wegscheider: 

Water 85  •  13 

Solids]  ?^^""^°: ^m\ 14-87 

(  Inorganic 1  •  16  )  

100-00 

The  proteids  of  breast-milk  are  almost  entirely  absorbed.  According 
to  Uff'elmann,  they  form  but  1  '5  per  cent  of  the  dry  residue  of  the  fjBces. 
The  stools  of  infants  fed  upon  cow's  milk  are  usually  larger,  and  gener- 
ally contain  casein.  If  the  percentage  of  casein  in  the  milk  as  fed  is  ex- 
cessive, it  may  be  present  in  the  faces  in  large  amount,  the  stools  then 
being  of  a  pale-yellow  or  white  colour,  quite  dry,  often  formed,  and  with 
an  odour  sometimes  cheesy,  at  other  times  foul. 


322  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

Fat  is  always  preseut,  and  forms,  according  to  Wegscheider  and  Uffel- 
mann,  from  9  to  25  per  cent  of  the  dry  residue  of  milk  fseces.  According 
to  Tschernoif  and  some  other  recent  observers,  the  proportion  is  as  high 
as  28  to  35  per  cent.  It  is  present  as  neutral  fat,  fatty  acids,  and  soaps. 
Sugar  is  not  found,  but  its  derivative,  lactic  acid,  may  be  present  in  a 
small  amount.  Inorganic  salts  form  about  8  per  cent  of  the  dry  residue. 
They  are  chiefly  the  salts  of  lime.  Of  the  biliary  elements  there  are  hydro- 
bilirubin,  unchanged  bilirubin,  and  cholesterin  in  considerable  amount. 
The  presence  of  biliary  acids  is  doubtful.  Mucus  is  always  present  in  con- 
siderable quantity  ;  also  columnar  intestinal  epithelium.  Leucin,  tyrosin, 
and  other  products  of  albuminous  decomposition — phenol  and  skatol — 
are  absent ;  indol  is  rarely  found  (Uffelmann). 

Microscopically  there  are  seen  epithelial  cells,  chiefly  of  the  columnar 
variety,  a  few  round  cells,  mucous  corpuscles,  fat-globules  and  crystals  of 
fatty  acids,  cholesterin,  mucin,  protein  substance,  crystalline  inorganic 
salts,  sometimes  bilirubin  in  crystals,  yeast  fungi,  and  bacteria  in  immense 
numbers. 

If  the  infant  is  taking  a  food  containing  starch,  this  will  appear  to  a 
greater  or  less  extent  in  the  stools,  a  larger  amount  in  the  case  of  very 
young  infants.  Starch  is  recognised  by  the  blue  reaction  with  iodine, 
or  the  violet  reaction  if  the  starch  has  been  converted  into  dextrine,  as  is 
often  the  case.     Starch  granules  may  be  seen  under  the  microscope. 

The  number  of  stools  during  the  first  two  weeks  is  from  three  to  six 
daily.  After  the  first  month  two  stools  a  day  are  the  average ;  many 
infants  have  three,  many  others  but  one. 

As  soon  as  an  infant  is  put  upon  a  mixed  diet,  the  peculiar  charac- 
ters of  the  stools  cease,  and  they  come  to  resemble  more  closely  those 
of  the  adult,  though  remaining  softer  throughout  infancy.  They  be- 
come darker  in  colour  and  assume  the  adult  odour,  while  retaining 
their  acid  reaction.  The  bacteria,  while  still  in  great  numbers,  are 
more  varied  than  are  met  with  in  milk-fgeces. 

MALPOSITIONS  AND   MALFORMATIONS  OF   THE  STOMACH. 

The  stomach  is  sometimes  in  the  thoracic  cavity  in  cases  of  diaphrag- 
matic hernia.  It  may  be  found  in  a  vertical  (foetal)  position,  variously 
adherent  to  the  colon  and  small  intestine.  Malformations  are  much  less 
frequent  than  those  of  other  parts  of  the  alimentary  tract.  There  may 
be  atresia  or  stenosis  at  either  orifice,  and  very  rarely  a  constriction  is 
found  near  the  middle  of  the  organ,  dividing  it  into  compartments.  The 
symptoms  of  atresia  at  either  orifice  are  persistent  vomiting,  and  death 
in  a  few  days  from  inanition. 

Congenital  stenosis  of  the  pylorus,  or  hypertrophic  stenosis,  as  it  has 
also  been  termed,  is  the  most  important  of  these  conditions,  and  the 


VOMITING.  323 

only  one  which  requires  special  consideration.  During  the  past  few 
years  this  has  been  observed  quite  frequentl}',  and  Pritchard  *  (London) 
in  1900  published  a  report  upon  twenty-three  collected  cases.  The  diag- 
nosis does  not  seem  to  me  in  all  these  cases  to  be  warranted  by  the  post- 
mortem appearances  described.  One  should  be  extremely  cautious  in 
drawing  the  inference  that  the  pyloris  is  thickened  or  the  muscular  wall 
of  the  stomach  hypertrophied,  when  the  viscus  is  empty  and  its  walls 
contracted.  In  well  marked  cases  the  pylorus  is  greatly  thickened  and 
almost  cartilaginous  in  its  firmness.  The  lumen  is  much  reduced,  some- 
times scarcely  more  than  admitting  a  probe.  The  microscopical  exami- 
nation has  shown  a  thickening  of  the  muscular  coats,  especially  of  the 
circular  fibres.  The  stomach  in  some  of  the  cases  is  contracted  and 
its  walls  thickened,  but  rarely  much  dilated.  The  symptoms  do  not 
"usually  appear  until  the  second  or  third  week  of  life.  The  prominent 
ones  are  frequent  vomiting,  progressive  wasting,  and  usually  death  in 
the  third  or  fourth  month.  In  a  few  instances  a  pyloric  tumour 
has  been  made  out  during  life.  The  pathogenesis  of  hypertrophic 
stenosis  is  not  altogether  clear,  but  it  is  probably  a  developmental  con- 
dition. 

Without  surgical  intervention  the  chances  of  recovery  are  small. 
With  well-marked  symptoms  laparotomy  is  justifiable,  and  in  at  least 
one  instance  has  been  successful.  Kicoll  f  has  reported  a  case  cured  in 
which  Loreta's  operation  was  done  at  the  age  of  six  weeks. 

VOMITING. 

Vomiting  is  exceedingly  frequent  in  infants  and  young  children,  and 
although  seen  in  many  forms  of  disease,  it  is  the  one  particular  symptom 
to  attract  attention  to  the  stomach.  The  physician  must  have  in  mind 
both. its  common  and  its  uncommon  causes.  Vomiting  takes  place  with 
great  facility  in  young  infants  even  from  slight  causes,  owing  to  the  posi- 
tion and  shape  of  the  stomach. 

1.  Vomiting  from  overfilling  of  the  stomach. — This  is  often  seen  in 
nursing  infants,  and  there  may  be  no  other  symptom  of  disease.  It  is 
characterized  by  the  fact  that  it  conies  within  a  few  minutes  after  nurs- 
ing, that  it  is  easy  and  without  effort,  and  that  the  food  is  but  little 
changed.  It  may  be  excited  by  moving  the  child  or  making  undue  pres- 
sure upon  the  stomach.  It  often  comes  with  eructations  of  gas  or  air 
which  has  been  swallowed.  Vomiting  from  overdistention  may  be  re- 
garded as  a  safety-valve,  and  requires  no  treatment  except  to  diminish 
the  quantity  of  food. 


*  Archives  of  Pa'diatrics,  April,  1900;  a  full  bibliography  is  given. 
f  British  Medical  Journal,  September  1,  1900. 


324  DISEASES  OF   THE  DIGESTIVE  SYSTEM. 

2.  Yomiting  is  almost  invariably  ^Diesent  in  cases  of  acute  gastric  in- 
digestion, whether  there  is  inflammation  of  the  stomach  or  not.  It  does 
not  usually  come  immediately  after  feeding,  and  it  may  be  delaj^ed  for 
several  hours.  It  is  often  preceded  by  fever  and  by  marked  prostration, 
which  in  young  infants  may  approach  collapse.  It  may  cease  when  the 
contents  of  the  stomach  have  been  expelled,  but  often  mucus,  serum, 
and,  in  severe  cases,  bile,  may  be  vomited  for  some  time  afterward.  In 
these  cases  vomiting  is  due  to  the  irritation  of  undigested  food,  and  to 
the  exaggerated  reflex  irritability  of  the  stomach  from  congestion  of  the 
mucous  membrane. 

3.  In  acute  intestinal  obstruction  vomiting  is  rarely  absent,  and  in 
most  cases  it  is  persistent.  In  the  newly  born,  persistent  vomiting  is 
almost  invariably  dependent  upon  congenital  obstruction  of  the  intes- 
tine, which  is  most  frequently  in  the  duodenum.  In  malformations  of 
the  colon  and  rectum  it  is  less  constant  and  appears  later.  In  intussus- 
ception, vomiting  is  forcible,  immediately  excited  by  the  taking  of  food, 
and  is  at  first  bilious,  but  later  may  become  faecal.  The  vomiting  in  in- 
testinal obstruction  is  associated  with  general  symptoms  of  marked  pros- 
tration, and  usually  with  obstipation. 

4.  Yomiting  is  a  frequent  and  almost  a  constant  symptom  of  general 
peritonitis.  It  is  then  associated  with  abdominal  distention,  tenderness, 
and  fever. 

5.  In  certain  nervous  diseases^  especially  tumour  of  the  brain  and 
acute  meningitis  whether  simple  or  tuberculous,  vomiting  is  very  com- 
mon. In  tumour  it  may  be  the  earliest,  and  for  some  time  the  only 
marked  symptom.  In  three  cases  recently  observed,  exactly  the  same  type 
of  vomiting  was  present.  It  occurred  only  in  the  morning,  sometimes 
before  breakfast,  sometimes  suddenly  during  the  meal,  and  was  repeated 
every  few  days.  Cerebral  vomiting  is  usually  forcible  or  projectile.  It 
may  have  no  relation  to  meals.  The  vomited  matters  are  not  character- 
istic, and  the  tongue  may  be  clean.  Headache,  dnlness,  slight  fever,  con- 
stipation, and  irregular  pulse  and  respiration  are  usually  present  sooner 
or  later. 

6.  In  infants,  and  less  frequently  in  older  children,  vomiting  is  one 
of  the  usual  symptoms  to  mark  the  onset  of  acute  infectious  diseases, 
especially  the  beginning  of  scarlet  fever,  pneumonia,  and  malaria.  In 
these  cases  vomiting  may  be  due  simply  to  the  arrest  of  digestion,  or  to 
the  effect  of  the  poison  upon  the  nerve  centres. 

7.  An  accumulation  in  the  blood  of  various  toxic  materials  may  pro- 
voke vomiting;  the  most  frequent  example  is  urfemia.  In  cyclic  vomit- 
ing it  is  quite  probable  that  the  cause  is  the  accumulation  of  some  toxic 
agent  in  the  blood.  The  absorption  of  ptomaines  and  other  poisons 
taken  in  with  milk  or  other  food,  or  developed  in  the  gastro-enteric  tract, 
may  excite  vomiting.     In  some  of  these  conditions  it  is  possible  that 


VOMITING.  325 

the  vomiting  may  be  eliminative — an  effort  on  the  part  of  l^ature 
to  get  rid  of  the  toxic  materials.  The  cases  dependent  iipon  renal 
disease  are  discovered  by  frequent  and  careful  examination  of  the 
urine.  The  other  forms  are-  often  exceedingly  obscure,  and  recognised 
only  by  the  exclusion  of  all  other  frequent  and  infrequent  causes  of 
vomiting. 

8.  Vomiting  may  be  reflex  from  irritation  in  the  pharynx.  This  is 
frequent  in  young  infants,  who  may  induce  vomiting  by  stuffing  the 
fingers  into  the  mouth.  In  certain  cases  the  irritation  from  worms  in 
the  intestinal  tract  may  cause  vomiting,  and  it  is  possible  that  even  den- 
tition may  produce  it. 

9.  Habit  is  a  frequent  cause  in  cases  of  chronic  vomiting.  I  have 
seen  a  child  who  had  the  power  of  vomiting  at  will  anything  in  the  nature 
of  food  which  he  did  not  like,  yet  whose  stomach  at  the  same  time  would 
bear  large  doses  of  quinine,  to  which  he  had  no  aversion,  without  the 
slightest  disturbance.  In  young  infants  a  habit  of  regurgitating  the 
food  may  be  acquired,  so  that  this  takes  place  more  or  less  during  the 
process  of  digestion  after  every  meal.  This  is  sometimes  preceded  by  a 
movement  of  the  mouth  and  fauces  resembling  swallowing,  until  finally 
the  milk  appears  in  the  mouth.  Habit  is  a  potent  cause  in  continuing 
vomiting  where  it  has  occurred  frequently.  In  children  who  have  this 
habit  the  most  trivial  cause  will  provoke  it.  It  may  be  present  without 
any  other  sign  of  gastric  disease,  and  appears  simply  to  depend  upon 
exaggerated  reflex  irritability  of  the  organ.  These  are  exceedingly 
troublesome  cases  to  control.  Sometimes  small  quantities  of  food  are 
better  borne,  and  sometimes  larger  meals  are  retained  when  small  ones 
are  vomited.  In  some  of  these  children  gavage  is  the  only  means  by 
which  the  vomiting  can  be  controlled. 

10.  Chronic  vomiting  may  depend  upon  habit,  as  just  described,  or 
upon  chronic  indigestion ;  or  it  may  be  associated  with  chronic  pulmonary 
disease — vomiting  here  being  excited  by  the  attacks  of  cough,  at  first  only 
when  the  paroxysms  are  severe,  and  later  even  when  they  are  slight.  In 
chronic  indigestion  the  vomited  matters  are  always  characteristic,  they 
have  a  distinct  relation  to  meals,  and  they  are  accompanied  by  other 
symptoms  of  deranged  nutrition. 

The  diagnosis  of  a  case  in  which  vomiting  is  the  chief  symptom 
may  be  difficult.  The  first  important  distinction  to  be  made  is  between 
cases  in  which  the  vomiting  is  of  gastric  origin,  alld  those  in  which 
it  depends  upon  other  causes,  like  intestinal  obstruction,  cerebral  dis- 
ease, toxic  conditions,  etc.  It  is  only  by  a  careful  consideration  of 
the  other  S5'mptoms  associated  that  an  accurate  diagnosis  can  be 
reached. 

The  treatment  of  vomiting  is  the  treatment  of  the  cause  upon  which 
it  depends. 


326  DISEASES   OF   THE  DIGESTIVE  SYSTEM. 


CYCLIC   VOMITING. 

This  is  not  an  infrequent  disease;  it  has,  however,  as  yet  attracted 
but  little  attention  except  in  this  country.*  Although  the  clinical  pic- 
ture is  a  very  clear  and  definite  one,  its  exact  pathology  is  undetermined. 
It  has  also  been  described  under  the  names  of  periodical  vomiting,  recur- 
rent vomiting,  and  a  gastric  neurosis.  It  is  characterized  by  periodical 
attacks  of  vomiting,  which  recur  at  regular  or  irregular  intervals  of 
weeks  or  months,  apparently  without  any  adequate  exciting  cause.  The 
usual  duration  of  the  attacks  is  two  or  three  days,  during  which  all  at- 
tempts to  control  the  vomiting  are  usually  without  avail,  but  at  the  end 
of  this  time  it  generally  ceases  spontaneously. 

Etiology. — The  first  attacks  are  usually  seen  between  the  ages  of 
two  and  four  years,  but  they  may  date  back  to  infancy.  The  two  sexes 
seem  to  be  almost  equally  liable.  A  few  of  the  patients  are  strong  chil- 
dren, but  the  great  majority  are  rather  delicate  and  of  a  highly  nervous 
temperament.  The  cases  are  seen  chieflj^  in  private  practice,  often  oc- 
curring among  those  who  have  the  best  surroundings.  In  most  cases  the 
antecedents  of  patients  are  of  the  neurotic  type,  and  in  the  family  of 
some  there  is  a  marked  tendency  to  gouty  manifestations.  The  attacks 
are  not  traceable  to  distinct  or  flagrant  errors  in  diet,  and  yet  the  habit- 
Tial  diet  seems  to  bear  some  relation  to  the  disease.  In  my  own  cases  I 
have  most  frequently  found  the  diet  to  be  excessive  in  carbohydrates, 
particularly  in  the  amount  of  oatmeal  and  potato.  The  exciting  cause  is 
often  a  nervous  one — great  fatigue  or  unusual  excitement,  sometimes  a 
railroad  journey  or  a  child's  party;  in  many  instances  it  seems  to  be 
induced  by  some  minor  illness  having  no  relation  to  the  digestive  tract, 
such  as  an  attack  of  tonsillitis  or  bronchitis. 

Symptoms. — The  clinical  picture  presented  by  these  cases  is  very 
characteristic,  and  is  well  illustrated  by  the  history  of  the  following  case : 

The  patient  was  a  well-nourished  boy  of  six  3-ears  when  he  first  came 
under  treatment.  He  belonged  to  a  neurotic  family,  and  the  attacks 
dated  back  to  infancy.  From  this  time  they  had  recurred  usually  at  in- 
tervals of  a  few  months ;  occasionally  five  or  six  months  would  pass  with- 
out one.  The  symptoms  in  all  the  attacks  were  similar  in  kind,  differ- 
ing only  in  degree.  They  were  preceded  by  a  prodromal  period  lasting 
from  twelve  to  twenty-four  hours,  marked  by  languor,  dulness,  dark 
rings  under  the  eyes,  loss  of  appetite,  and  a  general  sense  of  discomfort 
in  the  epigastrium.  At  this  time  the  temperature  was  generally  slightly 
elevated.  The  vomiting  then  began  suddenly.  It  was  attended  with 
great  retching  and  distress;  it  was  forcible,  and  often  repeated  every 

*  For  literature,  see  Griffith,  American  Journal  of  the  Medical  Sciences,  Novem- 
ber. 1900. 


CYCLIC   VOMITING.  327 

half  hour  or  hour  for  two  days.  On  one  occasion  it  occurred  seventeen 
times  in  a  single  night.  Vomiting  was  immediately  excited  by  the  tak- 
ing of  any  food  or  drink,  but  it  occurred  when  nothing  was  taken.  The 
vomited  matters  consisted  of  frothy  mucus  and  serum,  frequently 
streaked  with  blood,  apparently  from  the  violence  of  the  emesis.  The 
reaction  was  very  strongly  acid;  sometimes  there  was  bilious  vomiting. 
The  temperature  usually  fell  to  about  100°  F.  when  the  vomiting  began, 
and  continued  at  or  below  this  point  throughout  the  attack.  B}'^  the 
end  of  the  second  day  the  exhaustion  was  very  marked — so  severe,  in 
fact,  as  apparently  to  threaten  life.  The  child  lay  in  a  semi-stupor,  with 
eyes  half  open,  lips  and  tongue  dry,  rousing  at  times  to  beg  for  water. 
The  pulse  was  rapid  and  weak,  and  sometimes  slightly  irregular.  There 
was  no  distention  of  the  abdomen;  it  was  usually  flattened.  By  the 
third  day  the  vomiting  became  less  frequent  and  then  ceased  entirely. 
Convalescence  was  rapid,  and  by  the  end  of  the  week  the  boy  was  almost 
as  well  as  usual.  After  these  attacks  he  was  frequently  better  than  for 
some  time  previously.  They  continued  to  recur  at  gradually  lengthen- 
ing intervals  until  they  finally  ceased  altogether.  He  is  now  sixteen,  is 
strong  and  well,  and  has  had  no  attack  in  four  or  five  years. 

Over  twenty  of  these  cases  have  come  under  my  observation,  and  in 
many  of  them  I  have  had  an  opportunity  to  witness  several  attacks.  The 
usual  duration  is  one  to  three  days.  In  one  patient  they  lasted  regularly 
for  five  days.  Occasionally  a  severe  attack  will  last  a  week.  The  longest 
one  I  have  seen  was  a  fatal  case  lasting  over  seven  weeks.  The  average 
number  of  attacks  is  three  or  four  a  year. 

Prodromal  symptoms  are  present  in  most  of  them — headache,  gen- 
eral languor,  coated  tongue,  and  anorexia  are  the  most  frequent;  in 
some  there  is  marked  constipation,  with  a  history  of  very  white  stools 
for  some  time.  The  tongue  is  usually  coated  at  the  beginning  of  an 
attack,  and  at  its  height  it  is  often  dry  and  brown.  The  abdomen  seems 
empty  and  its  walls  sunken;  pain  and  tenderness  are  both  rare.  The 
bowels  are  constipated  and  move  only  by  artificial  means,  and  even  then 
not  freely.  There  is,  as  a  rule,  no  desire  for  food,  but  the  continual  cry 
is  for  water  to  quench  the  constant,  burning  thirst.  The  pulse  after 
the  second  day  becomes  rapid,  soft,  and  often  somewhat  irregular.  The 
respiration  is  shallow,  and  at  times  this  also  may  be  irregular.  The 
temperature  is  seldom  over  100  -5°  F.,  a  point  of  much  diagnostic  value. 
The  patients  are  dull,  apathetic,  and  usually  wish  to  have  the  room 
darkened  and  to  be  left  alone.  Headache  is  very  common.  The  dispo- 
sition to  vomit  is  sometimes  so  great  that  patients  are  afraid  to  move  or 
even  to  talk  lest  it  may  be  provoked.  The  vomited  matter  I  have  had  ex- 
amined in  several  instances.  It  contains  mucus,  free  HCl,  bacteria, 
many  epithelial  cells,  and  usually  traces  of  blood.  The  urine  is  concen- 
trated, and  frequently  contains  at  the  height  of  the  attack  a  trace  of 


328 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


albumin,  a  few  hyaline  casts,  and  some  blood  cells — evidences  of  a  mod- 
erate renal  hypersemia.  There  is  usually  an  excess  of  indican,  and  in 
two  of  his  cases  Griffith  found  acetone.  Dr.  C.  A.  Herter  made  the 
following  interesting  observations  upon  the  uric-acid  excretion  in  one  of 
my  patients.  All  the  results  are  based  upon  the  twenty-four  hours' 
urine : 


Time  taken. 

Urea, 
grammes. 

Uric  acid, 
grammes. 

Ratio  of  uric 
acid  to  urea. 

Before  the  attack  (normal) 

13-606 
17 •249 
12-023 
11-713 
15-040 

0-251 

0-110 

0-0912 

0-234 

0-283 

1  to  54 

First  day 

1  to  157 

Second  day 

1  to  132 

Third  day  (convalescent) 

1  to  50 

Several  vreeks  after  (normal) 

1  to  53 

Observations  made  upon  the  urine  in  a  second  attack,  three  months 
later,  gave  results  which  were  practically  identical  with  the  above.  A 
second  case  of  a  somewhat  similar  type,  but  less  severe,  showed  a  ratia 
of  uric  acid  to  urea  of  1  to  83  during  the  vomiting,  while  in  the  same 
individual  in  health  it  was  1  to  42.  Further  observations  are  necessary 
before  the  full  significance  of  these  changes  can  be  appreciated. 

The  Nature  of  the  Attacks. — These  cases  have  little  in  common 
with  the  ordinary  attacks  of  indigestion.  With  our  jaresent  knowledge 
they  are  to  be  regarded  as  nervous  explosions  due  to  faulty  metabolism, 
having  many  points  of  resemblance  to  migraine  in  the  adult.  The  effect 
upon  uric-acid  elimination  in  the  case  cited  is  very  similar  to  that  which 
occurs  in  migraine ;  and  Eachf  ord  has  observed  a  patient  in  which  the 
vomiting  attacks  were  later  in  life  replaced  by  migraine.  Whether  it  is 
to  be  looked  upon  as  a  manifestation  of  the  lithsemic  state  in  children 
must  be  determined  by  future  study.  It  is  probable  that  not  all  the  cases 
depend  upon  the  same  condition. 

Prognosis. — Although  these  patients  very  often  seem  to  be  most 
alarmingly  ill,  the  danger  to  life  is  slight.  I  have  seen  but  one  fatal 
case,  and  in  this  the  diagnosis  is  open  to  question  as  no  autopsy  could 
be  obtained.  The  patient  died  in  the  eighth  week  of  her  fifth  attack. 
Griffith  reports  two  fatal  cases,  the  autopsy  in  one  showing  nothing 
characteristic;  the  symptoms  in  the  other  case  were  fairly  typical.  The 
probabilities  are  always  in  favour  of  a  recurrence  of  attacks.  In  most 
of  the  patients  who  have  been  observed  they  have  extended  over  a  series 
of  several  years,  although  by  a  careful  regime  much  may  be  done  to 
reduce  their  frequency.  Toward  puberty  there  appears  to  be  a  tendency 
to  spontaneous  recovery. 

Diagnosis. — Organic  disease  of  the  brain  and  kidneys  must  first  be 
excluded,  the  latter  only  by  careful  and  repeated  examination  of  the 
■urine.     The  first  attacks  witnessed  may  strongly  suggest  the  onset  of 


GASTRALGTA.  329 

tuberculous  meningitis ;  and  only  the  course  of  the  symptoms  may  show 
that  this  is  not  present.  Usually  a  history  of  many  previous  attacks 
may  be  obtained.  From  acute  indigestion,  cj^clie  vomiting  is  differen- 
tiated by  the  fact  that  the  attacks  are  not  brought  on  by  indigestible 
food  and  also  by  the  persistence  of  the  vomiting.  It  is  distinguished 
from  gastritis  by  its  severity,  the  shorter  duration  of  its  symptoms,  and 
its  self-limited  course.  Appendicitis  is  excluded  by  the  absence  of 
iDain,  tenderness,  and  temperature;  intussusception  by  the  fact  that 
the  symptoms  are  less  severe,  by  the  absence  of  blood  and  mucus 
from  the  stools,  and  by  the  fact  that  most  of  the  attacks  occur  after 
infancy. 

Treatment. — When  the  premonitory  symptoms  appear,  free  purga- 
tion by  calomel  offers  the  best  prospect  of  aborting  an  attack.  If  the 
vomiting  has  once  begun,  nothing  seems  to  have  the  slightest  influence 
in  controlling  it.  It  is  usually  increased  by  the  taking  of  food  or  drink 
or  by  any  medication  by  the  mouth,  and  all  should  be  withheld.  The 
patient  should  be  kept  absolutely  quiet  and  water  given,  per  rectum,  at 
regular  intervals,  usually  six  to  eight  ounces,  four  or  five  times  a  day. 
This  keeps  up  the  urinary  secretion,  allays  thirst  and  often  restlessness, 
and  adds  much  to  the  patient's  comfort.  In  the  more  protracted  cases 
rectal  feeding  should  be  employed.  When  the  vomiting  has  ceased  for 
several  hours  it  is  not  likely  to  recur  if  food  is  very  judiciously  admin- 
istered, at  first  in  small  quantities.  Broth,  barley  water,  kumyss,  or 
small  quantities  of  iced  milk  and  lime-water  in  equal  proportions  may 
then  be  given.  Acting  upon  the  theory  that  the  symptoms  are  analo- 
gous to  those  of  migraine,  the  treatment  I  have  adopted  in  the  interval 
has  been  dietetic;  it  consists  in  excluding  all  sugar  and  sweets,  and  care- 
fully limiting  the  amount  of  starchy  foods.  The  diet  prescribed  has 
been  composed  principally  of  meat,  green  vegetables,  milk,  and  stale 
bread.  In  addition  to  careful  regulation  of  the  diet  the  general  nutrition 
should  be  considered,  and  the  patient's  life  so  regulated  that  extreme 
fatigue  and  exhaustion  are  prevented.  In  most  cases  close  attention  to 
these  matters  has  resulted  in  a  very  great  diminution  in  the  frequency 
of  the  attacks. 

GASTRALGIA. 

This  term  is  applied  to  sudden,  severe  attacks  of  abdominal  ]v.\h\. 
Gastralgia  occurs  as  a  symptom  in  most  of  the  severe  attacks  of  acute 
gastric  indigestion;  in  such  cases  it  is  more  marked  in  older  children 
than  in  infanc3^  The  ])ain  of  diaphragmatic  pleurisy  is  often  referred 
to  the  epigastrium,  and  may  be  so  severe  as  to  lead  one  to  think  that 
the  stomach  is  the  seat  of  disease.  Another  cause  may  be  appendi- 
citis. In  vertebral  caries  of  the  dorsal  region  epigastric  pain  is  a  very 
frequent,  early  synijitom.     It  is  also  common  in  cliildren  who  suffer 


330  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

from  malaria,  at  the  onset  of  acute  attacks,  and  it  may  be  severe  when 
the  febrile  symptoms  are  not  well  marked.  In  other  eases  pain  in  the 
stomach  is  of  the  nature  of  a  true  neuralgia,  which  may  be  excited  by 
exposure  to  cold,  by  wetting  the  feet,  by  drinking  ice-water,  and  by 
many  other  causes.  Children  who  are  predisposed  to  it  often  have  at- 
tacks of  considerable  severity  from  comparatively  slight  causes. 

In  mild  cases  there  is  an  intermittent  pain,  and  usually  no  other 
symptoms.  In  severe  cases  the  pain  may  be  so  great  as  to  cause  pallor, 
faintness,  cold  perspiration,  and  very  marked  prostration.  When  the 
origin  of  the  pain  is  in  the  stomach  the  epigastrium  may  be  hard  and 
sometimes  retracted,  the  stomach  appearing  to  be  in  a  state  of  spasm. 

Treatment. — During  the  attacks  the  patient  should  be  put  to  bed,  and 
counter-irritation  used  over  the  stomach,  best  by  means  of  a  turpentine 
stupe  or  a  mustard  paste ;  sometimes  a  hot-water  bag  will  suffice.  Inter- 
nally there  should  be  given  hot  water  containing  brandy  or  gin  and 
five  drops  of  spirits  of  chloroform;  all  food  should  be  withheld.  Hot 
bottles  should  be  applied  to  the  feet  if  they  are  cold.  In  the  interval 
between  the  attacks  the  treatment  should  be  directed  to  the  patient's 
general  condition ;  especially  should  the  cause  be  discovered.  In  cases  of 
recurring  pain  of  a  neuralgic  character  the  prolonged  use  of  arsenic  in  the 
form  of  Fowler's  solution,  two  or  three  drops  three  times  a  day,  may 
prove  of  great  benefit.  In  all  cases  attention  should  be  directed  to  the 
diet,  as  in  chronic  indigestion. 

ACUTE  GASTRIC   INDIGESTION. 

This  occurs  whenever  the  stomach  is  unequal  to  the  task  imposed 
upon  it.  It  may  be  either  because  the  task  is  too  great  or  because  the 
capacity  of  the  stomach  for  work  is  diminished.  Under  these  two  heads 
we  may  group  the  principal  causes  of  acute  indigestion. 

Under  the  first  head  the  most  important  thing  is  the  giving  of  im- 
proper food.  In  infants  this  is  sometimes  improper  breast-milk;  but 
more  often  cow's  milk  containing  too  high  proteids — i.  e.,  milk  without 
sufficient  dilution.  Other  common  causes  are  sudden  weaning  or  any 
other  abrupt  change  in  diet,  the  too  early  use  of  solid  food,  and  overload- 
ing the  stomach.  In  older  children  the  usual  causes  are  indigestible 
articles  of  food,  such  as  unripe  fruits,  pastry,  etc.,  overloading  the  stom- 
ach, and  swallowing  food  without  sufficiently  masticating  it.  Conditions 
which  may  diminish  for  the  time  the  capacity  of  the  stomach  for  work 
are  fatigue,  depression  induced  by  atmospheric  heat,  chilling  of  the  sur- 
face, especially  the  extremities,  dentition,  and  the  nervous  impression 
caused  by  the  onset  of  any  acute  disease.  The  effect  is  seen  both  on  the 
glandular  and  muscular  apparatus  of  the  stomach.  The  secretions  are 
diminished  or  altered  in  character,  and  the  motor  activity  of  the  organ 
is  arrested. 


ACUTE   GASTRIC   INDIGESTION.  33I 

Symptoms. — One  of  the  first  consequences  of  arrested  gastric  diges- 
tion is  tliat  tlie  food  remains  long  in  tlie  stomach.  Instead  of  being 
empty  in  two  or  two  and  a  half  hours  after  feeding,  as  is  normal  in  in- 
fancy, the  food  may  remain  in  the  stomach  five  or  six  hours,  or  even 
longer.  The  irritation  from  this  undigested  mass  excites  vomiting, 
which  usually  ceases  after  the  stomach  has  been  emptied.  The  vomiting 
may  be  preceded  by  nausea,  pain,  and  constitutional  depression  which 
varies  with  the  age  and  susceptibility  of  the  child;  in  infants  it  may  be 
very  alarming. 

It  seems  probable  that,  as  a  consequence  of  arrested  gastric  digestion, 
the  proteids  are  not  converted  into  peptones,  but  remain  in  the  form  of 
albumoses.  These  products  have  been  shown  by  experiments  on  animals 
to  be  toxic,  producing  stupor  and  circulatory  disturbances.  They  are 
diffusible  and  are  undoubtedly  absorbed  with  great  rapidity,  and  may  be 
the  cause  of  nervous  symptoms  of  a  striking  character.  There  may  be 
dulness,  stupor,  and  sometimes  contracted  pupils,  so  as  to  suggest  opium 
narcosis,  or  there  may  be  restlessness,  excitement,  and  even  convulsions. 
There  is  also  marked  prostration,  weak  pulse,  and  fever.  The  tempera- 
ture in  most  cases  of  acute  indigestion  is  from  101°  to  103°  F. ;  not  infre- 
quently it  rises  to  10-1°  or  105°  F.  The  tongue  is  coated  and  the  appetite 
entirely  lost.  In  infants  these  symptoms  are  usually  associated  with  or 
followed  by  more  or  less  intestinal  disturbance — generally  diarrhoea,  with 
undigested  food  in  the  stools.  Epigastric  distention  may  be  present. 
Usually  the  vomiting  ceases  in  from  six  to  twelve  hours,  and  after  the 
stomach  has  been  thoroughly  emptied  the  temperature  falls.  .Provided 
rest  to  the  organ  can  be  secured,  and  the  exciting  cause  is  one  that  can 
be  removed,  the  patient  may  be  quite  well  in  two  or  three  days.  Eelapses 
are,  however,  easily  excited;  and  in  a  susceptible  patient  it  is  surprising 
to  see  how  trivial  a  cause  may  excite  one. 

The  diagnosis  between  a  simple  attack  of  acute  indigestion  and  one  of 
gastritis  can  not  be  made  at  the  outset.  The  former  is  much  more  fre- 
quent, and  may  be  cpiite  as  severe,  but  is  of  shorter  duration.  The  con- 
tinuance of  the  severe  symptoms,  especially  pain,  thirst,  fever,  and  vomit- 
ing of  mucus  tinged  with  blood,  justify  the  inference  that  inflammatory 
changes  exist.  The  prognosis  in  these  cases  is  good,  except  in  very  young 
or  very  delicate  infants.  In  such  patients  an  attack  of  acute  indigestion 
is  not  infrequently  fatal. 

Treatment. — The  indications  are,  to  empty  the  stomach  as  completely 
as  possible  and  then  to  secure  to  it  absolute  rest.  If  proper  treatment  is 
employed  at  the  outset,  the  majority  of  such  attacks  can  be  cut  short. 
jSTothing  is  so  efficient  in  infants  as  stomach- washing.  (See  page  60.) 
A  single  washing  usually  suffices.  If  for  any  reason  this  can  not  be  em- 
ployed, the  child  may  take  from  its  bottle  a  large  amount  of  lukewarm 
water.    The  free  vomiting  which  this  usually  produces  may  be  sufficient 


332  DISEASES  OF   THE   DIGESTIVE  SYSTEM. 

to  cleanse  the  stomach  fairly  well,  but  by  no  means  so  thoroughly  as 
stomach-washing.  Persistent  vomiting  is  sometimes  arrested  by  giving 
small  quantities  of  hot  water. 

The  subsequent  treatment  is  chiefly  dietetic.  Everything  should  be 
withheld  for  three  or  four  hours,  when  barley  water,  albumin  water,*  or 
whey  may  be  given  frequently,  and  in  small  quantities — e.  g.,  half  an 
ounce  to  one  ounce  every  hour.  After  twenty-four  hours  raw  beef -juice 
or  broth  may  be  tried,  but  no  milk  should  be  given  for  at  least  three  days. 
When  begun,  it  should  be  peptonized  and  diluted  with  five  or  six  parts  of 
water.  In  a  nursing  child,  the  breast  should  be  withheld  altogether  for 
twenty-four  hours,  and  then  nursing  allowed  for  two  minutes  every  three 
hours,  the  time  of  nursing  being  gradually  increased  to  three,  five,  and  ten 
minutes  as  improvement  occurs.  The  great  mistake  made  in  these  cases 
is  to  begin  food  too  soon  and  to  give  too  much,  especially  of  cow's 
milk. 

Drugs  are  relatively  of  little  value.  If  the  measures  mentioned  have 
been  used  promptly  they  will  not  often  be  required.  In  many  cases  inju- 
dicious medication  aggravates  the  symptoms  and  prolongs  the  attack. 
Unless  the  bowels  have  acted  freely,  calomel  (gr.  -J  every  hour)  may  be 
given  until  this  effect  is  obtained.  Where  there  is  continuous  vomiting 
of  very  acid  mucus  and  serum,  alkalies  are  indicated — lime-water,  chalk 
mixture,  or  the  subcarbonate  of  bismuth.  It  is  important  to  keep  the 
child  as  quiet  as  possible.  Local  applications  to  the  epigastrium  are  very 
often  useful.  Either  dry  heat  may  be  applied  by  means  of  a  hot-water 
bag  or  hot  flannels,  or  more  active  counter-irritation  by  mustard.  In 
older  children  the  stomach  is  to  be  emptied  by  an  emetic  accompanied 
by  large  draughts  of  warm  water.  After  this  it  should  be  kept  entirely 
at  rest  for  half  a  day,  only  carbonated  waters  or  barley  water  being 
allowed  in  small  quantities  to  allay  thirst.  Later,  broth  or  beef-juice 
may  be  given,  afterward  milk  diluted  with  two  parts  of  lime-wa"ter. 
The  patient  should  be  kept  upon  a  very  low  diet  for  four  or  five  days. 

ACUTE  GASTRITIS. 

In  comparison  with  the  frecjuency  of  inflammatory  diseases  of  the 
intestine,  those  of  the  stomach  are  rare,  particularly  so  in  infancy. 
Owing  largely  to  the  character  of  its  secretion  and  its  contents,  the  stom- 
ach is  much  more  resistant  to  infecton  than  are  the  intestines.  Gastritis 
seldom  exists  alone,  but  is  usually  associated  with  enteritis  or  colitis. 

Etiology. — The  causes  of  gastritis  are,  in  the  main,  those  of  acute 
gastric  indigestion — improper  food   or   feeding — plus   infection.     This 

*  Albumin  water :  The  white  of  one  fresh  egg,  one  half  pint  cold  water,  previously 
boiled,  a  little  salt,  one  teaspoonful  of  brandy ;  shake  thoroughly,  and  feed  cold. 


ACUTE   GASTRITIS.  333 

may  be  of  many  kinds,  probably  the  most  frequent  being  the  streptococ- 
cus. Other  organisms  concerned  are  the  bacillus  of  tuberculosis,  of  diph- 
theria, the  bacillus  pyocyaneus,  etc.  Gastritis  may  also  be  caused  by  the 
introduction  of  irritants,  which  may  either  be  swallowed  accidentally  or 
given  as  drugs. 

Lesions. — The  mucous  membrane  of  the  stomach  may  be  the  seat  of 
acute  catarrhal,  ulcerative,  or  membranous  inflammation,  all  forms  ex- 
cept the  catarrhal  being  rare.  There  is  also  seen  a  mixed  form,  which 
from  its  cause  is  usually  termed  "  corrosive  "  gastritis. 

CatarrJial  gastritis. — This  is  characterized  by  hyperasmia  of  the  mu- 
cous membrane,  exudation  of  cells  into  the  mucosa,  a  great  increase 
in  the  secretion  of  the  mucous  glands,  and  changes  in  the  epithelium. 
About  the  only  change  which  can  be  recognised  by  the  naked  eye  is 
congestion  and  swelling  of  the  mucous  membrane.  These  are  usually 
more  marked  toward  the  pyloric  end  and  along  the  greater  curvature. 
There  may  be  small  extravasations  of  blood  into  the  mucosa.  The  stom- 
ach contains  undigested  food  and  mucus,  which  may  be  thick  and  tena- 
cious, adhering  very  closely  to  the  mucous  membrane.  The  mucus  may 
be  stained  brown  from  the  capillary  hsemorrhages.  The  stomach  may  be 
either  distended  or  contracted.  Under  the  microscope  the  changes  are 
seen  to  be  almost  entirely  in  the  mucosa.  In  some  places  there  is  loss  of 
the  superficial  epithelium,  in  others  only  degenerative  changes  in  it  are 
seen.  The  mucosa  is  infiltrated  with  round  cells,  this  process  being 
rarely  diffuse,  but  generally  occurring  in  patches.  The  blood-vessels  are 
distended  and  many  small  extravasations  are  seen.  Sometimes  there  is 
a  moderate  infiltration  of  the  submucosa.  Acute  catarrhal  gastritis 
alone  is  rarely  severe  enough  to  cause  death.  It  is  usually  seen  in  cases 
which  prove  fatal  from  other  causes,  particularly  diseases  of  the  in- 
testine. 

Gastric  softening  {gastromalacia)  is  a  condition  dependent  upon 
post-mortem  changes — probably  self-digestion  of  the  stomach.  It  is 
found  both  where  gastric  symptoms  were  present  and  where  they 
were  absent.  It  is  situated  nearly  always  in  the  posterior  wall,  and  usu- 
ally covers  a  considerable  area,  about  one-third  or  one-fourth  of  this 
wall.  It  is  recognised  by  the  gelatinous,  translucent  appearance  of  the 
walls  of  the  stomach,  which  are  so  softened  that  the  finger  may  be 
pushed  through  them  without  force,  or  that  sometimes  the  stomach 
ruptures  while  it  is  being  removed.  This  condition  is  rarely  seen  when 
the  stomach  is  empty.  It  can  scarcely  be  mistaken  for  a  pathological 
condition,  if  its  occurrence  is  borne  in  mind. 

Ulcerative  gastritis. — This  was  met  with  six  times,  not  including 

tuberculous  cases,  in  390  consecutive  autopsies  upon  infants  in  the 

Babies'  Hospital.    Three  of  the  patients  were  less  than  four  months  old, 

and  all  were  females.     The  ulcers  varied  from  one  twenty-fifth  to  one 

23 


334  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

quarter  of  an  inch  in  diameter,  and  usually  from  ten  to  fifty  were  pres- 
ent. They  seldom  extended  to  the  muscular,  and  never  to  the  peritoneal 
coat.  The  lesion  was  most  marked  in  the  posterior  wall,  toward  the 
pyloric  end  and  along  the  greater  curvature.  Evidences  of  catarrhal 
inflammation  were  present  in  most  of  the  cases,  and  in  four,  of  mem- 
branous inflammation.  Under  the  microscope  these  ulcers  resemble 
those  of  the  colon.  Lesions  in  some  other  part  of  the  digestive  tract 
were  present  in  all  but  one  case,  in  two  there  was  thrush  in  the  oesoph- 
agus; in  three  there  was  ulceration  somewhere  in  the  intestines.  Cul- 
tures showed  that  two  cases  were  due  to  pyocyaneus  infection,*  which 
was  found  to  be  general  throughout  the  body. 

Membranous  gastritis. — This  is  even  more  rare  than  the  varieties 
previously  mentioned.  I  have  met  with  it  but  four  times  in  infants. 
One  case  was  associated  with  a  membranous  colitis ;  a  second  case  with 
pseudo-diphtheria  of  the  fauces  and  larynx  in  an  infant  but  six  weeks 
old.  The  oesophagus  was  not  involved  in  this  case ;  and  indeed  it  often 
escapes.  No  Klebs-Loeffler  bacilli  could  be  found  either  in  cover-slip 
preparations  or  by  culture.  Both  these  cases  have  been  very  fully  re- 
ported by  Dr.  Wollstein.f  To  the  naked  eye  the  membrane  appears  as 
of  a  grayish-green  colour;  it  is  adherent,  but  can  be  detached  in  quite 
large  patches.  Only  a  portion  of  the  stomach  was  covered  in  any  of  the 
cases ;  in  two  the  principal  disease  was  about  the  pylorus ;  in  another 
along  the  greater  curvature.  In  Fenwick's  case  the  entire  surface 
of  the  stomach  was  lined  with  membrane.  The  microscopical  appear- 
ances resemble  those  of  membranous  colitis.  There  is  a  pseudo-mem- 
brane composed  of  fibrin,  granular  matter,  epithelial  cells,  and  bac- 
teria. The  mucosa  shows  a  moderately  dense  infiltration  with  round 
cells,  and  in  places  superficial  ulceration.  There  is  also  infiltration 
of  the  submucosa,  and  in  some  places  even  the  muscular  coat  is 
involved. 

Membranous  gastritis  occurring  in  patients  dying  of  diphtheria  is 
rare,  but  has  been  observed  by  many  writers,  the  diagnosis  being  con- 
firmed by  the  presence  of  diphtheria  bacilli. 

Corrosive  gastritis  {toxic  gastritis). — This  form  of  inflammation  is 
excited  by  various  irritating  and  caustic  substances,  which  are  usually 
taken  by  accident,  sometimes  for  the  purpose  of  producing  emesis.  The 
most  frequent  substances  are  carbolic  acid,  caustic  alkalies,  mineral 
acids,  arsenic,  salts  of  copper,  zinc,  or  antimonj^  croton  oil,  and  corro- 
sive sublimate. 

The  lesions  in  the  stomach  depend  upon  the  amount  of  the  substance 
swallowed,  the  degree  of  concentration,  and  whether  the  stomach  was 

*  See  Martha  Wollstein,  M.  D.,  Archives  of  Paediatrics,  1897,  p.  760,  for  full  report, 
f  Archives  of  PaBdiatrics,  July,  1892. 


ACUTE  GASTRITIS.  335 

full  or  empty  at  the  time.  Strong  caustics,  whether  acids  or  alkalies, 
usually  act  more  deeply  and  extensively  in  the  pharynx  and  oesophagus, 
for,  owing  to  the  spasmodic  contraction  of  the  muscles  of  these  parts, 
often  but  a  small  amount  of  the  substance  reaches  the  stomach.  Concen- 
trated irritant  poisons  produce  in  the  stomach,  especially  along  the 
greater  curvature,  irregular  ulcers,  which  may  be  so  deep  as  to  cause  per- 
foration, or  they  may  affect  the  mucous  membrane  only.  In  severe  cases 
death  takes  place  early,  often  in  a  few  hours.  Dark,  ragged  ulcers  are 
found  in  the  stomach,  the  surrounding  mucous  membrane  is  the  seat  of 
intense  congestion,  and  in  places  there  are  extravasations  of  blood.  If 
death  is  delayed  there  are  evidences  of  intense  inflammation,  sometimes 
with  the  production  of  a  pseudo-membrane.  If  the  amount  of  poison  is 
not  sufficient  to  cause  death,  and  if  the  patient  recovers  from  the  re- 
sulting gastritis,  a  cicatricial  condition  of  the  stomach  results,  which 
later  may  lead  to  stenosis  of  the  pylorus  or  other  deformity  of  the 
organ. 

Symptoms. — Catarrhal  gastritis  can  not  be  distinguished  at  its  begin- 
ning from  an  attack  of  acute  indigestion.  There  are  fever,  pain,  vomit- 
ing, thirst,  loss  of  appetite,  coated  tongue,  and  prostration.  The  pres- 
ence of  inflammatory  changes  is  indicated  by  the  continuance  of  these 
symptoms,  particularly  the  pain,  vomiting,  fever,  and  thirst.  With  the 
.pain  there  may  be  epigastric  tenderness.  All  food  or  liquids  are  imme- 
diately rejected,  and  even  when  nothing  is  taken  the  retching  and  vom- 
iting may  continue,  nothing  but  frothy  mucus  or  serum  being  brought 
up,  sometimes  streaked  with  blood.  The  vomited  matters  are  usually 
very  sour;  they  may  be  bilious.  The  temperature  is  rarely  high  except 
at  the  outset.  After  the  first  or  second  day  it  usually  ranges  between 
100°  and  101  -5°  F.  Thirst  is  intense,  and  all  liquids  are  taken  with  avid- 
ity, especially  if  cold,  even  though  they  are  immediately  vomited.  The 
tongue  is  thickly  coated  with  a  white  fur,  and  the  breath  may  be  foul. 
The  constitutional  symptoms  are  generally  most  severe  at  the  outset. 
The  usual  duration  of  such  attacks  is  from  four  to  seven  days,  but  with 
improper  management,  especially  injudicious  feeding,  the  disease  may 
be  much  prolonged.  One  attack  may  follow  another  until  a  chronic 
condition  is  established.  In  most  of  the  cases  there  is  some  disturb- 
ance of  the  intestines,  usually  a  sharp  attack  of  diarrhoea.  Sometimes 
the  gastric  symptoms  subside  after  a  few  days  and  those  of  the  intes- 
tines become  the  predominant  ones.  The  symptoms  above  given  are 
those  in  infancy.  In  older  children  there  is  less  of  fever,  prostration,  and 
diarrhoea,  but  pain  and  vomiting  are  prominent.  The  attacks  are  usually 
shorter  and  altogether  less  severe. 

The  rare  cases  of  ulcerative  gastritis  have  nothing  by  which  they  can 
be  distinguished  from  the  form  described,  except  a  more  prolonged 
course  and  a  greater  liability  to  haemorrhage. 


336  DISEASES  OF   THE  DIGESTIVE  SYSTEM. 

Membranous  gastritis  also  presents  no  peculiar  symptoms.  In  fact, 
in  the  cases  I  have  personally  seen,  the  gastric  symptoms  were  insignifi- 
cant, and  the  condition  not  suspected  during  life. 

In  corrosive  gastritis  the  effects  of  the  caustic  may  be  seen  in  the 
mouth  and  pharynx,  the  mucous  membrane  being  of  a  gray  or  whitisli 
colour.  Pain  and  a  sense  of  constriction  are  felt  in  the  oesophagus  and 
stomach,  and  thirst  is  great.  Vomiting  follows  almost  immediately, 
and  the  matters  vomited  are  usually  bloody.  The  subsequent  course  in 
most  of  the  cases  is  the  rapid  development  of  collapse,  and  death  in  a 
few  hours  from  shock.  The  younger  the  child  the  sooner  does  the  case 
terminate.  In  irritant  poisoning  not  severe  enough  to  produce  death, 
the  symptoms  of  acute  gastritis  follow,  usually  accompanied  by  more  or 
less  enteritis  owing  to  the  passage  of  the  irritant  into  the  intestine. 
There  is  seen  a  continuance  of  the  vomiting,  pain  and  epigastric  disten- 
tion, and  diarrhoea,  and  from  these  symptoms  death  may  result  in  two 
or  three  days.  It  is  extremely  rare  in  infancy  for  the  patient  to  sur- 
vive both  the  stage  of  shock  and  that  of  acute  inflammation,  so  that  the 
deformities  of  the  stomach  and  the  chronic  conditions  mentioned,  are 
practically  never  met  with  excepting  in  older  children. 

Treatment. — Cases  of  acute  catarrhal  gastritis  are  to  be  managed 
very  much  like  those  of  acute  gastric  indigestion.  Thirst  may  be  re- 
lieved by  swallowing  bits  of  ice.  Where  there  is  continuous  vomiting  of 
acid  mucus,  relief  is  sometimes  afforded  by  repeating  the  stomach-wash- 
ing once  in  twelve  hours  with  a  1-per-cent  solution  of  bicarbonate  of 
soda,  at  110°  F.  In  older  children,  beneficial  results  sometimes  follow 
the  use  of  bismuth  subcarbonate  (gr.  x  every  two  hours)  ;  but  in  in- 
fants I  must  confess  to  have  seen  but  little  effect  from  any  form  of 
medication,  the  reliance  being  upon  rest,  careful  feeding,  and  stomach- 
washing. 

Cases  of  corrosive  gastritis  require  special  trgatment.  The  first  indi- 
cation is  to  administer  the  proper  chemical  antidote  to  the  substance 
swallowed,  and  the  next  to  use  bland  mucilaginous  or  oily  fluids,  such 
as  milk,  albumin-water,  oils  in  large  quantities,  etc.  Especially  should 
stomach-washing  be  avoided.  Opium  is  always  required,  on  account  of 
pain,  and  should  be  given  hypodermically.  The  general  symptoms  are  to 
be  treated  according  to  the  indications  of  the  individual  case. 


GASTRO-DUODENITIS. 

This  is  a  catarrhal  inflammation  of  the  stomach  and  duodenum. 
Sometimes  only  the  duodenum  is  involved.  The  inflammation  com- 
monly extends  from  the  intestine  into  the  common  bile  duct,  the  swelling 
of  which  causes  jaundice.  The  term  gastro-duodenitis  is  sometimes 
used  synonymously  with  catarrhal  jaundice.     The  condition  is  a  rare 


GASTRO-DUODENITIS.  337 

one  in  young  children,  and  especially  so  in  infancy.  I  have  never  seen 
it  in  a  child  under  two  years  old. 

The  causes  are  for  the  most  part  obscure.  It  occasionally  compli- 
cates malarial  fever.  I  have  seen  it  several  times  with  influenza,  and  it 
may  occur  with  any  of  the  infectious  diseases.  Rehn  has  described  a 
form  which  occurred  epidemically. 

The  symptoms  of  the  disease  are  quite  uniform.  When  primary,  the 
onset  is  like  an  ordinary  attack  of  indigestion,  with  vomiting,  pain, 
slight  fever,  and  a  moderate  amount  of  prostration.  The  vomiting  in 
some  of  the  cases  is  repeated  for  several  days.  The  pain  may  be  quite 
severe,  and  localized  in  the  region  of  the  duodenum.  It  may  be  asso- 
ciated with  tenderness  in  this  region.  The  bowels  are  usually  consti- 
pated. After  three  or  four  days,  icterus,  which  is  the  only  diagnostic 
symptom,  appears.  It  is  first  seen  in  the  conjunctiva,  afterward  in  the 
skin,  varying  in  degree  according  to  the  severity  of  the  attack,  but  in 
most  cases  not  being  very  intense.  It  is  accompanied  by  the  regular 
symptoms  of  obstructive  jaundice.  The  stools  are  gray,  sometimes 
white;  there  is  a  marked  amount  of  intestinal  flatulence.  The  urine  is 
very  dark,  of  a  yellowish-green  or  bronze  hue,  and  stains  the  clothing. 
There  is  complete  anorexia;  the  tongue  is  thickly  coated  with  a  white 
fur.  Headache,  dulness,  and  languor  are  present,  and  the  patient  feels 
generally  wretched.  The  slow  pulse  and  the  itching  skin  are  uncommon 
symptoms  in  children.  The  liver  is  usually  found,  upon  examination, 
slightly  enlarged,  and  sometimes  tender  on  pressure.  The  duration  of 
the  disease  is  about  two  weeks,  the  general  symptoms  disappearing  be- 
fore the  icterus. 

The  diagnosis  rarely  presents  any  difficulty,  and  the  prognosis  is  in- 
variably good.  ' 

Treatment. — In  the  diet,  fats  and  starches  should  be  reduced  to  a 
low  point  or  be  entirely  prohibited.  Patients  usually  do  much  better 
upon  a  diet  of  rare  meat,  fruit,  and  a  moderate  amount  of  milk.  If 
there  is  very  much  vomiting,  the  milk  should  be  largely  diluted  with 
lime-water  or  partially  peptonized.  The  amount  of  food  given  should 
be  small,  but  water  should  be  allowed  freely,  particularly  the  mineral 
waters.  The  bowels  should  be  opened  every  other  day  by  calomel,  fol- 
lowed by  a  saline  purgative.  In  most  of  the  cases  no  other  treatment  is 
necessary.  When  the  pain  is  severe  it  may  be  relieved  by  counter-irrita- 
tion by  mustard,  turpentine,  or  even  cantharides.  The  gastric  symp- 
toms should  be  managed  as  are  those  of  ordinary  acute  gastritis.  The 
restricted  diet  should  in  all  cases  be  continued  for  at  least  a  week  after 
the  jaundice  has  disappeared. 


338  DISEASES   OF   THE   DIGESTIVE  SYSTEM. 


CHROXIC  GASTRIC  INDIGESTION— CHRONIC  GASTRITIS— GASTRIC 

CATARRH. 

Although  from  a  pathological  point  of  view  these  conditions  are  not 
identical,  from  a  clinical  standpoint  there  is  no  advantage  in  attempting 
to  separate  them.  Xothing  distinguishes  chronic  indigestion  from 
chronic  gastritis  except  that  in  the  latter,  in  addition  to  continued  de- 
rangement of  function,  there  is  a  great  increase  in  the  production  of  gas- 
tric mucus.  Chronic  indigestion  seldom  exists  long  without  the  pro- 
duction of  a  slight  amount  of  catarrhal  inflammation.  This  condition 
in  the  stomach  seldom,  if  ever,  exists  without  more  or  less  involvement 
of  the  intestine,  and  in  the  majority  of  cases  the  intestinal  condition  is 
the  more  important.  In  some,  however,  the  gastric  symptoms  predomi- 
nate, and  it  is  only  those  which  are  here  considered. 

Etiology. — Chronic  gastric  indigestion  may  follow  acute  attacks,  or 
it  may  be  chronic  from  the  outset.  If  the  latter,  it  depends  in  infancy 
upon  the  continued  use  of  improper  food  or  bad  methods  of  feeding. 
The  improper  food  is  ver}^  often  a  mixture  of  cow's  milk  in  which  the 
proportions  of  sugar,  proteids,  or  fat  are  not  suited  to  the  child.  Espe- 
cially important  is  too  high  a  percentage  of  fat.  As  a  consequence  of 
imperfect  digestion,  fermentation  in  the  residuum  takes  place,  and  the 
irritating  products  of  this  fermentation  soon  cause  a  catarrhal  inflam- 
mation with  a  production  of  mucus,  decomposition  of  which  adds  still 
further  to  the  irritation.  Chronic  gastric  indigestion  also  complicates 
most  of  the  constitutional  diseases  of  infancy,  especially  rickets,  syphi- 
lis, tuberculosis,  malnutrition,  and  marasmus.  It  may  follow  any  of  the 
acute  infectious  diseases.  In  older  children  it  is  due  chiefly  to  the  use 
of  improper  food,  sometimes  to  the  habit  of  rapid  eating  and  insufficient 
mastication.  It  is  associated  with  constitutional  diseases  as  in  infancy, 
and  may  complicate  valvular  disease  of  the  heart. 

Lesions. — The  changes  found  in  chronic  gastritis  are  usually  confined 
to  the  mucosa.  In  the  mild  form  there  are  degenerative  changes  of  the 
epithelium  of  the  tubules,  with  increased  production  of  mucus;  there 
may  be  a  slight  infiltration  of  the  mucosa  with  round  cells.  The  more 
severe  form,  with  marked  cell  infiltration  and  the  production  of  new 
connective  tissue,  is  extremely  rare.  The  submucous  coat  may  be 
thickened  and  the  muscular  coat  attenuated.  The  lesion  can  not  be 
recognised  by  the  naked  eye.  The  stomach  is  apt  to  appear  more  or 
less  dilated,  and  its  surface  is  coated  with  thick  and  very  adherent 
mucus.  This  lesion  rarely  exists  alone,  practically  never  in  infancy, 
but  is  associated  with  similar  lesions  in  the  intestines,  the  latter  being 
more  severe. 


CHRONIC  GASTRIC  INDIGESTION.  339 

Symptoms. — In  infants. — For  our  knowledge  of  the  conditions  exist- 
ing in  the  stomach  in  chronic  indigestion  we  are  indebted  to  the  work 
chiefly  of  Cassel,  Leo,  Troitzky,  and  Wohlmann.  The  results  obtained 
in  the  examination  of  stomach  contents  have  not  been  uniform,  and  in 
practice  one  should  not  lay  much  stress  upon  the  absence  of  the  normal 
secretions.  There  is  in  most  cases  an  excessive  production  of  mucus 
which  may  interfere  with  digestion,  even  though  secretions  are  normal. 
The  reaction  of  the  stomach  is  almost  invariably  acid.  The  rennet 
ferment  is  present.  Pepsin  is  absent  in  about  half  the  cases.  Hy- 
drochloric acid  is  generally  deficient,  but  is  increased  by  irrigating 
the  stomach.  The  following  changes  are  present  in  nearly  all  cases : 
Fermentation  takes  place  in  the  fats,  the  carbohydrates,  and  in  the  gas- 
tric mucus.  The  results  of  fermentation  are  the  production  of  lactic, 
acetic,  butyric,  and  other  volatile  fatty  acids,  which  are  especially  irri- 
tating to  a  mucous  membrane.  ISTew  products  are  also  formed  from  the 
decomposition  of  the  proteids,  and  gases  are  always  present.  Food  re- 
mains long  in  the  stomach  because  of  motor  inactivity,  which  is  partly 
the  cause  and  partly  the  result  of  the  disease.  It  often  continues  after 
all  other  symptoms  have  disappeared. 

The  most  important  local  symptoms  are  vomiting  or  regurgitation 
of  food,  vomiting  of  mucus,  regurgitation  of  a  sour  watery  fluid,  belch- 
ing of  gas,  and  pain  from  gastric  distention.  Vomiting  is  almost  inva- 
riably present,  and  may  occur  soon  or  long  after  feeding.  It  is  often 
accompanied  by  regurgitation  of  food,  which  may  begin  soon  after  one 
feeding  and  continue  quite  to  the  time  for  the  next.  Sometimes  a  con- 
siderable quantity  of  the  food  taken  is  vomited  at  one  time,  but  more 
often  the  food  is  regurgitated  in  small  quantities  and  at  short  intervals. 
In  nearly  all  protracted  cases  the  vomited  matters  contain  mucus,  and 
sometimes  this  is  a  conspicuous  feature.  The  regurgitation  of  a  sour 
irritating  fluid  occurs  even  when  but  little  food  is  rejected,  and  usually 
accompanies  the  belching  of  gas.  In  infants  some  of  the  most  striking 
symptoms  are  due  to  the  gas.  The  stomach  may  be  distended  and  hard 
most  of  the  time,  and  often  so  much  gas  is  present  that  infants  find  the 
greatest  difficulty  in  taking  food.  Though  evidently  very  hungry,  they 
can  take  so  little  at  a  time  that  an  hour  or  more  may  be  required  to 
take  four  or  five  ounces.  That  the  food  remains  long  in  the  stomach 
is  best  demonstrated  by  stomach-washing.  Instead  of  the  stomach  being 
empty  in  two  or  three  hours,  as  it  should  be,  food  is  almost  invariably 
found  four  or  five  hours,  and  in  some  cases  six  or  eight  hours,  after 
feeding. 

The  appetite  may  be  abnormally  great,  or  it  may  be  very  poor.  As  a 
rule,  children  take  less  food  than  in  health.  The  tongue  is  usually 
coated.  Tlie  general  symptoms  are  those  of  malnutrition;  there  is  con- 
stant fretfulness  and  sleep  is  irregular  or  disturbed;   the  weight  is  sta- 


34D  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

tionary^  or  there  is  steady  loss;  there  is  also  anaemia,  and  the  child's 
development  is  arrested.  There  is  nearly  always  some  derangement  of 
the  bowels,  occasionally  constipation  with  the  constant  presence  of 
masses  of  undigested  food  in  the  stools,  but  more  frequently  there  is 
diarrhoea.  There  may  be  dilatation  of  the  stomach.  This  is  especially 
liable  to  occur  in  rachitic  children  where  overfeeding  has  long  been  prac- 
tised. 

The  course  of  these  symptoms  is  indefinite.  There  is  little  tendency 
to  spontaneous  recovery,  and  they  often  go  on  for  several  months,  until 
some  intercurrent  disease  develops  which  proves  fatal. 

In  older  children. — The  disease  is  not  so  common  as  in  infants.  In 
all  cases  the  most  constant  symptom  is  vomiting,  which  may  occur  regu- 
larly after  meals,  or  only  in  the  morning  before  breakfast.  If  the  latter, 
the  vomited  matters  consist  chiefly  of  mucus.  In  addition  to  these 
regular  attacks  there  may  be  the  frequent  regurgitation  of  small  quan- 
tities of  food.  There  are  gastric  flatulence  and  pain,  due  to  hyperacid- 
ity or  to  acid  fermentation.  The  appetite  is  variable — sometimes  inor- 
dinate, sometimes  entirely  lost;  it  may  be  capricious,  there  being  usu- 
ally a  craving  for  highly  seasoned  food.  The  tongue  is  constantly 
furred,  and  the  breath  usually  disagreeable.  These  symptoms  are  seen 
in  all  degrees  of  severity.  Intestinal  disturbances  are  not  so  frequent 
as  in  infancy.  Constipation  is  more  common  than  diarrhoea.  The  gen- 
eral symptoms  are  those  of  malnutrition.  There  are  anaemia,  wasting, 
constant  fretfulness,  disturbed  sleep,  and  various  other  nervous  disor- 
ders. 

Prognosis. — The  prognosis  depends  upon  the  age  of  the  patient,  the 
duration  of  the  disease,  the  surroundings,  and  upon  how  well  treatment 
can  be  carried  out.  In  infants  under  three  months  the  prognosis  as  to 
life  is  bad.  If  children  live  to  the  age  of  seven  or  eight  months,  they 
may  recover  with  proper  treatment.  These  patients  do  much  better  in 
private  practice  than  in  institutions.  Much  depends  upon  the  co-opera- 
tion of  an  intelligent  mother  or  nurse.  Chronic  gastric  indigestion  is  not 
dangerous  to  life  except  in  young  infants.  Its  principal  danger  consists 
in  the  predisposition  it  gives  to  acute  diarrhoeal  diseases  in  summer, 
which  in  such  patients  are  very  likely  to  be  fatal.  It  may  also  lead  to  the 
development  of  marasmus. 

In  older  children,  as  in  the  case  of  infants,  these  symptoms  may  con- 
tinue indefinitely;  there  is  little  tendency  to  spontaneous  recovery,  but 
under  favourable  circumstances,  with  constant  care,  much  may  be  done 
for  all  these  patients  and  many  of  them  may  be  completely  cured. 

Treatment. — Infants. — The  general  treatment  is  too  apt  to  be  ig- 
nored, but  it  is  just  as  important  as  measures  directed  more  specifically 
to  the  stomach.  A  large,  roomy  nursery,  and  plenty  of  fresh  air  by 
night  and  by  day,  are  very  important ;  sometimes  under  the  influence  of 


CHRONIC   GASTRIC  INDIGESTION.  341 

these  alone  improvement  begins.  General  friction  of  the  body  with 
cocoa-butter  is  useful  in  delicate  children  with  poor  circulation.  Infants 
must  be  properly  covered,  and  it  is  of  the  utmost  importance  that  the 
feet  be  kept  warm.  Of  the  measures  directed  to  the  stomach,  two  are 
chiefly  to  be  depended  upon — stomach-washing  and  diet. 

Stomach-washing  (page  60)  is  useful,  first,  in  removing  the  mucus 
which  is  so  abundant  in  most  of  these  cases;  secondly,  in  cleansing  the 
organ  thoroughly  at  least  once  a  day,  this  of  itself  being  most  impor- 
tant; thirdly,  as  a  stimulant  to  the  gastric  secretions,  especially  hydro- 
chloric acid.  Plain  boiled  water,  or  a  weak  alkaline  solution — sodium 
bicarbonate,  one  drachm  to  the  pint — may  be  employed.  In  the 
early  part  of  the  treatment  the  washing  should  be  done  daily;  later, 
every  second  or  third  day.  The  time  selected  is  not  very  important, 
but  it  is  better  to  make  this  about  three  hours  after  feeding.  The 
mother  or  nurse  may  easily  be  taught  to  wash  the  stomach,  so  that  it 
may  be  done  as  frequently  and  for  as  long  a  period  as  circumstances 
require. 

The  question  of  diet  has  been  quite  fully  discussed  in  the  chapter  on 
Infant-Feeding,  particularly  in  the  pages  in  which  the  feeding  in  diffi- 
cult cases  is  considered.  If  milk  is  being  given,  one  should  first  en- 
deavour to  determine  which  of  the  elements  is  the  chief  cause  of  the 
trouble.  This  is  most  frequently  the  fat,  next  the  proteids,  and  only 
rarely  the  sugar.  The  fat  should  be  reduced,  and  if  trouble  also  exists 
with  the  proteids,  these  should  be  managed  in  the  manner  indicated  on 
pages  206-209.  Where  very  serious  and  long-continued  trouble  exists 
with  both  the  fat  and  proteids,  a  change  of  diet  to  a  farinaceous  food 
may  be  the  most  efficient  means  of  checking  the  gastric  fermentation. 
Malted  foods  seldom  succeed. 

The  quantity  of  food  and  the  frequency  of  feeding  are  both  matters 
of  importance.  As  a  rule  with  a  serious  amount  of  chronic  gastric  dis- 
turbance in  infants  over  three  months  old  the  feedings  should  not  be 
less  than  three  and  seldom  more  than  five  hours  apart ;  four  hours  is 
a  good  average.  Small  meals  of  a  somewhat  concentrated  food  are 
usually  better  than  large  feedings  of  a  very  dilute  food.  Careful  study 
of  the  individual  child  is  indispensable  to  success. 

Drugs  have  a  very  limited  application  in  the  treatment  of  this  con- 
dition in  infants.  Generally  they  are  too  much  used,  too  little  attention 
is  given  to  the  details  of  feeding,  by  which  means  alone  permanent  im- 
provement is  reached.  The  continued  use  of  pepsin  and  hydrochloric 
acid  has  given  me  but  little  satisfaction.  But  for  the  relief  of  one  symp- 
tom drugs  are  of  the  greatest  advantage;  wherever  the  production  of 
gas  and  constant  eructations  are  prominent  symptoms,  the  salicylate  of 
soda  is  invaluable.  It  may  be  given  with  tlie  feeding  in  doses  of  one  or 
two  grains. 


342  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

The  management  of  these  eases  in  older  children  must  be  conducted 
along  the  lines  laid  down  for  infants.  With  them,  stomach-washing  can 
not  be  so  easily  employed,  and  other  means  must  be  used  to  clear  the 
stomach  of  mucus.  The  best  is  undoubtedly  the  use  of  large  draughts  of 
water,  as  hot  as  can  be  borne,  an  hour  before  eating.  From  six  to  eight 
ounces  should  be  taken,  preferably  slowly  by  sipping.  To  this  may  be 
advantageously  added,  in  many  cases,  fifteen  or  twenty  grains  of  bicar- 
bonate of  soda. 

The  diet  should  consist  of  milk  diluted  at  least  three  times,  kumyss 
or  matzoon,  beef  juice,  raw  meat,  beef  peptones,  and  a  moderate  amount 
of  starchy  food,  preferably  dried  bread  or  zwieback.  Sweet  fruits,  and 
in  many  cases  all  fruits,  must  be  avoided.  The  amount  of  water  taken 
at  meal-time  should  be  carefully  restricted.  Beneficial  results  are  ob- 
tained in  niost  of  these  cases  by  the  use  of  nux  vomica  or  simple  bitters 
before  meals,  and  the  regular  administration  of  hydrochloric  acid  (gtt. 
V  to  viij  of  the  dilute  acid)  shortly  after  meals.  All  pastry,  sweets,  nuts, 
and  candies  must  be  absolutely  prohibited.  With  improvement  in  the 
symptoms  green  vegetables  may  be  added  to  the  diet,  and  the  amount  of 
starchy  food  increased.  The  general  treatment  must  not  be  neglected. 
The  patient  should  lead  an  out-of-door  life  as  much  as  possible,  and 
regular  but  very  moderate  exercise  allowed.  Great  caution  is  necessary 
against  over-fatigue.  Iron  may  be  given  in  most  cases  during  convales- 
cence; but  cod-liver  oil  should  be  carefully  avoided  until  the  gastric 
symptoms  have  quite  disappeared.  Eelapses  are  easily  excited,  and 
the  most  constant  care  regarding  the  food  must  be  maintained  for 
months,  or  even  years. 

DILATATION  OF  THE  STOMACH. 

Moderate  dilatation  of  the  stomach  is  quite  a  frequent  condition, 
although  it  is  not  so  large  a  factor  in  the  disorders  of  digestion  in 
infancy  and  childhood  as  many  who  have  written  upon  the  subject 
would  lead  us  to  believe.  A  very  marked  degree  of  dilatation  is  rare, 
but  in  these  cases  its.  recognition  is  important  and  its  treatment  diffi- 
cult. 

Dilatation  is  almost  invariably  regular  or  cylindrical;  it  is  usually 
most  marked  at  the  cardiac  extremity  (Fig.  59).  Cases  of  irregular  or 
saccular  dilatation,  except  when  associated  with  cicatricial  conditions,  are 
of  somewhat  doubtful  occurrence.  The  irregular  shapes  of  the  stomach 
found  at  autopsy  dependent  upon  the  contraction  of  the  muscular  coats, 
may  be  easily  mistaken  for  hour-glass  contraction  or  saccular  dilatation. 
The  degree  of  dilatation  may  be  very  great ;  thus,  the  stomach  of  a  child 
three  months  old  measured  at  autopsy  nine  ounces;  another,  four  and 
a  half  months  old,  ten  ounces.    The  greatest  dilatation  I  have  measured 


DILATATION   OF   THE   STOMACH.  343 

during  life  was  in  a  child  four  months  old,  where  the  stomach  hold  twelve 
ounces. 

In  very  rare  instances  dilatation  may  result  from  congenital  stenosis 
of  the  pylorus.  The  most  important  predisposing  cause,  however,  is  the 
muscular  atony  which  accompanies  rickets.  It  is  found  to  a  slight  degree 
in  almost  all  severe  cases  of  rickets.  The  principal  exciting  causes  are 
continued  distention  from  overfeeding  and  chronic  indigestion. 

In  most  cases  the  only  symptoms  are  those  of  the  chronic  indigestion 
which  almost  invariably  accompanies  dilatation.  If  there  is  pyloric  steno- 
sis, vomiting  is  present.  In  young  infants  the  pressure  symptoms  may  be 
very  serious.  This  is  particularly  true  in  infants  with  acute  bronchitis  or 
broncho-pneumonia,  or  in  those  with  atelectasis.  In  these  patients  I  have 
seen  very  grave  symptoms  accompany  the  rapid  distention  of  a  dilated 


Fig.  59. — A,  dilated  stomach  from  rachitic  child  of  six  months ;  B,  stomach  of  healthy  child 
of  same  age.     (Outlines  reduced  from  photographs.) 

stomach,  and  in  one  very  delicate  infant  of  three  months  this  was  appar- 
ently the  cause  of  death.  A  positive  diagnosis  of  dilatation  is  only 
made  by  the  physical  signs.  There  are  epigastric  fulness  and  distention, 
and  in  some  very  thin  patients  the  outline  of  the  stomach  can  be  distinctly 
seen.  Dilatation  of  the  transverse  colon,  however,  may  be  mistaken  for 
dilatation  of  the  stomach.  In  the  latter,  the  lower  outline  is  convex,  while 
in  the  former  it  is  usually  slightly  concave.  The  most  satisfactory  means 
of  diagnosis  is  by  percussion.  The  examination  should  be  made  three  or 
four  hours  after  feeding,  at  which  time  the  whole  abdomen  is  apt  to  be 
tympanitic.  The  stomach  should  then  be  filled  with  water;  the  lower 
limit  of  the  area  of  flatness  will  be  the  lower  border  of  the  stomach.  This 
is  much  more  satisfactory  than  determining  the  outline  after  the  genera- 
tion of  gas  in  the  stomach.  If  the  lower  border  comes  nearly  to  the 
umbilicus  the  stomach  is  dilated  ;  if  it  is  below  the  umbilicus,  it  is  much 
dilated.  In  many  cases  the  capacity  of  the  stomach  can  be  measured  by 
simply  seeing  how  much  water  can  be  easily  introduced  into  it  by  means 
of  the  funnel  and  stomach  tube. 


344  DISEASES  OF   THE  DIGESTIVE   SYSTEM. 

In  moderate  dilatation  of  the  stomach  the  prognosis  is  good  except 
when  it  is  due  to  pjdoric  stenosis.  If  the  infant  has  any  acute  or  chronic 
pulmonary  disease,  dilatation  of  the  stomach  may  add  to  the  discomfort 
and  even  to  the  danger  from  that  condition. 

In  the  management  of  these  cases  the  first  point  is  to  restrict  the 
use  of  fluids,  reduce  the  size  of  the  meals,  and  regulate  the  diet  in 
accordance  with  the  general  plan  outlined  in  the  chapter  on  Chronic 
Indigestion.  If  the  dilatation  is  marked,  the  stomach  should  he  washed 
once  a  day.  The  general  condition  of  the  patient  usually  requires  tonics, 
the  best  of  which  is  strychnine;  and  rickets,  if  present,  should  receive 
its  appropriate  constitutional  treatment. 

ULCER   OF   THE   ST03IACH. 

Ulceration  of  the  stomach  may  be  found  in  connection  with  several 
pathological  processes  which  are  quite  distinct  from  one  another : 

1.  Ulcers  in  the  newly  born.  These  have  already  been  referred  to  in 
the  chapter  on  Hemorrhages  of  the  Xewly  Born  (page  101).  The  only- 
characteristic  symptom  is  hsemorrhage. 

2.  Ulcers  resulting  from  acute  gastritis.  These  also  are  not  fre- 
quent (page  333).  As  a  rule  they  give  no  symptoms  except  those  of 
gastritis,  although  in  several  cases  I  have  known  severe  hemorrhage  to 
result  from  them.    This  symptom  will  be  considered  later. 

3.  Tuberculous  ulcers.  These  are  quite  rare.  I  met  with  gastric 
ulcers  five  times  in  one  hundred  and  nineteen  autopsies  on  tubercu- 
lous cases;  however,  the  evidence  was  not  conclusive  in  all  of  them 
that  the  ulcers  were  tuberculous;  but  in  three  the  tubercle  bacilli  were 
found.  Usually  there  were  several  small  ulcers;  in  one  case  but 
two  were  present,  the  larger  one  being  nearly  three-fourths  of  an  inch 
in  diameter,  and  situated  on  the  posterior  wall  near  the  middle  of  the 
greater  curvature.  All  but  one  of  these  cases  were  in  infants,  one  child 
being  onty  ten  months  old.  The  ulcers  gave  no  symptoms  during  life, 
and  death  took  place  from  general  tuberculosis.  This  is  the  history  of 
nearh'  all  the  few  cases  on  record.  In  one,  however,  reported  by  Casin, 
a  tuberculous  ulcer  perforated  the  stomach  and  caused  death  from  peri- 
tonitis. Active  symptoms — bloody  vomiting  and  bloody  stools — were 
excited  by  the  use  of  an  emetic. 

4.  Simple  perforating  ulcers.  These  are  of  great  rarity  and  uncer- 
tain patholog}^  I  have  found  but  five  recorded  cases  in  young  children 
in  non-tuberculous  patients,  two  of  these  being  young  infants.  Kotclrs 
patient  was  but  seven  weeks  old,  and  Cade's  but  two  months.  Two  other 
cases  were  under  four  years  old. 

The  s}Tnptoms  of  ulcer  before  perforation  are  gastric  pain  and  ten- 
derness, vomiting  of  blood,  and  often  bloody  stools.  In  most  of  these 
cases  in  children  there  were  no  symptoms  until  perforation,  then  fol- 


HiEMORRHAGE   FROM   THE  STOMACH.  345 

lowed  collapse,  sometimes  high  temperature,  the  rapid  development  of 
tympanites,  and  death  from  shock  or  from  peritonitis. 

The  prognosis  is  bad  in  all  forms  of  ulcer  of  the  stomach,  except  the 
small  follicular  variety.  In  this,  however,  the  diagnosis  can  not  posi- 
tively be  made  except  by  gastric  hgemorrhage,  and  it  is  only  this  which 
makes  these  cases  serious. 

Treatment. — The  treatment  is  absolute  rest,  ice,  small  doses  of 
opium,  rectal  feeding,  stimulants;  later,  bismuth,  arsenic,  or  nitrate  of 
silver.  If  symptoms  of  perforation  occur  the  abdomen  should  be  opened 
without  delay,  as  offering  the  only  chance  of  recovery. 

TUMOURS  OF   THE  STOMACH. 

Although  exceedingly  rare,  tumours  of  the  stomach  occur  in  child- 
hood, and  are  seen  even  in  infancy.  A  case  of  sarcoma  of  the  stomach  in 
a  child  of  three  and  a  half  years  has  been  reported  by  Finlayson  (British 
Medical  Journal,  December  2,  1899).  It  was  apparently  primary.  The 
microscopical  examination  showed  it  to  be  of  the  spindle-celled  variety. 
This  writer  could  find  no  other  recorded  case  under  the  age  of  fifteen. 

Lymjjhadenoma  of  the  stomach  in  a  rachitic  infant  of  eighteen 
months  has  been  recorded  by  Rolleston  and  Latham  (Lancet,  May  14, 
1898).  There  were  multiple  tumours  arising  from  the  mucous  mem- 
brane in  the  pyloric  region.  The  case  in  many  features  resembled  leu- 
kaemia. 

Six  cases  of  cancer  of  the  stomach  in  children  under  ten  years  are 
collected  in  an  article  by  Osier  and  McCrae  (New  York  Medical  Jour- 
nal, April  21,  1900).  Four  of  these  were  in  young  infants  and  probably 
congenital.  One  case,  in  a  child  of  eight,  presented  the  usual  symptoms 
and  lesions  of  the  adult  disease. 

HEMORRHAGE  FROM   THE  STOMACH   (HiEMATEMESIS). 

The  most  frequent  variety  of  haemorrhage  from  the  stomach,  that 
met  with  in  the  newly  born,  has  already  been  considered.  (See  page 
103.) 

I  have  met  with  three  fatal  cases  in  young  infants,  the  eldest  being 
fifteen  months  old.  In  the  first  case  there  were  symptoms  of  ordinary 
gastro-enteritis.  On  the  seventh  day  the  vomiting  of  blood  began,  and 
was  repeated  about  ten  or  twelve  times  during  the  next  twenty-four 
hours,  when  death  took  place.  The  blood  was  quite  abundant,  as  much  as 
a  drachm  of  red  blood  being  discharged  at  once.  At  autopsy  there  were 
found  in  the  stomach  about  two  ounces  of  dark-brown  fluid,  but  no  gross 
lesion  was  discovered,  and  no  explanation  of  the  l)lecding.  This  hemor- 
rhage was  apparently  capillary.  In  the  second  case  there  were  symptoms 
of  acute  ffastro-cntcritis  of  thirty-six  hours'  duration.     After  this  time 


346  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

there  was  marked  abdominal  distention  with  symptoms  of  collapse ;  then 
a  profuse  hsemorrhage  from  the  stomach,  the  child  dying  while  vomiting 
blood.  At  least  half  a  pint  was  discharged.  The  stomach  contained  at 
autopsy  two  ounces  of  dark  fluid  blood,  and  the  mucous  membrane  was 
filled  with  minute  ulcers  extending  quite  through  the  mucosa.  In  the 
third  case  there  was  no  vomiting  of  blood,  but  the  patient  died  with 
symptoms  of  internal  haemorrhage.  There  was  blood  in  the  upper  part 
of  the  intestine,  and  the  stomach  was  filled  with  blood;  it  contained 
many  small  follicular  ulcers  resembling  those  found  in  the  previous  case. 

Haemorrhage  from  the  stomach  may  occur  in  purpura,  haemophilia, 
scurvy,  and  rarely  in  malaria.  In  young  girls  about  puberty  it  may  be  a 
form  of  vicarious  menstruation.  Occasionally  blood  may  be  vomited  in 
cases  of  haemorrhagic  measles.  Two  cases  are  reported  in  which  fatal 
haemorrhage  followed  the  swallowing  of  a  foreign  body.  In  both,  vomit- 
ing of  blood  occurred  long  after  the  original  accident.  In  one  case  two 
and  a  half  years  had  elapsed.  The  autopsy  in  this  case  showed  impac- 
tion of  the  foreign  body  and  ulceration  into  the  arch  of  the  aorta.  Spu- 
rious haemorrhages  may  occur  where  blood  has  been  swallowed  and  then 
vomited.  The  source  of  this  is  most  frequently  the  nose  or  pharynx. 
It  may  happen  in  infants  at  the  breast,  where  the  blood  is  drawn  from 
a  fissure  or  ulcer  in  the  nipple.  The  amount  of  blood  vomited  under 
these  circumstances  may  be  large  enough  to  be  quite  alarming.  It  may 
be  recognised  by  the  child's  general  condition  being  normal,  and  by  the 
presence  of  fissures  or  ulcers  upon  the  nipple.  It  may  sometimes  be 
noticed  that  the  vomiting  of  blood  follows  nursing  from  one  breast  and 
not  from  the  other. 

Symptoms. — There  may  be  no  symptoms  except  those  of  internal 
haemorrhage,  but  this  is  rare.  Usually  there  is  vomiting  of  blood,  and 
blood  appears  in  the  stools.  If  the  haemorrhage  is  rapid  and  vomiting 
speedily  occurs,  the  blood  may  be  of  a  bright-red  colour.  If  it  has  been 
long  in  the  stomach  it  is  of  a  dark-brown  or  black  colour  resembling 
coffee-grounds.  The  stools  containing  blood  from  the  stomach  are 
black  and  tarry  in  appearance.  The  general  symptoms  will  depend  upon 
the  amount  of  blood  lost. 

In  a  case  where  blood  is  vomited,  the  first  point  is  to  distinguish  spu- 
rious from  true  gastric  haemorrhage.  The  nose  and  pharynx,  especially 
its  posterior  wall,  should  be  carefully  examined.  If  the  child  is  at  the 
breast,  the  nipples  should  be  examined.  In  older  children  it  is  important 
to  distinguish  vomiting  of  blood  from  haemoptysis.  This  distinction  is 
to  be  made  in  accordance  with  the  rules  laid  down  in  text-books  on  gen- 
eral medicine.  The  prognosis  is  bad  if  the  haemorrhage  is  due  to  ulcer, 
if  it  is  very  profuse,  or  if  it  occurs  in  young  infants.  When  it  occurs  in 
connection  with  constitutional  diseases  the  prognosis  depends  upon  the 
original  disease. 


MALFORMATIONS   OF   THE   INTESTINES. 


347 


Treatment. — Altogether  the  most  efficient  remedy  is  the  suprarenal 
extract.  It  may  be  given  very  freely,  at  least  two  grains  every  half  hour 
to  a  child  of  one  year.  The  patient  should  be  kept  quiet,  preferably  upon 
the  back;  if  there  are  signs  of  collapse,  stimulants  may  be  given  hypo- 
dermically  or  by  the  rectum.  ISTo  food  should  be  given  by  the  stomach 
for  at  least  twenty-four  hours  after  the  haemorrhage  has  ceased. 


CHAPTER    VI. 

DISEASES  OF  THE  INTESTINES. 

MALFORMATIONS  AND  MALPOSITIONS. 

Malformations  are  not  very  frequent,  but  are  of  great  variety. 
With  the  exception  of  those  situated  at  the  lower  end  of  the  intestine 
they  are  not  of  much  practical  importance,  for  the  condition  is  such 
ordinarily  as  to  be  incompatible  with  life.  Malformations  may  be  met 
with  at  any  point  in  the  canal,  but  most  frequently  in  the  rectum  and 
anus.  Aside  from  these,  malformations  of  the  large  intestine  are  much 
less  common  than  those  of  the  small  intestine. 

Malformations  of  the  Rectum. — In  Fig.  60  are  shown  the  usual  vari- 
eties of  malformation  of  the  rectum.  The  most  frequent  is  atresia  of 
the  anus  (1).  In  this  the  cu- 
taneous septum  has  not  been  1 
absorbed,  but  the  intestine  is 
normal  to  its  lower  extrem- 
ity. This  form  is  readily 
curable  by  a  surgical  opera- 
tion. In  the  next  variety  (2) 
the  cutaneous  orifice  and  the 
lower  part  of  the  rectum  arc 
normal,  but  a  membrane 
separates  this  portion  from 
the  upper  part  of  the  gut ; 
this  is  usually  situated  within  two  or  three  inclies  of  the  anus.  The 
bulging  of  the  lower  part  of  the  distended  intestine  can  usually  be  felt  by 
the  finger  in  the  rectum,  and  a  simple  division  of  the  membrane  by  a 
guarded  bistoury  may  relieve  the  condition.  The  third  form  (3)  is  more 
serious.  Here  the  rectum  terminates  in  a  blind  pouch  at  a  variable  dis- 
tance from  the  anus,  and  is  represented  below  by  an  impervious  fibrous 
cord.  The  diagnosis  of  this  condition  can  not  positively  be  made  without 
opening  the  abdominal  cavity.  The  bulging  of  the  intestine  appreciable 
by  the  finger  in  the  rectum,  is  the  only  point  which  differentiates  the 


R 


Fio.  tJO. — Malforinntions  of  the  rectum.     A,  anus; 
K,  rectum. 


348  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

preceding  variety  from  this  one.  Instead  of  atresia  of  the  rectum  there 
may  be  stenosis  of  varying  degrees,  which  may  give  rise  to  the  usual 
symptoms  of  stricture.    This  is  often  curable  by  dilatation. 

Malformations  of  the  Small  Intestine. — There  may  be  stenosis  or 
atresia  at  any  point,  often  at  man}^  points.  Obstruction  is  much  more 
frequent  in  the  upper  than  in  the  lower  part  of  the  small  intestine,  the 
most  common  seat  being  the  duodenum.*  Atresia  is  more  often  seen  than 
stenosis.  There  may  be  a  single  point  of  obstruction,  or  the  lumen  of 
the  intestine  may  be  obliterated  for  a  considerable  distance,  the  intestine 
being  represented  only  by  a  fibrous  cord  which  connects  the  two  open  por- 
tions, or  there  may  be  no  connection  between  them.  In  all  cases  the  in- 
testine above  is  found  very  greatly  distended,  while  that  below  is  empty 
and  usually  atrophied.  The  causes  of  these  multiple  deformities  are 
mainly  two — foetal  peritonitis  and  volvulus,  f  In  foetal  peritonitis  there 
are  usually  found  bands  of  adhesions  between  the  intestinal  coils,  and  be- 
tween the  intestine  and  the  solid  viscera.  Syphilis  has  been  assigned  as 
a  cause  in  many  cases.  Volvulus,  or  a  twisting  of  the  intestine  during 
its  development,  is  a  more  satisfactory  explanation  for  the  majority  of 
the  cases,  especially  where  there  are  multiple  points  of  atresia.  All 
these  conditions  are  beyond  the  reach  of  surgical  treatment.  The  symp- 
toms appear  soon  after  birth  and  are  those  of  intestinal  obstruction. 
(See  page  115.)  The  higher  the  point  of  obstruction  the  shorter  the 
■duration  of  life ;  it  is  rarely  more  than  a  week  in  any  case  of  atresia ; 
in  stenosis  it  may  be  two  or  three  months. 

Meckel's  diverticulum. — This  is  the  remains  of  the  omphalo-mesen- 
teric  duct,  which  in  foetal  life  forms  a  communication  between  the  intes- 
tine and  the  umbilical  vesicle.  It  is  given  off  from  the  ileum,  usually 
about  a  foot  above  the  ileo-cgecal  valve.  Most  frequently  it  exists  as  a 
blind  pouch  from  one-half  to  two  or  three  inches  long,  communicating 
with  the  intestine.  At  the  extremity  of  this  there  may  be  a  fibrous  cord, 
which  is  free  in  the  abdominal  cavity  or  attached  to  the  umbilicus.  In 
other  cases  the  duct  ma}^  remain  pervious  quite  to  the  umbilicus,  so  that 
there  is  a  fscal  fistula.  Prolapse  of  the  mucous  membrane  of  the  duct 
may  lead  to  an  umbilical  tumour.  (See  page  112.)  Meckel's  diverticu- 
lum, especially  when  present  as  a  cord  connecting  the  ileum  with  the 
umbilicus,  may  compress  a  coil  of  intestine,  leading  to  obstruction  or  even 
strangulation.     This  may  occur  in  infancy  or  later  in  life. 

Malpositions. — The  ascending  colon  may  be  found  upon  the  left  side. 
There  may  be  a  complete  transposition  of  the  abdominal  viscera.     In 


*  See  Cordes,  Archives  of  Paediatrics,  June,  1901,  for  a  report  of  fifty-seven 
cases. 

f  Silbermann  (Jahrb.  fiir  Kinderh.,  Bd.  xviii,  p.  420) ;  Gaertner  (Jahrb.  fiir  Kinderh., 
Bd.  XX,  p.  403). 


DIARRHOEA. 


349 


cases  of  congenital  nmbilical  hernia  a  large  part  of  the  intestines  may  be 
found  in  the  tumour,  and  in  diaphragmatic  hernia  they  may  be  in  the 
thoracic  cavity. 

DIARRHCEA. 

The  term  diarrhaa  is  used  to  cover  all  conditions  attended  by  fre- 
quent loose  evacuations  of  the  bowels.  These  depend  upon  an  in- 
crease in  peristalsis  and  in  the  intestinal  secretions.  There  are  certain 
■etiological  factors  which  are  common  to  all  forms  of  diarrhoea. 

Age. — A  peculiar  susceptibility  exists  in  very  young  children.  This 
is  well  brought  out  by  the  following  statistics.  My  former  associate,  Dr. 
Crandall,  has  tabulated  three  thousand  cases  of  diarrhoea,  including 
those  treated  by  both  of  us  in  private  and  dispensary  practice,  and  others 
from  the  records  of  two  large  dispensaries  in  New  York.  The  ages  of 
those  applying  for  treatment  were :  under  six  months,  l-i  per  cent ;  six 
to  twelve  months,  29  per  cent ;  twelve  to  eighteen  months,  24  per  cent ; 
eighteen  to  twenty-four  months,  17  per  cent;  over  two  years,  16  per 
cent.  It  will  be  noted  that  the  greatest  susceptibility  is  between  six  and 
eighteen  months,  and  that  over  four-fifths  of  all  the  cases  occurred  dur- 
ing the  first  two  years. 

Season. — The  next  striking  fact  about  diarrhoeal  diseases  is  their 
prevalence  during  the  summer  season.     This  is  graphically  shown  in 


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Fifi.  61.— Mortality  from  diarrha-ul  diseases  in  New  York  for  ten  years  in  children  under  five; 

compared   with  the  mean  temperature  for  the  same  period.    ,  mortality ; , 

mean  temperature.     (Seibert.) 

Figs.  61  and  62,  where  are  given  by  months  the  cases  treated  in  a  large 
New  York  dispensary  for  ten  years,  and  the  mortality  records  for  the 
entire  city  during  the  same  period.  The  enormous  increase  in  the  num- 
ber of  cases  occurring  in  the  summer  months  does  not  have  reference  to 
any  single  form  of  diarrhoea,  but  to  all  forms.  The  significance  of  these 
facts  will  be  considered  later. 

Surroundings. — Wliile  diarrhcoal  diseases  are  especially  frequent  in 
cities  and  among  the  poor,  still  they  are  not  essentially  diseases  of  the 
24 


350 


DISEASES   OF   THE   DIGESTIVE   SYSTEM. 


city  or  of  poverty.  Severe  and  even  fatal  cases  are  constantly  met  with 
among  all  classes  and  in  all  places.  Sufficient  evidence  has  not  yet  accu- 
mulated to  establish  a  direct  connection  between  a  polluted  atmosphere 
and  the  prevalence  of  diarrhoeal  diseases.  They  are  not  essentially  tilth- 
diseases  ;  yet  their  frequency  and  severity  are  both  increased  by  want  of 


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Fig.  62. — Cases  of  diarrhoeal  disease  treated  in  the  German  Dispensary  (New  York)  in  ten 
years  in  cliildren  under  five;  compared  with  the  mean  temperature  for  the  same  period. 
,  cases  of  diarrhcea; ,  mean  temperature.     (Seibert.) 

cleanliness  in  apartments,  and  in  the  persons  and  clothing  of  infants,  es- 
pecially the  napkins,  chiefly  because  these  lead  to  a  contamination  of  the 
food.  Vacher  has  shown  that  the  mortality  from  diarrhoea  in  the  large 
English  towns  had  no  constant  relation  to  the  densit}'  of  population. 
Poverty,  neglect,  and  bad  surroundings,  predispose  to  diarrhoea  in  sum- 
mer, just  as  they  do  to  other  forms  of  acute  disease  in  the  cold  season. 

Constitution. — Everything  which  lowers  the  general  vitality  in- 
creases the  liability  to  diarrhoeal  diseases.  Children  suffering  from 
marasmus,  malnutrition,  syphilis,  rickets,  or  tuberculosis  are  especially 
prone  to  be  affected,  and  these  make  up  the  bulk  of  the  fatal  cases  in 
cities. 

Dentition. — There  are  cases  in  which  diarrhoea  and  dentition  are 
closely  associated,  for  the  bowels  quickly  become  normal  when  the  teeth 
have  pierced  the  gum.  These  cases,  although  rare,  do  occur.  Too  much, 
however,  can  not  be  said  in  contradiction  of  the  wide-spread  belief 
among  the  laity  that  diarrhoea  accompanying  dentition  is  normal  or 
even  beneficial.  The  infrequency  of  diarrhoea  during  dentition  in  the 
cold  season,  is  the  best  argument  against  its  importance  as  an  etiological 
factor. 

Food  and  feeding. — Of  1,943  fatal  cases  which  I  have  collected,  only 
three  per  cent  had  the  breast  exclusively.  In  my  own  experience  fatal 
cases  of  diarrhoeal  disease  in  nursing  infants  are  extremely  rare.  These 
are  significant  facts.  They  show  that  the  manner  of  feeding  is  one  of 
the  most  important  factors  in  the  production  of  diarrha?a.     This  fact  is 


DIARRHCEA.  351 

to  be  connected  with  the  statistics  witli  reference  to  age.  The  poor  in 
Xew  York  are  wont  to  nurse  their  infants  exclusively  for  about  six 
months.  If  nursing  is  continued  longer,  it  is  usually  with  the  addition 
of  other  food,  often  of  the  most  indigestible  kind.  Children  among  the 
poor  in  tenements  enjoy  immunity  from  intestinal  disease  very  nearly 
in  proportion  as  they  are  breast-fed,  and  just  so  long  as  they  are  so ;  but 
as  soon  as  artificial  feeding  is  begun,  diarrha?al  diseases  are  prevalent. 
There  are  many  reasons  for  this.  In  most  cases,  however,  it  is  not  arti- 
ficial feeding  per  se,  but  artificial  feeding  ignorantly  and  improperly 
done,  which  is  to  be  blamed.  If  cow's  milk  is  employed  as  a  substitute 
for  breast-milk,  the  differences  in  composition  are  either  not  appreciated 
or  else  ignored,  so  that  many  artificially-fed  children  suffer  from  malnu- 
trition. The  comparative  safety  of  cow's  milk  in  winter  and  in  the 
country,  however,  shows  that  the  chemical  composition  of  cow's  milk  is 
not  the  most  important  factor.  Another  common  and  very  serious  mis- 
take is  that  of  over-feeding.  Artificially-fed  children  are  almost  always 
over-fed.  The  common  practice  of  feeding  an  infant  every  time  it  cries, 
or  of  keeping  the  bottle  at  its  mouth  the  greater  part  of  the  time,  is  pro- 
ductive of  untold  harm. 

The  feeding  of  impure  milk  is  an  important  cause  of  diarrhoea,  espe- 
cially among  the  poor  in  cities  during  the  summer.  The  condition  of 
,the  milk  may  be  due  to  disease  in  the  cow,  to  adulteration  or  pollution 
at  the  dairy,  during  transportation,  or  in  the  homes.  (See  pages  138- 
142.)  It  may  come  from  dirty  vessels  in  which  the  milk  is  kept,  or 
dirty  Ijottles  from  which  it  is  fed.  In  some  cases  the  milk  may  be  the 
vehicle  of  specific  infection.  In  others,  its  condition  is  owing  to  the  ordi- 
nary fermentation  changes  due  to  the  age  of  the  milk — it  being  often 
two  and  sometimes  three  days  old  before  it  is  consumed,  and  very  often 
kept  with  little  or  no  ice.  It  is  surprising  to  see  how  quickly  diarrhoea 
is  excited  by  impure  milk.  I  once  saw  in  the  New  York  Infant  Asylum 
every  one  of  the  twenty-three  healthy  children,  all  over  two  years  old 
and  occupying  one  ward,  attacked  in  a  single  day  with  diarrhoea  which 
was  traced  to  this  cause.  Articles  of  food  totally  unsuited  to  the  child's 
digestion  are  often  given.  Among  the  poor  it  is  a  common  practice  to 
give  all  kinds  of  solid  food  to  children  from  twelve  to  eighteen  months 
old,  while  those  of  two  years  often  get  only  the  regular  diet  of  the  fam- 
ily. The  great  majority  of  the  attacks  of  diarrhoea  in  children  over  two 
years  old  can  be  traced  directly  to  improper  food. 

The  factors  mentioned — over- feeding,  too  frequent  feeding,  and  the 
habitual  use  of  improper  food — all  combine  to  produce  a  chronic  indiges- 
tion which  is  probably  the  most  important  pi'cdisposing  cause  of  dinr- 
rha'al  diseases. 

The  Different  "Varieties  of  Acute  Diarrhoea. — Mechanical  diarrha\i. — 
This  includes  cases  in  which  diarihu'a  is  produced  by  foreign  bodies,  or 


352  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

substances  taken  as  food  which  virtually  act  as  foreign  bodies :  such  are 
partially  cooked  rice  or  other  cereals,  dried  fruits,  or  fresh  fruits  contain- 
ing seeds ;  green  corn,  radishes,  celery,  cabbage,  or  other  vegetables ;  nuts 
and  unripe  fruits.  The  irritation  caused  by  such  substances  may  pro- 
duce only  increased  secretion  and  peristalsis  by  which  the  offending  arti- 
cles are  removed,  or,  if  sufficiently  severe  and  continuerl,  it  may  lead  to 
actual  inflammation  of  the  mucous  membrane  of  the  intestine. 

The  indications  for  treatment  are  first  to  give  an  active  cathartic — 
castor  oil,  calomel,  or  a  saline — and,  after  thorough  evacuation  of  the 
bowel  has  taken  place,  to  quiet  the  excessive  irritation  by  opium.  The 
particular  preparation  used  is  not  important.  For  two  or  three  days 
after  such  an  attack  the  diet  should  be  very  light,  and  of  such  a  character 
as  to  leave  but  little  residue — e.  g.,  for  infants,  broth,  beef  juice,  white  of 
egg;  and  for  older  children,  diluted  milk  or  kumyss.  The  patient  should 
be  kept  quiet,  preferably  in  bed,  until  the  stools  are  quite  normal.  The 
neglect  of  such  mild  attacks  is  a  frequent  cause  of  more  severe  ones. 

Diarrhcea  from  drugs. — In  susceptible  infants  any  of  the  ordinary 
cathartics  may  cause  an  attack  of  diarrhoea,  because  the  physiologi- 
cal effects  have  been  either  exaggerated  or  prolonged.  It  is  doubtful 
whether  such  attacks  are  often  produced  in  nursing  infants  by  cathartics 
taken  by  the  mother.  The  organic  acids  contained  in  fruits  may  operate 
in  the  same  way  as  cathartic  drugs.  In  cases  like  these  the  diarrhoea  is 
readily  controlled  by  opium,  usually  by  small  doses,  which  should  be 
repeated  after  each  action  of  the  bowels. 

Diarrhcea  from  nervous  influences. — Certain  nervous  impressions 
seem  to  be  able  to  produce  diarrhcea  Avhere  no  other  factors  are  present. 
Sometimes  these  act  in  conjunction  with  other  causes.  The  most  im- 
portant are  chilling  of  the  surface,  depression  caused  by  atmospheric 
heat,  fatigue,  exhaustion,  fright,  and  dentition.  Diarrhoea  may  be  seen 
in  older  children  with  anaemia,  chorea,  and  general  malnutrition.  It  is  a 
characteristic  of  many  of  these  cases,  that  the  taking  of  food  into  the 
stomach  immediately  excites  a  movement  of  the  bowels.  The  stools  usu- 
ally contain  undigested  food,  because  the  intestinal  contents  are  so  rap- 
idly hurried  forward.  The  chief  abnormal  condition  in  such  cases  is 
exaggerated  peristalsis.  This  is  best  controlled  by  rest  and  opium; 
only  small  doses  are  usually  required. 

Eliminative  diarrhcea. — This  term  has  been  applied  to  cases  in  which 
diarrhoea  is  evidently  an  effort  on  the  part  of  Nature  to  rid  the  body  of 
some  irritant  or  toxic  product.  The  best-known  example  is  the  diarrhnni 
of  uraemia.  It  is,  however,  very  probable  that  the  diarrhwa  of  many 
acute  infectious  diseases  belongs  in  this  category.  The  danger  of  sud- 
denly arresting  such  a  discharge  is  a  real  one.  It  should  be  closely 
watched,  not  allowed  to  become  itself  a  drain  upon  the  patient,  and 
checked  only  when  excessive. 


DIARRHCEA.  353 

Acute  mtestinal  indigestion. — Diarrhoea  is  a  constant  s3'mptom  of 
this  condition,  which  is  of  such  importance  that  it  will  be  considered  at 
length.  The  exciting  cause  of  the  diarrhoea  may  be  either  the  mechani- 
cal irritation  of  particles  of  undigested  food,  or  the  various  putrefactive 
products  which  are  formed  from  the  decomposition  of  such  food.  This 
form  is  especially  severe  in  infancy,  and  is  usually  accompanied  by  high 
fever  and  other  marked  constitutional  symptoms.  Gastric  symptoms 
are  present  in  most  of  the  cases. 

Diarrhceas  of  infectious  origin. — In  the  forms  of  diarrhea  above 
enumerated  there  are  no  lesions,  and  the  bacteria  found  in  the  stools 
are  the  ordinary  bacteria  of  the  intestines.  There  is  merely  altered 
functional  activity,  both  motor  and  secretory;  so  that  the  normal  chem- 
istry of  digestion  is  disturbed.  All  other  forms  of  acute  diarrhoea  are 
to  be  regarded  as  infectious.  The  source  of  infection  may  be  from  with- 
out, bacteria  being  introduced  with  the  food,  water,  or  accidentally;  or 
it  may  be  from  within,  where  bacteria  normally  or  frequently  present 
in  the  intestines,  but  not  pathogenic,  develop  pathogenic  properties  under 
the  altered  conditions  there  existing.  This  second  group,  the  diarrhoeas 
from  auto-infection,  embraces,  no  doubt,  a  very  considerable  proportion 
of  those  met  with  in  ordinary  practice.  This  may  explain  the  origin 
of  severe  attacks  developing  while  taking  a  food  practically  free  from 
germs,  such  as  breast-milk  or  sterilized  cow's  milk. 

All  infectious  diarrhoeas  are  associated  with  some  anatomical  lesions, 
the  extent  and  severity  of  which  depend  upon  the  nature  and  degree  of 
the  infection  and  the  duration  of  the  process.  In  the  mildest  cases  and 
in  those  of  short  duration,  even  though  severe,  the  lesions  involve  chiefly 
or  solely  the  epithelial  lining  of  the  intestine.  These  changes  may  bo 
compared  to  acute  degeneration  of  toxic  origin  in  other  organs,  the  kid- 
ney, for  example.  Nearly  the  whole  intestinal  tract  is  usually  affected, 
and  often  the  stomach  in  addition.  The  symptoms  in  this  group  of 
cases  are  due  not  so  much  to  the  anatomical  changes  as  to  functional 
disturbance  and  to  the  toxins  produced  in  the  intestine.  These  act  as 
local  irritants,  and  are  absorbed  into  the  circulalion.  ]u-oducing  the  con- 
stitutional symjitoms  of  the  disease. 

These  cases  have  been  classed  as  acute  gastro-enteric  intoxication. 

In  the  more  severe  forms  and  in  cases  of  longer  duration  more  ex- 
tensive lesions  are  present.  The  epithelium  is  destroyed ;  the  bacteria 
penetrate  into  the  deeper  layers  of  the  intestines,  producing  lesions  which 
vary  greatly  in  character  and  degree.  They  ni-o  important  as  modifying 
the  symptoms,  course,  and  termination  of  the  disease.  These  cases  are 
sometimes  classed  as  inflammatory  diarrhcra;  here,  from  the  location  of 
the  lesions,  they  are  grouped  under  the  term  ilco-colitis.  In  some  in- 
stances bacteria  find  their  way  from  the  intestines  into  the  general 
circuhition,   producing  the  constitutional   symptoms  of  a  grave  septi- 


354  DISEASES   OF   THE   DIGESTIVE  SYSTEM. 

cffimia,  or  they  may  set  up  inflammation  in  other  organs,  particularly  the 
kidneys. 

The  pathological  relation  existing  between  the  different  forms  of 
diarrhceal  disease  is  a  very  close  one.  The  same  case  may  pass  succes- 
sively through  the  stages  of  acute  indigestion,  gastro-enteric  intoxica- 
tion, and  ileo-colitis.  This  transition  may  be  very  slow,  or  it  may  be  so 
rapid  that  the  different  stages  can  not  be  distinguished.  Instead  of 
passing  through  the  entire  series,  the  process  may  stop  at  any  stage  and 
the  case  recover,  or  it  may  at  any  stage  prove  fatal. 

ACUTE   INTESTIXAL  INDIGESTION". 

In  infants,  acute  indigestion  is  seldom  limited  either  to  the  stomach 
or  to  the  intestine,  although  in  one  case  the  disturbance  of  the  stomach 
is  slight  and  that  of  the  intestine  serious,  and  in  another  the  reverse  may 
be  observed.  In  these  little  patients  the  intestinal  symptoms  are  much 
more  frequent,  and  as  a  rule  they  are  more  severe  than  those  referable  to 
the  stomach.  There  will  be  considered  in  this  connection  only  the  intes- 
tinal symptoms  of  acute  indigestion ;  the  gastric  symptoms  have  been 
described  on  page  331.  It  should  be  remembered  that  these  may  be  seen 
in  all  possible  combinations.  In  older  children  it  is  not  uncommon  to 
see  the  intestinal  symptoms  alone. 

Etiology.- — The  causes  are  essentially  the  same  as  those  mentioned 
under  Acute  Gastric  Indigestion — the  use  of  improper  food,  over-feeding, 
sudden  change  of  food  as  in  weaning,  or  the  change  from  some  other  food 
to  a  rich  breast-milk;  also  various  conditions  affecting  the  nervous  sys- 
tem, such  as  heat,  cold,  fatigue,  or  the  onset  of  any  acute  disease.  A  pre- 
disposition to  such  attacks  is  furnished  by  summer  weather,  a  delicate 
constitution,  a  feeble  digestion,  and  b}^  previous  attacks  of  any  intestinal 
disorder.  In  susceptible  children,  both  infants  and  those  who  are  older, 
the  slightest  error  in  feeding  may  induce  an  attack. 

Symptoms. — lii  infants,  if  the  attack  develops  suddenly,  gastric 
symptoms  are  usually  present;  if  more  gradualh',  they  are  usually  ab- 
sent. The  local  symptoms  are  colicky  pain,  tympanites,  and  later  diar- 
rhoea. The  important  constitutional  symptoms  are  fever,  prostration, 
and  various  nervous  disturbances.  In  older  children  the  pain  generally 
precedes  the  diarrhoea  by  some  hours,  and  is  referred  to  the  region  of 
the  umbilicus.  Pain  is  indicated  by  the  sharp,  piercing  cry,  great  rest- 
lessness, and  drawing  up  of  the  legs.  Tympanites  is  rarely  very  marked, 
and  may  be  wanting. 

The  stools  are  always  increased  in  number  and  are  from  four  to 
twelve  a  day.  If  more  frecpient  they  are  very  small.  The  first  stools  are 
more  or  less  fsecal,  but  this  character  is  soon  lost.  In  infancy  the  colour 
is  first  yellow,  then  yellowish-green,  and  finally  often  grass-green.    Vlog- 


ACUTE  INTESTINAL   INDIGESTION.  355 

scheider  lias  shown  that  this  colour  is  due  to  biliverdin.  The  exact  na- 
ture of  the  process  in  the  intestine,  in  consequence  of  which  biliverdin 
takes  the  place  of  bilirubin  as  the  colouring  matter  of  the  stools,  is  still 
a  disputed  point,  but  in  infancy  this  change  in  colour  is  nearly  constant. 
The  reaction  of  the  stools  is  almost  invariably  acid.  The  odour  may  be 
sour,  or  it  may  be  very  foul.  The  stools  are  much  thinner  than  normal, 
and  frothy  from  the  presence  of  gases.  Blood  is  not  present,  nor  is 
mucus  seen,  unless  the  symptoms  have  lasted  several  days.  Undigested 
food  is  always  present ;  in  infants  upon  a  milk  diet,  this  occurs  as  fat  or 
lumps  of  casein.  Fat  may  appear  as  small,  yellowish-white  masses  re- 
sembling casein,  but  distinguished  by  their  solubility  in  equal  parts  of 
alcohol  and  ether.  Casein  masses  are  more  numerous,  larger,  and 
whiter.  Unchanged  starch  may  be  recognised  by  the  iodine  reaction. 
The  microscope  shows,  in  addition  to  food-remains,  mucus,  epithelial 
cells,  and  bacteria.  Epithelial  cells,  usually  of  the  cylindrical  variety, 
are  numerous  in  proportion  to  the  severity  and  duration  of  the  attack. 
The  bacteria  are  the  ordinary  forms  found  in  the  faeces  (Booker). 

In  the  cases  with  sudden  onset  the  temperature  is  invariably  elevated. 
In  infants  it  ranges  from  102°  to  105°  F. ;  in  older  children  from  100°  to 
103°  F.  The  high  temperature  does  not  continue.  Usually  after  twelve 
or  twenty-four  hours  it  falls  nearly  or  quite  to  normal.  In  the  cases  with 
.a  more  gradual  onset,  or  in  those  of  a  less  severe  character,  the  tempera- 
ture does  not  often  go  above  101°  F.  The  general  prostration,  like  the 
temperature,  is  greatest  in  infants  and  in  the  cases  beginning  abruptly. 
It  is  sometimes  so  severe  as  to  threaten  life.  Tliere  are  rapid  pulse,  pal- 
lor, drawn  features,  and  general  muscular  weakness.  There  may  be  rest- 
lessness, due  to  pain  and  the  general  discomfort,  or  there  may  be  dul- 
ness,  apathy,  or  convulsions. 

The  course  and  termination  of  the  disease  depend  upon  the  previous 
condition  of  the  patient,  the  nature  of  the  exciting  cause,  and  the  treat- 
ment employed.  In  a  previously  healthy  child,  if  the  cause  is  at  once  re- 
moved and  proper  treatment  instituted,  the  severe  symptoms  rarely  last 
more  than  a  day  or  two,  and  in  four  or  five  days  the  patient  may  be  quite 
well.  In  delicate  infants,  a  severe  attack  of  acute  intestinal  indigestion 
in  the  hot  season  is  likely  to  prove  the  first  stage  of  a  pathological  pro- 
cess whjcli  may  continue  until  serious  organic  clianges  in  the  intestine 
Iiavc  taken  phice.  Tliis  result  may  not  f<»1l<iw  (ho  first  attack.  Imt  one  is 
often  succeeded  by  others  until  it  occurs.  If  firuumstances  are  such  that 
]iroper  dietetic  treatment  and  general  liygienic  measures  can  not  be  car- 
rie(l  out,  this  teniiinnl  ion  is  very  common. 

Diagnosis. — 11  i-  iiiipossiljle  to  recognise  an  attack  of  acute  intestinal 
indigestion  until  the  diarrh(ea  begins;  tlie  previous  symptoms  of  fever, 
prostration,  etc..  are  seen  in  many  infantile  diseases.  From  the  other 
forms  of  diaiTlio'n.  tliis  is  (li<t  ini^ni^lied  liv  its  brief  dvration,  although  its 


350  DISEASES   OF   TEE   DIGESTIVE   SYSTEM. 

symptoms  may  be  very  alarming.  The  nervous  symptoms  are  usually 
less  marked  than  in  gastro-enteric  intoxication,  and  vomiting  is  less  fre- 
quent. 

Prognosis. — Such  attacks  do  not  endanger  life  except  in  very  young 
or  very  delicate  infants,  in  whom  they  may  be  fatal.  The  worst  feature 
of  most  cases  is  that  such  attacks  predispose  to  more  serious  intestinal 
diseases,  many  of  which  have  their  origin  in  acute  indigestion  which  has 
been  either  neglected  or  badly  managed. 

Treatment. — The  same  general  plan  is  to  be  followed  as  in  cases  of 
gastric  indigestion — viz.,  first  to  empty  the  bowels  as  completely  as  pos- 
sible of  all  decomposing  or  irritating  masses  of  food;  secondly,  to  secure 
to  the  patient,  and  especially  to  the  digestive  organs,  as  complete  rest  as 
possible.  For  the  first  indication  nothing  is  better  than  calomel,  which 
may  be  given  in  one-eighth-grain  doses,  and  repeated  every  hour  until 
the  full  efi'ect  is  seen.  Any  other  active  purge,  such  as  castor  oil  or 
syrup  of  rhubarb,  may  be  substituted.  Thirst  is  always  great  on  account 
of  the  fever  and  the  loss  of  fluid  by  the  stools,  but  digestion  even  in  the 
stomach  is  feeble,  and  often  arrested  altogether.  For  the  first  twenty- 
four  hours  no  plan  succeeds  better  than  that  of  withholding  everything 
in  the  shape  of  food,  giving  to  allay  thirst  such  articles  as  whey,  albu- 
min-water, mineral  waters,  or  cold  boiled  water.  Small  quantities  must 
be  given — i.  e.,  one  to  four  teaspoonfuls — but  the  interval  may  be  as 
short  as  ten  or  fifteen  minutes.  If  the  prostration  is  very  great,  stimu- 
lants may  be  needed.  Brandy  is  the  best  form  for  their  administration. 
After  the  offending  materials  have  all  been  swept  from  the  intestine,  but 
never  before,  opium  may  be  given  in  doses  large  enough  to  control  the  ex- 
cessive catharsis.  For  a  child  a  year  old,  one-quarter  grain  of  Dover's 
powder  after  each  stool  is  usually  sufficient,  and  often  a  smaller  dose 
may  answer  the  purpose. 

The  difficult  problem  is  to  feed  these  cases  during  the  latter  part  of 
the  attack.  In  nursing  infants,  the  breast  may  be  begun  after  twenty- 
four  hours,  the  nursing  interval  being  six  hours,  and  the  time  of  one 
nursing  not  longer  than  five  minutes.  Between  the  nursings  other 
food  may  be  given.  In  the  case  of  infants  past  the  nursing  age,  or  those 
who  are  being  artificially  fed,  cow's  milk  must  be  withheld  in  all  forms 
for  five  or  six  days,  and  the  child  kept  upon  a  diet  of  broths,  farinaceous 
or  malted  foods.  As  improvement  continues  milk  may  be  cautiously 
and  very  gradually  added,  at  first  to  one  or  two  feedings  each  day,  and 
later  to  every  feeding.  It  should  be  boiled.  Since  the  fat  is  especially 
likely  to  cause  disturbance,  diluted  milk  is  better  than  a  milk-and-cream 
mixture.  In  some  cases  there  is  an  advantage  in  using  partially  or  com- 
pletely peptonized  milk  (page  154). 

The  diet  of  older  children  in  the  acute  stage  should  be  much  like  that 
of  infants.     Later  it  should  consist  of  meat,  broths,  eggs,  boiled  milk. 


ACUTE   GASTRO-EXTERIC   IXTOXICATIOX.  357 

and  a  small  quantity  of  dried  bread.  All  cereals,  vegetables,  and  espe- 
cially all  fruits,  should  be  withheld  for  some  time,  and  then  given  only  in 
small  quantities,  and  the  effect  on  the  stools  closely  watched.  Kumyss 
and  matzoon  are  frequently  better  borne  than  plain  milk. 

The  use  of  drugs  in  these  attacks,  except  those  already  referred  to  as 
indicated  during  the  early  stage,  seems  to  me  to  influence  the  disease 
very  little.  Sometimes  good  results  follow  the  giving  of  the  extractum 
pancreatis  half  an  hour  after  meals,  or  some  of  the  preparations  of 
malt  when  farinaceous  food  is  first  allowed.  If  the  diarrhoea  following 
the  acute  symptoms  is  prolonged  or  excessive,  it  usually  indicates  that 
either  intestinal  infection  or  inflammation  is  present,  and  the  case 
should  be  treated  accordingly.  General  measures,  especially  rest,  fre- 
quent bathing,  fresh  air,  and  change  of  air,  are  very  important  in  the 
management  of  all  these  cases,  especially  when  they  occur  during  the 
summer. 


CHAPTER    YII. 

DISEASES  OF  THE  INTESTINES.— {Continued.) 

ACUTE   GASTRO-ENTERIC  INTOXICATION. 

Synonyms:  Summer  diarrhoea,  gastro-intestinal  catarrh,  gastro-enteritis, 
cholera  infantum,  mycotic  diarrhoea. 

This  is  the  form  of  diarrhcea  which  is  so  prevalent  in  summer.  It 
occurs  regularly  each  season,  being  epidemic  in  most  large  cities  of  the 
temperate  zone.  The  lesions  in  the  intestines  are  slight,  amounting  in 
most  cases  only  to  a  superficial  catarrhal  inflammation,  often  bearing  no 
relation  to  the  severity  of  the  symptoms  which  are  due  mainly  to  the 
absorption  of  toxic  materials,  the  result  of  the  putrefactive  changes  in 
the  stomach  and  intestine.  This  form  of  diarrhcea  may  follow  closely 
upon  an  attack  of  acute  indigestion,  in  which  it  very  often  has  its  begin- 
ning. When  the  infection  is  of  sufhcient  intensity  and  duration,  it  leads 
to  the  development  of  marked  structural  c-liangcs  in  the  intestine,  espe- 
cially in  the  lower  ileum  and  the  colon.  Acute  gastro-enteric  intoxica- 
tion thus  stands  midway  between  acute  indigestion  and  ileo-colitis. 

Etiology. — Among  the  causes  of  acute  gastro-enteric  intoxication  are 
to  be  mentioned,  first,  those  which  give  rise  to  acute  indigestion,  and, 
secondly,  the  general  factors  mentioned  as  predisposing  to  all  forms  of 
diarrhceal  disease — age,  surroundings,  constitution,  food,  and  methods 
of  feeding.  (See  page  349.)  The  most  striking  thing  about  these  cases  is 
their  prevalence  during  hot  weather;  hence  this  feature  demands  a  closer 
examination.  While  all  varieties  of  diarrhoea  are  more  frequent  in  sum- 
mer, it  is  the  form  under  consideration  which  is  especially  prevalent. 


358  DISEASES   OP  THE  DIGESTIVE  SYSTEM. 

Year  after  year  are  repeated  in  New  York  the  conditions  which  are  graph- 
ically represented  in  the  charts  on  pages  349  and  350 — viz.,  an  epidemic 
which,  beginning  in  June,  rapidly  increases  in  severity,  reaching  its 
height  in  July,  from  which  time  it  diminishes  steadily  during  August 
and  September,  regularly  coming  to  an  end  in  October.  What  is  true 
of  jSTew  York  is  true  also  of  Philadelphia,  Baltimore,  and  other  large 
American  cities,  as  well  as  of  Berlin  and  other  cities  of  central  Europe. 
A  study  of  these  charts  shows  that  while  the  mean  temperature  rises 
gradually  during  April  and  May,  it  is  not  until  June  is  reached  with  its 
mean  temperature  of  61°  F.,  that  any  notable  increase  in  diarrhceal  dis- 
eases begins.  It  appears  then  that  an  average  mean  temperature,  or, 
according  to  Seibert,  an  average  minimum  temperature,  of  about  60°  F. 
is  needed  to  start  the  epidemic.  Kot  many  cases  are  seen  until  such  a 
temperature  has  lasted  for  some  days,  usually  about  a  week.  The  epi- 
demic then  begins  in  force  and  increases  in  severity  through  July.  The 
explanation  of  the  high  mortality  of  this  month  appears  to  be,  not  the 
4°  or  5°  F.  by  which  the  temperature  of  July  exceeds  that  of  June  and 
August,  but  that  the  majority  of  the  susceptible  infants  are  unable  to 
withstand  the  first  very  hot  month.  Humidity  and  rainfall,  according  to 
the  careful  investigations  of  both  Seibert  in  New  York  and  Baginsky  in 
Berlin,  do  not  influence  either  the  prevalence  of  summer  diarrhoea  or 
its  mortality. 

The  action  of  heat  in  producing  diarrhoea  was  formerly  regarded  as  a 
direct  one.  The  worst  cases  were  looked  upon  as  examples  of  heat-stroke 
or  thermic  fever.  There  is  no  doubt  that  the  constitutional  depression 
produced  by  high  atmospheric  temperature  may  seriously  interfere  with 
digestion,  and  that  sometimes  the  thirst  which  excessive  perspiration 
produces  may  lead  to  the  giving  of  too  much  food,  which  also  may  be 
a  cause  of  indigestion.  While  this  explanation  may  be  satisfactory  for  a 
small  proportion  of  the  cases,  it  is  not  adequate  for  the  great  majority. 
The  view  almost  universally  held  at  the  present  time  regarding  summer 
diarrhoea  is  that  it  is  of  infectious  origin.  The  grounds  for  this  opinion 
are  briefly  as  follows:  A  certain  temperature  is' required,  which  is  the 
same  as  that  at  which  the  growth  of  bacteria  begins  to  be  very  active. 
This  disease  prevails  to  the  extent  to  which  other  food  than  breast-milk 
is  given  to  infants.  Thus  it  affects  infants  after  weaning,  and  those 
younger  who  are  partly  or  entirely  fed  upon  cow's  milk,  or  at  least  who 
are  not  nursed.  Cow's  milk,  as  ordinarily  handled,  contains  in  summer 
an  enormous  number  of  bacteria,  which  increase  directly  with  the  age 
of  the  milk  and  the  height  of  the  temperature  at  which  it  is  kept.  De- 
spite the  fact  that  since  1886  many  series  of  bacteriological  studies  of 
the  intestinal  discharges  have  been  made  by  Booker  in  this  country,  by 
Baginsky,  Escherich,  and  their  pupils,  and  by  others  in  Germany,  our 
knowledge  of  this  subject  is  still  very  incomplete.     The  conditions  are 


ACLTTE   GASTRO-ENTERIC   INTOXICATION.  359 

exceeding!}'  complicated,  and  the  problem  is  therefore  a  difficult  one. 
It  is  now  pretty  generally  agreed  that,  from  a  bacteriological  point  of 
view,  two  kinds  of  infection  must  be  considered,  and  that  these  diar- 
rhceas  may  be  the  result  of  infection  either  from  without  or  from  within. 

It  has  been  established  that  infection  from  without  is  sometimes  due 
to  the  streptococcus  (Escherich,  Libman,  Hirsch,  et  al.),  and  sometimes, 
although  rarely,  to  the  bacillus  pyocyaneus ;  the  claims  of  the  bacillus  of 
Shiga,  the  proteus,  the  colon  bacillus,  and  the  staphylococcus  have  also 
been  urged  as  etiological  factors.  These  and  other  varieties  of  bacteria, 
chiefly  saprophytic,  may  be  introduced  with  water,  milk,  or  other  food, 
and  it  is  possible  that  some  of  those  not  ordinarily  pathogenic  may, 
under  favourable  conditions,  become  so. 

Infection  from  within — auto-infection — may  result  from  the  devel- 
opment of  pathogenic  properties  in  bacteria  normally  present  in  the 
intestine ;  or  j)oisonous  substances  may  be  produced  by  chemical  changes 
in  the  food  elements  through  the  agency  of  bacteria,  which,  although 
occasionally  or  habitually  present  in  the  intestines,  are  not  active.  The 
change  in  the  action  of  bacteria  and  in  the  nature  of  their  products  is 
dependent  upon  the  altered  conditions  there  existing,  viz.,  imperfect 
digestion  and  delayed  absorption. 

There  are  other  cases  in  which  toxic  sj'mptoms  of  a  severe  type  de- 
velop abruptly  in  children  previously  quite  well.  Vaughan  and  others 
have  demonstrated  in  the  milk  which  children  suffering  from  such  symp- 
.  toms  have  taken,  toxic  substances  capable  of  producing  in  animals  symp- 
toms resembling  a  severe  attack  of  cholera  infantum.  Although  the 
bacteria  in  such  milk  may  have  been  previously  destroved  by  steriliza- 
tion, the  toxins  produced  by  them  are  still  present,  and  are  not  affected 
by  the  subsequent  heating.  This  is  doubtless  the  usual  explanation  of 
the  simultaneous  development  of  several  cases  of  acute  milk  poisoning 
in  a  family  or  an  institution. 

As  to  the  nature  of  the  poisons  produced  liy  the  action  of  the  intes- 
tinal bacteria,  not  much  is  as  yet  definitely  known.  There  is,  however, 
considerable  evidence  that  the  most  important  of  them  are  acid  in  char- 
acter, and  the  conditions  present  arc  included  by  some  writers  among 
the  acid  intoxications  of  the  body.  AVe  are  as  yet  unable  to  connect 
closely  the  variety  of  bacterial  infection  and  the  clinical  form  of  the 
disease.  Stre])tococci  may  be  associated  with  mild  or  severe  cases,  and 
sometimes  with  those  of  the  cholera-infantum  type.  The  clinical  type 
seems  to  depend  less  upon  tlio  variety  of  l^acteria  than  upon  the  viru- 
lence of  the  infection,  and  other  conditions,  such  as  the  state  of  the 
mucous  membrane,  the  nature  of  the  intestinal  contents,  and  the  re- 
sistance of  the  patient. 

While  these  findings  do  not  solve  all  the  questions  of  the  etiology  of 
these  conditions,  they  have  shed  light  upon  them.    The  theory  that  many 


360  DISEASES   OF   THE  DIGESTIVE  SYSTEM. 

of  these  cases  are  due  to  auto-infection  explains  why  serious  attacks  may 
occur  while  the  diet  is  pure  fresh  milk,  sterilized  milk,  or  even  breast- 
milk;  also  why  functional  disturbance  so  often  precedes  symptoms  of 
infection. 

With  our  present  knowledge  we  can  not  believe  that  direct  contagion 
is  the  usual  way  in  which  this  disease  is  spread.  When  occurring  in  in- 
stitutions or  in  families,  it  usually  happens  that  a  number  of  children 
are  attacked  simultaneously  rather  than  successively,  this  indicating  a 
common  cause,  usually  to  be  found  in  the  food.  However,  we  know 
enough  about  the  spread  of  typhoid  fever  and  cholera  from  faecal  dis- 
charges, to  appreciate  the  importance  of  careful  disinfection  of  all  stools 
and  napkins,  particularly  in  institutions. 

Relation  of  the  different  etiological  factors. — The  predisposition  to 
attacks  of  summer  diarrhoea  is  partly  general  and  parth'  local.  The  gen- 
eral influences  are  age  (under  two  years),  feeble  constitution,  unhygienic 
surroundings,  and  a  condition  of  general  malnutrition  dependent  upon 
improper  food  or  feeding.  The  most  important  of  the  local  causes  is  a 
previous  derangement  of  digestion,  usually  the  result  of  improper  feed- 
ing. In  addition  there  may  be  present  a  low  grade  of  catarrhal  inflam- 
mation. The  exciting  cause  of  an  attack  may  be  acute  indigestion.  In 
consequence  of  undigested  food  decomposing  in  the  stomach  or  intes- 
tines there  are  furnished  conditions  in  which  bacteria,  previously  present 
in  small  numbers,  may  multiply  very  rapidly ;  or  those  previously  present 
as  saproph3'tes  may  become  pathogenic;  bacteria  may  be  introduced  in 
such  numbers  and  of  such  virulence  as  to  overpower  the  digestive  or- 
gans ;  or,  finally,  bacterial  products  may  be  ingested  with  the  food,  re- 
quiring only  absorption  to  produce  their  effects. 

Lesions. — The  statements  which  follow  are  based  upon  a  study  of 
forty  autopsies,  in  twentj'-two  of  which  microscopical  examinations  were 
made.  The  lesion  may  be  briefly  described  as  a  superficial  catarrhal  in- 
flammation affecting  the  entire  gastro-enteric  tract,  although  it  varies 
much  in  severity  in  the  different  regions  and  in  the  different  cases.  The 
colon,  the  lower  ileum,  and  the  stomach,  are  apt  to  suffer  most,  the 
duodenum  and  the  jejunum  least. 

The  gross  appearances. — These  are  usually  disappointing,  and  may 
often  show  but  little  that  is  abnormal.  The  stomach  is  distended  with 
gas,  and  contains  undigested  food.  Its  walls  may  be  coated  with  mucus. 
The  upper  part  of  the  small  intestine  is  empty.  The  lower  portion  con- 
tains particles  of  food,  and  yellow,  gray,  or  green  material,  often  offen- 
sive, resembling  the  stools  passed  during  life.  The  transverse  colon,  the 
cfficum,  and  sigmoid  flexure  are  apt  to  be  distended  with  gas,  and  contain 
material  similar  to  those  mentioned,  while  the  rest  of  the  large  intes- 
tine is  usually  empty  and  its  walls  contracted.  It  may  be  coated  with 
mucus.     The  mucous  membrane  of  the  stomach  mav  show  intense  con- 


ACUTE   GASTRO-ENTERIC   INTOXICATION.  301 

gestion,  generally  in  patches,  or  it  may  be  pale.  The  mucous  membrane 
of  the  small  intestine  may  be  pale  throughout ;  there  are  often  irregular 
areas  of  congestion,  or  a  very  intense  congestion  of  a  large  part  of  its 
surface,  particularly  in  the  ileum.  With  this  there  may  be  redness  and 
swelling  of  Peyer's  patches  and  the  lym|)h  nodules  (solitary  follicles). 
In  the  colon  the  mucous  membrane  is  congested,  especially  upon  the 
rugaj.  This  congestion  may  be  general  or  in  patches.  The  lymph  nod- 
ules are  usually  swollen;  but  this  may  be  due  to  an  antecedent  process, 
and  not  to  the.  final  attack.  There  is  no  thickening  of  the  intestinal 
walls.  The  changes  described  are  not  at  all  uniform,  and  do  not  differ 
very  greatly  from  the  appearances  often  seen  in  the  intestines  when 
patients  have  died  of  other  diseases. 

In  the  eases  classed  clinically  as  cholera  infantum,  the  pathological 
changes  are  more  characteristic.  The  greater  part  of  the  small  intes- 
tine, and  sometimes  the  entire  colon,  are  distended  with  gas,  and  contain 
material  of  a  grayish-white  colour  about  the  consistency  of  a  thin  gruel. 
It  has  a  mawkish  odour,  but  usually  not  a  very  offensive  one.  The  mu- 
cous membrane  of  the  entire  intestinal  tract  has  in  most  cases  a  pale, 
"  washed-out  "  appearance.  Sometimes  this  is  seen  only  in  the  small  in- 
testine, while  there  are  areas  of  congestion  in  the  colon.  If  cholera  in- 
fantum has  been  ingrafted  upon  some  other  pathological  process  in  the 
intestines,  as  is  not  infrequent,  there  is  found  post-mortem  evidence  of 
this  in  the  form  of  severe  catarrhal  inflammation,  sometimes  old  ulcera- 
tions. In  some  cases,  where  the  sj'mptoms  have  been  those  of  choleri- 
form  diarrhoea,  there  are  found  evidences  of  an  intense  diffuse  gastro- 
enteritis, as  shown  by  congestion  of  the  stomach  and  almost  the  entire 
intestinal  tract,  with  swelling  of  the  mucous  membrane,  and  especially 
of  Payer's  patches. 

The  microscopical  appearances. — Unless  autopsies  are  made  very 
soon  after  death — at  least  within  four  hours — it  is  not  safe,  in  most  of 
the  cases,  to  draw  conclusions  from  the  conditions  found;  as  post- 
mortem changes  take  place  so  readily  in  the  intestines,  and  these 
changes  are  so  like  those  of  the  disease  under  consideration.  This  ap- 
plies particularly  to  the  condition  of  the  epithelium.  One  should  also 
be  cautious  in  interpreting  the  appearances  of  portions  of  the  intestine 
wdiich  have  been  greatly  distended  with  gas. 

The  essential  lesion  consists  in  degenerative  changes  in  the  epithe- 
lium of  the  stomach  and  intestines.  The  cells  may  still  be  present,  but 
witli  tlic  cell  pr()t(>])]asm  and  nuclei  so  clinngcd  (hat  tlicy  do  not  stain 
normally.  Bacteria  are  found  in  the  ejiithclial  layer  and  in  the  upper 
portion  of  the  crypts  of  Lieberkiihn.  In  more  severe  and  prolonged 
cases  the  superficial  epithelium  in  places  is  entirely  destroyed,  and 
through  such  breaks  the  bacteria  can  be  seen  penetrating  into  the  deeper 
structures  of  the  intestine  (Plate  VIII,  B)  ;  these  changes  mark  the 


362  DISEASES   OF   THE  DIGESTIVE  SYSTEM. 

beginning  of  ileo-colitis.  In  simple  intestinal  intoxication  the  bacteria 
are  not,  as  a  rule,  found  in  the  deeper  structure  of  the  intestines  nor  in 
the  lymph  nodes  of  the  mesenter\-.  Unless  autopsies  are  made  immedi- 
ately after  death,  little  significance  can  be  attached  to  the  presence  of 
bacteria,  particularly  the  colon  bacillus  in  the  deeper  layers  of  the  intes- 
tine, in  the  other  organs,  or  in  the  blood. 

The  changes  in  and  about  the  blood-vessels  are  variable.  The  small 
vessels  may  be  distended,  and  there  may  be  haemorrhages  or  an  exuda- 
tion of  leucocytes  in  their  neighbourhood.  These  appearances  are  seen 
either  in  the  mucous  or  submucous  layer.  The  exudation  from  the 
blood-vessels  is  usually  slight,  and  in  many  cases  is  wanting.  Peyers 
patches  and  the  lymph  nodules  may  be  enlarged  from  cell-proliferation. 
Pathologically  no  sharp  line  can  be  drawn  between  these  lesions  and 
those  of  the  early  stage  of  ileo-colitis  :  the  latter  affect  the  lower  ileum 
and  colon  chiefly,  often  exclusively,  are  more  advanced,  and  involve  the 
deeper  parts  of  the  intestinal  wall. 

Lesions  in  other  organs. — These  are  much  less  frequent  and  less 
severe  than  in  the  more  protracted  eases  of  ileo-colitis.  Acute  bronchitis 
and  broncho-pneumonia  are  frequent.  Acute  degeneration  of  the  kid- 
ney is  found  to  some  degree  in  every  case  which  is  severe  enough  to 
cause  death,  and  in  a  few  there  is  acute  diffuse  nephritis.  In  rare  cases 
a  general  septicaemia,  due  most  frequently  to  the  streptococcus,  is  pres- 
ent with  its  usual  manifestations.  Degenerative  changes  are  sometimes 
found  in  the  liver  cells,  and  even  in  the  nervous  centres.  Some  of  these 
lesions  are  accidental,  while  others  are  the  direct  result  of  the  circulation 
in  the  blood  of  toxins  derived  from  the  intestines. 

Clinically,  there  are  two  C[uite  distinct  forms  of  gastro-enteric  intoxi- 
cation, which  will  be  separately  considered — (1)  the  simple  form  and 
(2)  true  cholera  infantum. 

Simple  Gasteo-Exteeic  Ixtoxicatiox. — There  are  seen  in  infants 
mild  cases  with  a  gradual  onset,  little  or  no  fever,  and  no  gastric  dis- 
turbance, and  severe  cases  with  a  sudden  onset,  usually  attended  by  high 
temperature  and  by  vomiting.  In  the  mild  form  the  symptoms  of  in- 
testinal indigestion  usually  precede.  The  children  may  be  peevish  and 
fretful — especially  at  night — and  may  seem  generally  out  of  sorts,  while 
the  stools  are  abnormal.  From  the  fact  that  the  general  symptoms  are 
so  few,  such  cases  are  often  allowed  to  go  on  for  several  da3^s,  under 
the  impression  that  the  children  are  "  only  teething."  The  stools  grad- 
ually become  more  frec|uent;  they  are  thin,  green,  yellow,  or  brown, 
and  always  contain  undigested  food.  After  a  time  the  odour  becomes 
offensive,  and  mucus  is  present.  The  infants  become  pale,  their  limbs 
grow  soft  and  flabby,  they  lose  their  spirits,  are  fretful,  sleep  badly, 
and  the  scales  may  show  a  steady  loss  in  weight. 

With  proper  treatment  most  of  the  cases  recover  after  active  symp- 


ACUTE   G ASTRO-ENTERIC   INTOXICATION. 


363 


toms  lasting  from  one  to  three  weeks,  although  it  may  be  one  or  two 
months  before  a  steady  gain  in  weight  begins  (Fig.  63).  Severe  symp- 
toms may,  however,  supervene  at  any  time,  and  the  attack  become  one  of 
the  eholera-infantum  type.  This  often  takes  place  with  great  sudden- 
ness, and  is  frequently  coincident  with  a  few  days  of  very  hot  weather,  or 


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Fig.  63. —  Weight  curve  of  artificially  fed  infant  for  the  first  year,  showing  the  effect  of  acute 
gastro-ent'eric  intoxication.  Konnal  proo:ress  until  A^  acute  attack  witli  fever:  B,  acute 
symptoms  relieved,  but  continued  intestinal  indigestion;  C,  digestion  practically  normal, 
and  child  put  back  upon  its  nioditied-milk  food. 

follows  some  gross  dietetic  error.  In  other  cases  the  symptoms  may 
continue  with  the  gradual  formation  of  follicular  ulcers,  the  case  becom- 
ing one  of  ileo-colitis.  The  entire  illness  may  continue,  with  exacerba- 
tions and  remissions,  until  the  cool  weather  of  autumn. 

In  the  cases  developing  suddenly,  the  clinical  picture  is  quite  a  differ- 
ent one.  The  attack  may  begin  abruptly  in  a  child  previously  healthy, 
or  there  may  have  been  for  some  days  a  slight  intestinal  derangement.  If 
an  infant,  it  is  restless,  cries  much,  sleeps  but  a  few  minutes  at  a  time,  and 
seems  in  distress.  The  skin  is  hot  and  dr}',  the  temperature  rises  rapidly 
to  102°  or  103°  F.,  sometimes  to  106°,  and  all  the  symptoms  indicate  the 
onset  of  some  serious  illness.  The  infant  may  lie  in  a  dull  stupor,  with 
eyes  sunken,  weak  pulse,  and  general  relaxation,  or  there  may  be  rest- 
lessness, excitement,  or  even  convulsions.  There  may  be  great  thirst,  so 
that  everything  offered  is  eagerly  taken,  or  everything  may  be  refused. 
Vomiting  may  be  an  early  and  important  symptom.  It  is  first  of  food, 
often  that  which  was  taken  many  hours  before;  retching  continues  even 
after  the  stomach  has  been  emptied,  so  that  mucus,  serum,  and  some- 


364  DISEASES   OP   THE   DIGESTIVE   SYSTEM. 

times  bile  ma}^  be  ejected.  It  does  not  usually  persist  throughout  the 
attack,  and  in  many  cases  it  is  absent  altogether.  Diarrhoea  is  some- 
times delayed  for  twenty-four  hours  or  even  longer  after  the  beginning 
of  the  grave  constitutional  symptoms.  At  first  there  are  fgecal  stools, 
then  great  bursts  of  flatus,  with  the  expulsion  of  a  thin  yellow  material 
with  an  offensive  odour.  Four  or  five  such  discharges  may  occur  in  as 
many  hours.  At  other  times  the  stools  are  gray,  green,  or  greenish-yel- 
low, and  sometimes  brown.  They  often  do  not  differ  at  first  from  those 
of  an  ordinary  attack  of  acute  intestinal  indigestion.  The  characteristic 
features  are  the  amount  of  the  gas  expelled,  the  colicky  pains  preceding 
the  discharges,  and  the  foul  odour.  After  the  first  day  the  stools  may 
be  almost  entirely  fluid,  varying  in  number  from  six  to  twenty  a  day, 
and  often  large  even  then.  Their  offensive  character  usually  continues. 
After  two  or  three  days  mucus  may  appear.  The  microscopical  examina- 
tion of  the  stools  shows,  besides  the  things  mentioned  in  the  stools  of 
acute  indigestion,  great  numbers  of  separate  epithelial  cells,  and  some- 
times groups  of  cells  attached  to  a  basement  membrane.  In  addition 
there  may  be  round  cells  and  some  red  blood-corpuscles. 

If  stained  for  bacteria  after  Escherich's  *  method,  the  number  of 
colon  bacilli  is  usually  found  to  be  diminished,  while  many  new  forms, 
chiefly  cocci  in  groups  or  chains,  are  present.     (See  Plate  VIII,  A.) 

In  many  cases  the  free  evacuation  of  the  bowels  is  followed  by  a 
drop  in  the  temperature  and  subsidence  of  the  nervous  symptoms,  and 
the  child  may  fall  asleep,  to  awaken  after  a  few  hours  for  a  stool.  The 
prostration,  though  often  great  in  the  beginning,  may  not  be  of  long 
duration.  Under  the  most  favourable  circumstances,  after  one  or  two 
days  of  severe  symptoms,  the  case  may  go  on  to  a  rapid  convalescence. 
The  stools  continue  abnormally  frequent  for  five  or  six  days,  hut  grad- 
ually assume  their  normal  character,  and  recovery  follows.     The  chief 

*  Escherich's  stain,  which  is  a  modification  of  Grain's  method,  is  as  follows:  Solu- 
tions needed :  (1)  Aqueous  gentian  violet,  5  :  200,  boiled  one-half  hour  and  filtered  ; 
(2)  absolute  alcohol  11  parts,  aniline  oil  3  parts.  The  stain  is  made  by  mixing  (1)  and 
(2)  in  the  proportion  of  85  to  15 ;  it  will  keep  two  or  three  weeks.  {?>)  Iodine  1  part, 
potassium  iodide  2  parts,  and  water  GO  parts;  (4)  equal  parts  of  aniline  oil  and  xylol; 
(5)  pure  xylol ;  (6)  concentrated  solution  of  fuchsine  in  alcohol,  diluted  with  an  equal 
quantity  of  absolute  alcohol. 

The  faeces  or  bacteria  are  spread  thin  on  a  slide,  fixed  in  a  flame,  and  the  stain 
dropped  on.  It  is  dried  in  a  few  moments  with  filter  paper,  the  iodine  solution  is 
poured  on,  and  quickly  removed  with  the  paper.  The  specimen  is  now  thoroughly 
decolorized  with  aniline-xylol ;  pure  xylol  is  then  poured  on,  and  the  slide  dried. 
The  fuchsine  solution  is  now  applied,  but  immediately  washed  off  thoroughly  with 
water.  After  drying,  the  specimen  is  ready  for  examination.  The  cocci  stain  blue, 
the  colon  bacilli  red.  Escherich  states  that  in  normal  stools  of  breast-fed  infants 
most  of  the  colon  bacilli  resist  the  iodine  solution  and  remain  blue,  while  in  diarrhoeal 
stools  the  colon  bacilli  are  decolorized  and  take  the  red  stain. 


PLATE    VIII. 


.V 


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Intestinal  I'acteria,  and  Lksions  of  Ileo-colitis. 

A.  Escherich's  douhlc  slain  for  inicstinal  diachargos  ;  cocci  in  chains  and  masses  are  stained  bine, 
bacilli  red. 

B.  Early  lesions  of  ileo-colitis,  showint^  the  breaking  down  of  the  superficial  epithelium,  and  the 
penetration  of  the  bacteria  into  the  deeper  structures  of  the  mucosa.    (Booker.) 

C.  More  advanced  lesions  in  the  colon  ;  the  epithelium  is  destroyed,  the  upper  part  of  the  mucosa 
is  degenerated,  infiltrated  with  round  cells,  and  contains  immense  numbers  of  bacteria.    (Booker). 


ACUTE  GASTRO-ENTERIC   INTOXICATIOX.  305 

features  contriljuting  to  such  favourable  results  are  a  good  constitution 
on  the  part  of  the  child,  energetic  and  intelligent  treatment  at  the  out- 
set, and  proper  feeding  afterward. 

If  the  circumstances  are  not  so  favourable,  if  the  patient  is  a  very 
young,  delicate,  or  cachectic  infant,  there  may  be  no  reaction  from  the 
first  severe  symptoms,  and  the  attack  may  terminate  fatally  in  from 
one  to  three  days.  In  such  cases  the  temperature  remains  high;  the 
stomach  may  or  may  not  be  disturbed;  but  the  diarrhoea,  prostration, 
and  nervous  symptoms  continue,  and  death  occurs  from  exhaustion,  in 
coma  or  convulsions.  Instead  of  a  rapidly  fatal  termination,  the  severity 
of  the  early  acute  symptoms  may  abate  somewhat,  and  the  attack  as-^ume 
the  character  of  ileo-colitis,  with  a  lower  but  continuous  temperature  of 
100^  to  103°  F.,  frequent  mucous  stools,  wasting,  etc.  The  urine  is 
scanty  and  concentrated,  and  in  most  of  the  severe  cases  with  very  high 
temperature  contains  a  small  amount  of  albumin,  and  occasionally  a  few 
hyaline  and  granular  casts.  These  are  the  result  of  degenerative  changes 
in  the  renal  epithelium  from  the  irritating  toxins.  In  rare  cases  there 
are  evidences  of  acute  nephritis.  (See  Cholera  Infantum.)  Broncho- 
pneumonia is  also  sometimes  seen. 

Relapses. — Re-infection.. — It  not  infrequently  happens,  after  the 
storm  of  the  acute  attack  with  its  high  temperature,  intense  prostration, 
,and  grave  nervous  symptoms  is  passed,  and  the  stools  are  so  much  im- 
proved that  the  patient  is  regarded  as  out  of  danger,  that  all  the  former 
symptoms  may  develop  with  such  rapidity  and  severity  as  sometimes 
to  carry  off  the  patient  in  from  twelve  to  twenty-four  hours.  Such  re- 
lapses are  usually  the  result  of  re-infection  of  the  intestinal  tract,  gen- 
erally excited  by  some  mistake  in  the  diet,  usually  that  of  allowing  milk 
too  soon.  The  amount  of  milk  given  may  be  small,  and  yet  the  symp- 
toms follow  its  administration  so  soon  that  there  can  be  no  doubt  re- 
garding the  connection  between  them.  This  only  indicates  that  virulent 
bacteria  may  remain  in  the  intestine  for  a  considerable  time  after  the 
disappearance  of  severe  symptoms,  waiting  only  for  favourable  condi- 
tions to  develop  again  with  all  their  former  intensity  (Fig.  64).  Besides 
such  severe  cases,  many  of  a  milder  grade  of  re-infection  are  seen,  and 
the  cause  is  usually  some  error  in  diet;  occasionally,  however,  it  is  due  to 
checking  the  discharges  by  the  too  free  use  of  opium. 

Cases  icithoiit  diarrhoea. — Attacks  of  acute  intestinal  intoxication  in 
which  there  is  no  diarrhoea,  but  constipation  instead,  are  most  puzzling 
and  frequently  most  serious.  Fortunately,  they  are  not  of  common  oc- 
currence. I  have,  however,  seen  several  striking  examples  with  very 
high  temperature,  grave  nervous  symptoms,  and  sometimes  marked 
abdominal  distention  in  which  it  seemed  almost  impossible  to  move  the 
bowels  by  drugs.  Castor  oil,  calomel,  and  salines  have  in  some  cases 
been  tried  in  succession  in  four  or  five  times  the  ordinary  doses  without 


366 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


the  slightest  effect,  even  when  supplemented  b}^  frequent  intestinal  irri- 
gation. It  has  sometimes  been  nearly  two  days  before  free  movements 
were  finally  produced.  These  are  often  exceedingly  foul.  It  is  some- 
what difficult  to  explain  such  cases.    There  seems  to  exist  for  the  time 


I 


I 


1 


i 


Fig.  64. — Acute  intestinal  intoxication  with  fatM  re-infection. 

Infant  five  months  old ;  early  symptoms,  both  intestinal  and  nervous,  severe ;  rapid  im- 
provement followed  stopping  milk,  free  catharsis  and  irrigation.  After  stools  had  been  nearly 
normal  for  three  days  relapse  occurred,  apparently  from  adding  milk  to  the  diet,  althougli  less 
than  two  ounces  a  day  were  given.  Autopsy  :  Intestines  showed  the  usual  changes  of  intoxica- 
tion ;  other  organs  essentially  normal. 

almost  complete  intestinal  paralysis.  The  toxic  materials  are  locked 
up  in  the  small  intestine,  for  the  colon  is  frequently  quite  empty.  When 
one  meets  such  a  ease  he  can  appreciate  the  fact  that  in  acute  intestinal 
intoxication  diarrhoea  is  a  conservative  process  of  the  greatest  possible 
value. 

In  children  over  tivo  years  old  there  are  seen  some  features  which 
differ  from  those  of  the  cases  above  described  as  occurring  in  infants. 
The  attacks  are  more  often  due  to  other  causes  than  to  milk.  Vomiting 
does  not  occur  so  readily  as  in  infants,  pain  is  a  more  prominent  symp- 
tom, and  the  temperature,  as  a  rule,  is  lower.  The  nervous  symptoms  are 
much  less  prominent.  Skin  eruptions,  however,  are  more  frequently 
seen,  particularly  urticaria,  which  is  a  feature  of  most  severe  attacks, 
and  in  obscure  cases  has  some  diagnostic  value.  Although  often  begin- 
ning with  severe  symptoms,  these  cases  usually  make  good  recoveries; 
there  is  much  less  danger  of  their  going  on  to  the  development  of  ileo- 
colitis than  in  the  case  of  infants. 

Diagnosis. — Attacks  of  acute  gastro-enteric  intoxication  can  not 
always  be  distinguished  from  those  of  acute  indigestion,  but  as  a  rule 
they  are  characterized  by  a  higher  temperature,  greater  disturbance  of 
the  nervous  system,  very  offensive  fluid  stools,  and  by  occurring  epi- 


ACUTE   GA8TR0-EXTERIC   INTOXICATION,  367 

demically  in  summer.  To  differentiate  these  cases  from  those  of  ileo- 
colitis, may  be  impossible  for  the  first  two  or  three  days.  Xor  is  it  impor- 
tant to  do  so.  The  onset  may  be  similar  in  both  conditions.  The  con- 
tinuance of  high  temperature  beyond  the  third  day  points  to  inflamma- 
tory changes ;  so  also  do  the  appearance  of  blood  and  of  much  mucus  in 
the  stools,  and  the  existence  of  continuous  pain. 

The  acute  indigestion  manifested  by  vomiting  and  diarrhoeal  stools 
■which  marks  the  beginning  of  so  many  febrile  diseases  in  infancy,  par- 
ticularly scarlet  fever,  pneumonia,  malaria,  and  influenza,  is  often  diffi- 
cult to  distinguish  from  an  attack  of  intestinal  intoxication.  The  ques- 
tion to  decide  is  whether  the  digestive  symptoms  are  the  cause  or  the 
result  of  the  fever.  It  is  only  by  a  thorough  examination  of  the  patient, 
by  carefully  weighing  all  the  symptoms,  and  sometimes  not  until  the 
case  has  been  watched  for  at  least  forty-eight  hours,  that  one  can  be  cer- 
tain as  to  the  diagnosis.  Usually  where  digestive  symptoms  are  sec- 
ondary they  diminish  after  the  first  day  or  two,  although  the  severity 
of  the  general  symptoms  may  steadily  increase.  Where  the  nervous 
S3'mptoms  are  prominent  at  the  outset,  it  is  sometimes  difficult  to  dis- 
tinguish acute  intestinal  intoxication  from  meningitis.  I  have  seen 
many  cases  where  great  doubt  existed  for  several  days.  Opisthotonus, 
stupor,  convulsions,  and  increased  reflexes  may  be  present  in  both  con- 
ditions. The  temperature  of  intestinal  intoxication  is  sometimes  mis- 
taken for  that  of  malaria;  it  may  be  high  and  fluctuate  widely,  and 
where  there  is  reinfection  from  time  to  time  it  may  assume  a  somewhat 
intermittent  type. 

Prognosis. — Simple  cases  bt  gastro-enteric  intoxication  do  not  often 
prove  fatal,'  except  in  young  infants  or  those  already  suffering  from  mal- 
nutrition. Such  patients  are  often  overcome  in  the  first  stage  of  intoxi- 
cation. It  is  surprising  to  see  with  how  few  symptoms  they  succumbs 
Even  ail  apparently  mild  attack  may  prove  fatal,  and  a  guarded  prog- 
nosis should  always  be  given. 

In  other  ca«es  the  prognosis  resolves  itself  into  this  question :  "What 
are  the  probabilities  of  arresting  the  attack  before  the  production  of 
serious  intestinal  lesions?  If  the  child  is  delicate,  living  in  poor  sur- 
roundings, has  previously  suffered  from  digestive  derangements  or  acute 
diarrhoea,  and  does  not  receive  proper  early  treatment,  the  attack  will 
probably  result  in  structural  changes  in  the  intestines.  In  hot  weather 
this  is  especially  liable  to  be  the  case.  The  existence  of  rickets,  syphilis, 
pertussis,  or  any  other  general  disease,  greatly  increases  the  gravity  of 
the  attack. 

Prophylaxis. — So  long  as  dentition  and  atmospheric  heat  per  se  were 
regarded  as  the  great  causative  factors,  the  field  of  prophylaxis  was  lim- 
ited;  but  a  better  understanding  of  the  etiology  brings  with  it  great 
possibilities  in  the  prevention  of  this  disease. 


368  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Prophylaxis  must  have  regard,  first,  to  the  hygienic  surroundings  of 
children,  and  to  all  sanitary  conditions  in  the  cities — cleaner  streets  and 
more  parks.  In  the  tenement  homes  and  in  all  institutions  for  infants, 
there  should  be  more  air  and  sunlight,  less  crowding,  greater  cleanliness 
about  the  persons  of  children,  frequent  bathing,  and  proper  care  of  nap- 
kins. In  summer,  napkins  should  either  be  washed  immediately  or 
thrown  into  a  disinfectant  solution.  In  case  infants  are  suffering  from 
diarrhoea  this  latter  plan  should  invariably  be  followed.  City  children 
should  be  sent  to  the  country,  wherever  it  is  possible,  for  the  months  of 
July  and  August.  Part  of  the  benefit  here  is  derived  from  the  change  of 
air,  and  a  larger  part  from  the  pure  milk,  which  is  almost  out  of  the 
question  for  the  poor  in  the  city.  Where  a  long  stay  is  impossible,  day 
excursions  do  much  good.  The  fresh-air  funds  and  seaside  homes  have 
done  more  in  ISTew  York  to  diminish  the  mortality  from  diarrhoeal  dis- 
eases in  summer  (see  page  41)  than  all  medicinal  treatment;  their 
value  can  not  be  overestimated. 

The  second  part  of  prophylaxis  relates  to  foods  and  feeding.  Mater- 
nal nursing  should  be  encouraged  by  every  possible  means.  Weaning 
should  be  avoided  during  summer.  jSTothing  is  better  established  than 
the  close  relation  existing  between  artificial  feeding  and  diarrhoeal  dis- 
eases. Yet,  as  stated  elsewhere,  it  is  not  artificial  feeding  per  se,  but 
ignorant  and  improper  feeding  which  are  the  real  causes.  Among  infants 
in  private  practice  who  are  properly  fed  these  attacks  are  certainly  rare. 
The  general  rules  laid  down  elsewhere  on  the  subject  of  artificial  feeding 
should  be  carried  out,  as  to  the  quantity  of  food,  frecjuency  of  feeding, 
modification  of  cow's  milk,  and  all  matters  relating  to  the  care,  trans- 
portation, and  handling  of  milk.  Whatever  causes  indigestion,  whether  it 
be  acute  or  chronic,  may  also  be  ranked  as  a  cause  of  diarrhoeal  diseases. 
The  important  dangers  to  be  emphasized  in  this  connection  are  over- 
feeding, too  frequent  feeding,  the  use  of  improper  foods  or  impure 
foods,  especially  impure  milk. 

Overfeeding  is  particularly  to  be  avoided  during  days  of  excessive 
heat.  It  is  at  such  times  an  excellent  rule  with  infants  to  diminish  each 
meal  by  at  least  one-half,  making  up  the  deficiency  with  water,  and  to 
give  water  very  freely  between  the  feedings.  All  water  given  to  infants 
or  young  children  should  first  be  boiled.  Children,  like  adults,  require 
less  food  in  very  hot  weather,  but  more  water.  Infants  cry  more  from 
thirst  and  heat  than  from  hunger,  and  even  those  at  the  breast  are  likely 
to  be  given  too  much  food.  Infants  should  never  be  fed  more  frequently, 
but  always  less  frequently  during  hot  weather. 

No  more  important  work  in  practical  philanthropy  can  be  done  among 
the  poor  of  our  large  cities  in  summer  than  to  provide  means  for  supply- 
ing pure  milk  to  infants  and  young  children.  This  has  been  done  on  a 
large  scale  in  many  American  cities,  notably  New  York,  Brooklyn,  Bos- 


ACUTE   GASTRO-ENTERIC   INTOXICATION.  309 

ton,  Yonkers,  Buffalo,  and  Rochester,  and  it  has  effected  a  very  decided 
reduction  in  the  death-rate  from  diarrhoeal  diseases.  In  some  places 
this  has  been  accomplished  through  private  generosity,  in  others  the 
matter  has  been  taken  up  by  the  department  of  health.  Sometimes  the 
milk  has  been  supplied  free  of  cost,  sometimes  a  nominal  charge,  usu- 
ally one  cent  a  bottle,  has  been  made.  In  all  places  it  has  been  found 
essential  that  it  be  distributed  in  small  feeding  bottles,  that  only  enough 
for  one  day  be  furnished  at  a  time,  and  that  sterilization  in  some  form 
be  employed;  generally  212°  F.  for  one  hour,  inasmuch  as  ice  is  usually 
•out  of  the  question.  Second  in  importance  to  this  supply  of  suitable 
food  is  the  education  of  the  poor  in  proper  methods  of  feeding  and  other 
matters  of  infant  hygiene,  by  means  of  the  distribution  of  leaflets  giv- 
ing in  simple  language  accurate  information  on  these  subjects.  This 
should  be  done  at  all  milk  stations,  dispensaries,  and  hospitals  for 
children. 

Early  and  prompt  attention  should  be  given  to  all  the  milder  de- 
rangements of  the  stomach  and  intestines.  ^  The  larger  proportion  of 
serious  attacks  are  preceded  for  some  time  by  milder  symptoms,  which 
are  often  easily  managed  hj  prompt  attention  at  the  outset.  Too  much 
can  not  be  said  in  condemnation  of  the  practice  of  allowing  a  diarrhoea 
to  continue  for  a  week  or  more,  simply  because  the  child  happens  to  be 
teething.  Yet  many  mothers,  and  unfortunately  some  physicians,  be- 
lieve such  a  condition  of  the  bowels  to  be,  not  only  harmless,  but  posi- 
tively beneficial. 

In  brief,  prophylaxis  demands  (1)  sending  as  many  infants  out  of 
the  city  in  summer  as  posssible;  (2)  the  education  of  the  laity  as  to  the 
importance  of  regularity  in  feeding,  the  dangers  of  overfeeding,-  and  as 
to  what  is  a  proper  diet  for  infants  just  weaned;  (3)  proper  legal  regu- 
lations regarding  the  transportation  and  sale  of  milk;  (4)  the  exclusion 
of  germs  or  their  destruction  in  all  foods  given,  but  especially  in  milk, 
by  some  form  of  sterilization  in  summer,  and  by  scrupulous  cleanliness 
in  bottles,  nipples,  etc. ;  (5)  prompt  attention  to  all  mild  derangements ; 
(6)  cutting  down  the  amount  of  food  and  increasing  the  amount  of 
water  during  the  days  of  excessive  summer  heat. 

Hygienic  Treatment. — If  the  attack  occurs  in  the  city  in  midsummer, 
and  does  not  yield  in  three  or  four  days  to  the  treatment  emploj-ed,  the 
child  should,  if  possible,  be  sent  to  the  country.  Convalescent  cases 
should  also  be  sent  away  on  account  of  the  dangers  of  relapses.  In  the 
case  of  an  infant  under  a  year  this  is  imperative.  Usually  the  seashore 
is  to  be  preferred  to  the  mountains,  but  this  is  not  so  important  as  that 
the  child  shall  go  where  it  is  likely  to  have  the  best  food  and  the  best 
surroundings.  Children  must  not  only  be  sent  away;  they  must  be  kept 
away  until  quite  recovered.  In  the  country  or  in  small  towns  a  change 
is  not  so  necessary,  and,  in  fact,  not  generally  required.    In  cases  which 


370  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

have  become  somewhat  chronic,  more  can  sometimes  be  accomplished  by 
a  change  of  air  than  by  all  other  means. 

Fresh  air  is  of  the  utmost  importance  for  all  diarrhoeal  cases  in  sum- 
mer. N'o  matter  how  much  fever  or  prostration  there  may  be,  these  cases 
always  do  better  if  kept  out  of  doors  the  greater  part  of  the  day.  Nothing 
is  so  depressing  as  close,  stifling  apartments.  Children  should  be  kept 
quiet,  and  especially  should  not  be  allow^ed  to  walk,  even  if  they  are  old 
enough  and  strong  enough  to  do  so.  They  can  be  kept  out  in  carriages, 
in  perambulators,  or  in  hammocks. 

The  clothing  should  be  very  light  flannel ;  a  single  loose  garment  is- 
preferable.  Linen  or  cotton  may  be  put  next  the  skin  if  this  is  very 
sensitive  and  there  is  much  perspiration.  At  the  seashore  and  in  the 
mountains,  special  care  should  be  taken  that  sufficient  clothing  at  night 
is  supplied. 

Bathing  is  useful  to  allay  restlessness,  as  well  as  for  cleanliness  and 
the  reduction  of  temperature.  For  the  first  purpose  a  sponge  bath  of 
alcohol  and  water  or  vinegar  and  water  is  sufficient.  For  the  reduction 
of  temperature,  only  the  tub  bath  is  to  be  relied  on.  If  the  temperature 
continues  above  102°  F.,  systematic  bathing  should  be  emplo3'ed.  The 
temperature  of  the  bath  should  be  about  100°  F.  when  the  child  is  put 
into  it,  and  should  then  be  gradually  reduced  to  80°  or  85°  F.  by  adding 
ice.  The  bath  should  be  continued,  with  gentle  friction  of  the  body,  for 
from  five  to  tw^enty  minutes,  according  to  the  effect  produced. 

Scrupulous  cleanliness  should  be  secured  in  the  child's  person  and 
clothing.  jSTapkins,  as  soon  as  soiled,  should  be  removed  from  the  child 
and  from  the  room  and  placed  in  a  disinfectant  solution.  Excoriations  of 
the  buttocks  and  genitals  are  to  be  prevented  by  absolute  cleanliness 
and  the  free  use  of  some  absorbent  powder,  such  as  starch  and  boric  acid. 

Dietetic  Treatment. — It  is  of  the  first  importance  to  remember  that 
during  the  early  stage  of  the  acute  cases,  digestion  is  practically  arrested. 
To  give  food  at  this  time,  manifestly  can  do  only  harm. 

In  nursing  infants  the  severe  forms  of  the  disease  are  extremely  rare ; 
bnt  the  breast  should  be  withheld  so  long  as  a  disposition  to  vomit  con- 
tinues, and  no  food  whatever  given  for  at  least  twenty-four  hours. 
Thirst  may  be  allayed  by  giving  frequentW,  but  in  small  quantities,  cold 
whey,  thin  barley  water,  or  albumin  water.  Stimulants  may  be  added 
if  required.  If  they  are  refused  or  vomited,  absolute  rest  to  the  stomach 
will  do  more  than  an3^thing  else  to  hasten  recovery.  After  the  stomach 
has  been  allowed  to  rest  for  twenty-four  bours,  it  is  generally  safe  to 
permit  a  nursing  child  to  take  the  breast  tentatively.  The  intervals  of 
nursing  should  not  be  shorter  than  four  hours,  and  the  amount  allowed 
at  one  feeding  should  not  be  more  than  one-fourth  the  usual  quantity. 
This  may  be  regulated  by  allowing  an  infant  to  nurse  at  first  only  two  or 
three  minutes.    Between  the  nursings  may  l)e  given  whe}'',  barley  water^, 


ACUTE   GASTRO-ENTERIC  INTOXICATION.  371 

or  albumin  water,  so  that  something  is  given  every  two  hours.  Nursing 
may  be  gradually  increased,  so  that  in  three  or  four  days  the  breast  may 
be  taken  exclusively.  If  there  is  any  reason  to  suspect  the  quality  of 
the  breast-milk,  such  as  menstruation,  pregnancy,  or  some  special  nerv- 
ous disturbance,  it  may  be  necessary  to  stop  the  nursing  for  a  longer 
time. 

In  infants  under  four  months  who  are  being  artificially  fed,  all  food, 
and  especially  milk,  should  be  stopped  at  once,  and  withheld  during  the 
period  of  acute  symptoms,  and  for  several  days  thereafter.  Besides  the 
articles  mentioned  above  as  suitable  for  the  period  of  most  acute  symp- 
toms, the  following  substitutes  for  milk  will  be  found  useful:  rice  or 
barley  water,  either  plain  or  dextrinized;  the  farinaceous  foods;  the 
malted  foods ;  broth  or  bouillon  made  of  veal,  chicken,  or  beef,  and  such 
beef  preparations  as  Mosquera's  fluid  beef  jelly,  panopepton,  liquid  pep- 
tonoids,  or  bovinine. 

Cow's  milk,  boiled,  should  be  used  at  first  in  very  small  quantities, 
and  the  effect  upon  the  stools  and  temperature  carefully  watched.  The 
general  indications  for  modifying  milk  are  the  same  as  in  acute  intesti- 
nal indigestion.  Wet-nurses  are  not  to  be  employed  during  the  acute 
symptoms,  but  during  the  period  of  prolonged  malnutrition  and  feeble 
assimilation  which  follows  an  acute  attack,  they  may  be  of  the  greatest 
service. 

The  same  general  principles  of  feeding  must  be  applied  in  older  chil- 
dren. All  food  is  to  be  withheld  until  the  vomiting  ceases,  when  broths 
and  beef  juice  may  be  given ;  later,  kumyss  or  matzoon,  afterward  milk, 
or  thin  gruels  made  with  milk.  Solid  food  should  not  be  allowed  for 
several  days  after  the  stools  have  become  normal. 

General  principles  of  feeding. — All  food,  but  especially  cow's  milk, 
should  be  stopped  at  once.  Ko  food  whatever  should  be  given  upon  a 
very  irritable  stomach;  but  thirst  should  always  be  relieved  by  bland 
fluids  given  frequently  in  small  quantities,  and  cold.  Articles  requiring 
the  least  digestion  and  leaving  the  smallest  residue  should  next  be  tried. 
Food  prescriptions  must  be  made  with  the  same  care  and  exactness  as 
those  for  drugs,  for  in  most  cases  they  are  more  important.  Quantity 
and  frequency  must  be  definitely  stated,  as  well  as  the  articles  ordered. 
Directions  should  be  given  in  writing,  or  they  will  be  forgotten  before  the 
physician  is  out  of  the  house.  A  practical  acquaintance  with  the  proper 
appearance  and  taste  of  every  food  ordered,  is  absolutely  indispensable. 
It  is  a  common  mistake  to  give  too  much  at  a  time,  to  feed  too  frequently, 
to  try  too  many  articles  at  once,  and  to  change  before  a  thing  has  been 
fairly  tested.  For  a  single  feeding  the  quantity  allowed  will  vary  accord- 
ing to  the  tolerance  of  the  stomach,  but  it  should  generally  be  much  less 
than  is  given  in  health,  usually  from  one-fourth  to  one-half  that  amount. 
It  is  very  rarely,  if  ever,  necessary  to  nurse  or  feed  a  sick  child  oftener 


372  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

than  ever}-  two  hours,  and  four-hour  intervals  are  in  many  cases  to  be 
preferred.  In  cases  of  great  prostration,  stimulants  may  be  required 
much  more  frequently. 

Still,  after  all  has  been  said,  it  is  a  difficult  problem  to  feed  these 
children  under  three  years  of  age,  capricious  as  they  are  by  nature  and 
still  more  by  education,  and  the  judgment  and  tact  of  the  physician  are 
taxed  to  their  utmost.  We  must  have-  many  resources,  for  a  food  which 
one  child  takes  well  the  next  utterly  disdains.  The  best  plan  is  to  select 
from  a  list  of  articles  of  accepted  value,  such  as  circumstances  will  per- 
mit, and  such  as  are  most  likely  to  be  properly  prepared,  and  try  them 
patiently,  one  after  another,  until  one  is  found  which  the  child  under 
treatment  will  take,  and  which  agrees  with  him. 

Medicinal  and  Mechanical  Treatment. — It  must  be  borne  in  mind 
that  we  are  not  treating  an  inflammation  of  the  stomach  or  intestines, 
although  such  may  be  the  ultimate  result  of  the  process.  The  essential 
condition,  it  should  be  remembered,  is  one  of  acute  intoxication  arising 
from  the  intestinal  contents — food-remains  from  arrested  digestion,  al- 
tered secretions,  acids,  and  other  toxic  substances  produced  by  bacteria — 
to  which  not  only  the  constitutional  S3miptoms,  but  the  local  lesions  are 
chiefly  due.  We  can  hardly  do  better  than  to  imitate  and  assist  Xature 
in  her  treatment  of  this  condition.  Let  us  consider  what  this  is.  Lest 
too  much  food  be  swallowed,  appetite  is  taken  away;  by  vomiting,  the 
stomach  is  emptied;  to  neutralize  the  acid  poisons  in  the  intestine,  an 
alkaline  serum  is  poured  out  from  the  intestinal  walls;  to  remove  irri- 
tant poisons,  increased  peristalsis  is  excited. 

The  first  indication  is,  therefore,  to  evacuate  the  stomach  and  the  en- 
tire intestinal  tract  at  the  earliest  moment,  and  to  do  this  as  thoroughly 
as  possible.  Under  no  circumstances  should  the  treatment  be  begun  with 
the  use  of  measures  to  stop  the  discharges.  To  empty  the  stomach  is 
not  necessary  in  every  case,  since  the  initial  vomiting  may  have  done  this 
efficient^.  Whenever  vomiting  persists  one  should  immediately  resort 
to  stomach-washing.  A  single  washing  is  generally  sufficient,  and  if  em- 
ployed at  the  outset  may  do  much  to  shorten  the  attack.  With  high 
fever  and  great  thirst,  it  is  often  advisable  to  leave  an  ounce  or  two  of 
water  in  the  stomach.  If  the  vomited  matters  have  been  very  sour,  ten 
grains  of  bicarbonate  of  soda  may  be  introduced  with  the  portion  which 
is  to  be  left  behind.  As  a  substitute  for  stomach-washing  in  children 
over  two  years  old,  or  where  it  can  not  be  employed,  coj)ious  draughts  of 
boiled  water  may  be  given.  This  is  taken  readily,  and  as  it  is  usually 
vomited  almost  at  once  it  may  cleanse  the  stomach  thoroughly ;  but  it 
is  inferior  to  stomach-washing. 

To  clear  out  the  small  intestine,  only  cathartics  are  available.  For 
the  colon,  we  may  in  addition  employ  irrigation.  Calomel,  castor  oil. 
or  the  salines  may  be  used  as  cathartics,  and  enough  of  anv  one  of  them 


ACUTE   GAbTRO-ENTERIC  INTOXICATION.  373 

must  be  given  not  simply  to  move  the  bowels,  but  to  clear  out  the 
intestinal  tract  thoroughly.  There  is  little  danger  from  too  free  purga- 
tion at  the  outset.  Calomel  has  the  advantage  of  ease  of  administra- 
tion :  one-fourth  of  a  grain  should  be  given  every  hour  up  to  six  or  eight 
doses,  or  until  the  characteristic  green  stools  are  seen.  When  the  stom- 
ach is  not  disturbed,  I  prefer  castor  oil  in  most  cases,  as  it  sweeps  the 
whole  canal,  causes  little  griping,  is  very  certain,  and  its  after-effects 
are  soothing.  Two  drachms  should  be  given  to  a  child  a  year  old,  and 
half  an  ounce  to  one  of  four  years.  Of  the  salines,  Rochelle  salts  and 
magnesia  are  the  best ;  either  the  sulphate,  citrate,  or  the  milk  of  mag- 
nesia may  be  used.  Of  the  sulphate  as  much  as  one  drachm  should  be 
given  in  divided  doses  in  the  course  of  two  or  three  hours,  and  an  equiva- 
lent amount  of  the  other  preparations. . 

The  occasional  use  of  cathartics  is  an  important  part  of  the  later 
treatment.  Whenever  there  are  signs  of  an  accumulation,  or  fresh  symp- 
toms of  intoxication  develop,  such  as  increase  in  temperature,  nervous 
symptoms,  etc.,  another  thorough  cleaning  out  of  the  intestinal  tract  is 
indicated.  The  accumulation  may  not  be  the  result  of  food,  but  simply 
of  intestinal  secretions.  So  long  as  the  processes  of  fermentation  and 
decomposition  continue  active,  the  indications  are  to  facilitate  elimina- 
tion, not  to  check  the  discharges. 

Irrigation  of  the  colon  (page  63)  is  advisable  in  all  cases,  as  it  hastens 
the  effect  of  the  cathartic  and  removes  at  once  much  irritating  and  offen- 
sive material.  It  should  be  done  two  or  three  times  the  first  day,  but 
afterward  once  daily  is  sufficient.  A  saline  solution  (one  tablespoonful 
of  salt  to  two  quarts  of  water),  at  a  temperature  of  about  100°  F.,  is  to 
be  preferred;  and  a  long  rectal  tube  should  always  be  used.  Thorough 
initial  evacuation,  almost  no  food,  but  plenty  of  water  for  twenty-four 
hours,  and  careful  feeding  after  that  time,  are  all  the  treatment  that  is 
necessary  in  a  large  number  of  cases. 

Otlier  drugs  are  of  secondary  importance.  Their  value  is  certainly 
very  much  overestimated.  This  statement  is  made  after  a  thorough  and 
honest  trial,  in  hospital  and  private  practice,  of  most  of  those  that  have 
been  recommended.  Since  the  recognition  of  the  fact  that  putrefactive 
processes  play  so  important  a  role  in  these  cases,  the  drift  of  opinion  and 
practice  has  Ijeen  toward  the  use  of  drugs  believed  to  act  m  the  alimen- 
tary tract  as  antiseptics.  In  comparison  willi  (lie  gastric  and  intestinal 
contents  the  amount  of  any  dn^g  Avhich  can  be  given  is  small,  it  is  true, 
and  we  have  still  much  to  learn  regarding  the  nature  of  the  putrefactive 
processes  we  are  seeking  to  control.  It  may  therefore  be  questioned 
whether  as  yet  any  scientific  antiseptic  treatment  of  the  gastro-enteric 
tract  is  possible.  However,  clinical  experience  points  to  the  fact  that  the 
internal  use  of  antiseptics  is  of  value,  even  though  such  remedies  do  no 
more  than  inhibit  bacterial  orowth.     Those  which  are  soluble  can  be 


374  DISEASES  OP   THE  DIGESTIVE  SYSTEM. 

expected  to  influence  only  the  stomach  and  upper  small  intestine.  The 
insoluble  ones  may  affect  the  lower  small  intestine  and  colon.  Those 
which  in  my  experience  have  been  found  most  useful  are  bismuth,  salol, 
salicylate  of  soda,  and  resorcin ;  although  the  list  might  be  very  greatly 
extended. 

Bismuth  has  the  advantage  that  it  rarely  causes  vomiting,  and  that 
most  of  its  preparations  can  be  given  in  large  doses.  Of  the  newer  prepa- 
rations, the  subgallate  is  easily  superior  to  the  others.  This  may  be 
given  in  doses  of  from  two  to  four  grains  every  two  hours,  to  a  child  of 
one  year.  Like  the  subnitrate  it  is  insoluble  and  is  best  given  suspended 
in  mucilage.  For  most  cases,  however,  I  think  the  subnitrate  is  still  to 
be  preferred.  To  be  efficient,  from  one  to  two  drachms  should  be  given 
daily  to  a  child  two  years  old.  It  usually  blackens  the  stools.  It  may 
be  kept  up  throughout  the  attack.  Of  the  salicylate  of  soda,  to  a  child 
of  one  year,  two  grains  may  be  given,  dissolved  in  water,  every  two 
hours,  after  feeding.  This  is  not  to  be  used  if  the  stomach  is  very  irri- 
table, as  it  may  excite  vomiting.  Its  best  effect  is  seen  after  the  vomit- 
ing has  stopped,  and  when  the  stools  are  fluid.  It  should  be  given  alone. 
Salol  is  decomposed  in  the  intestine  into  salicylic  and  carbolic  acids. 
To  a  child  of  two  years  one  or  two  grains  may  be  given  every  two  hours ; 
sometimes  more  will  be  borne.  Eesorcin  may  be  used  in  doses  half  as 
large.  Either  of  these,  however,  may  cause  vomiting.  The  best  results 
are  seen  from  acids  in  the  later  stages  and  in  the  subacute  cases;  of  the 
dilute  hydrochloric  acid,  from  one  to  three  drops  may  be  given,  best 
alone.  Alkalies  are  of  value  only  in  the  acute  stage,  especially  where 
there  is  acid  fermentation  of  the  stomach,  with  vomiting  and  eructations 
of  gas.  Lime-water,  bicarbonate  of  soda,  magnesia,  or  chalk-mixture 
may  be  employed.  My  own  experience  accords  with  that  of  most  recent 
writers  in  according  a  very  limited  place  to  astringents.  They  do  little 
good,  and  often  much  harm.  They  are  indicated  only  in  the  catarrhal 
diarrhoea  which  often  follows  the  symptoms  of  acute  intoxication,  but 
may  be  advantageously  used  in  this  condition  in  combination  with  opium. 
A  useful  astringent  is  tannalbin,  which  may  be  given  in  two-grain  doses 
every  two  hours  to  an  infant  of  one  year. 

While  opium  in  some  form  is  required  in  many  cases,  as  often  used 
it  undoubtedly  does  great  harm.  The  chief  indications  for  opium  are 
great  frequency  of  movements  and  severe  pain.  It  is  contraindicated 
until  the  intestinal  tract  has  been  thoroughly  emptied  by  cathartics  and 
irrigation ;  also  when  the  number  of  discharges  is  small,  particularly  if 
they  are  very  offensive ;  it  is  especially  to  be  avoided  in  the  early  stage 
of  very  acute  cases,  and  never  to  be  given  when  cerebral  symptoms  and 
high  temperature  coexist  with  scanty  discharges.  Opium  is  admissible 
in  the  early  part  of  the  disease  after  the  tract  has  been  thoroughly  emp- 
tied.   It  is  particularly  indicated  where  there  is  a  persistence  of  large, 


ACUTE  GASTRO-ENTERIC  INTOXICATION.  375 

fluid  movements  attended  by  symptoms  of  collapse,  and  in  all  cases  ap- 
proaching the  cholera-infantum  tyi^e.  In  such  circumstances  morphine 
should  be  given  hypodermically,  one  one-hundredth  of  a  grain  to 
an  infant  of  six  months,  to  be  repeated  in  an  hour  if  no  effect  is  seen. 
Opium  is  useful  during  convalescence,  when  the  administration  of 
food  is  immediately  followed  by  a  movement  of  the  bowels;  and  when 
without  an  elevation  of  temperature,  often  with  good  appetite,  the  stools 
are  frequent  and  contain  undigested  food,  because  peristalsis  is  so  active 
that  the  intestinal  contents  are  hurried  along  with  such  rapidity  that 
there  is  not  time  for  complete  intestinal  digestion  and  absorption.  ISTotli- 
ing  requires  nicer  discrimination  than  the  use  of  opium  in  diarrhoea.  It 
is  wise  to  administer  it  always  in  a  separate  prescription,  and  never  in 
composite  diarrhoeal  mixtures.  The  dose  should  be  regulated  according 
to  its  effect  upon  the  number  of  stools.  Enough  is  to  be  given  to  produce 
a  distinct  effect — the  diminution  of  pain  and  the  control  of  excessive 
peristalsis — but  never  enough  to  check  the  discharges  entirely,  or  to  cause 
stupor.  The  uncertainty  of  absorption  must  also  be  remembered;  a 
second  full  dose  should  not  be  given  until  a  sufficient  time  has  elapsed 
for  the  effect  of  the  first  to  pass  away.  For  an  average  child  of  one  year, 
five  minims  of  paregoric,  one-fourth  minim  of  the  deodorized  tincture, 
or  one-fourth  grain  of  Dover's  powder,  may  be  used  as  an  initial  dose, 
to  be  repeated  every  one,  two,  or  four  hours,  according  to  the  effect 
produced. 

Stimulants  are  required  in  the  majority  of  the  severe  cases.  The 
prostration  is  great  and  develops  rapidly ;  frequently  almost  no  food  can 
be  assimilated  for  twenty-four  or  thirty-six  hours,  while  the  drain  from 
the  discharges  continues.  The  general  condition  of  the  patient  is  the 
best  guide  as  to  the  time  for  stimulation  and  the  amount  required. 
Often  stimulants  are  not  begun  early  enough.  Old  brandy  is  the  best 
preparation  for  general  use,  champagne  being  possibly  preferred  for 
older  children  when  the  stomach  is  very  irritable.  An  infant  a  year  old 
will,  under  most  circumstances,  take  half  an  ounce  of  brandy  in  twenty- 
four  hours.  Stimulants  should  always  be  diluted  with  at  least  eight 
parts  of  water,  and  be  given  in  small  quantities,  at  short  intervals. 

In  cases  of  extreme  prostration,  the  hot  bath,  mustard  to  the  ex- 
tremities, and  sometimes  the  mustard  pack,  are  beneficial.  Where  the 
drain  is  rapid  and  very  great,  and  in  all  cases  approaching  the  cholera- 
infantum  type,  subcutaneous  saline  injoctions  should  be  used,  in  the  man- 
ner described  under  Cholera  Infantum. 

General  considerations  in  treatment. —  (1)  All  severe  cases  must  be 
watched  very  closely,  especially  those  in  infants  under  six  months.  If 
the  temperature  is  rising  and  the  passages  are  very  fluid,  one  should 
always  l)e  a]iprehensive.  (2)  The  character  of  the  discharges  is  a  better 
indication  than  is  their  number,  of  the  patient's  condition  and  of  the 


376  DISEASES  OF   THE  DIGESTIVE  SYSTEM, 

effect  of  an}'  plan  of  treatment.  (3)  Xothing  is  more  simple  than  to 
give  opium  enough  to  reduce  the  numher  of  passages;  but  unless  there 
is  some  other  sign  of  improvement,  very  little  good,  and  probably  much 
harm,  may  be  done.  (4)  We  must  treat  the  patient,  and  not  direct  all 
our  thought  to  acid  or  alkaline  stools,  ptomaines,  or  bacteria.  The  value 
of  every  therapeutic  measure  is  to  be  estimated  by  its  effect  upon  the 
patient's  general  condition.  (5)  Xo  matter  how  strongly  we  may  be- 
lieve in  the  value  of  any  drug  or  combination  of  drugs,  if  they  continue 
to  disturb  the  stomach  they  are  worse  than  useless.  (6)  Both  the 
mother  and  nurse  should  be  impressed  with  the  fact  that  the  diet  is 
an  important  part  of  the  treatment,  and  that  foods  need  to  be  given 
just  as  carefully  as  drugs.  (7)  In  the  management  of  any  single  .case 
the  important  thing  is  prompt  and  thorough  evacuation  of  the  stomach 
and  bowels,  then  rest  for  these  organs  for  from  twelve  to  twent3^-four 
hours,  or,  as  some  one  has  tersely  put  it,  "  bold  starvation  " ;  but  it  is 
necessar}'  in  all  cases  that  water  be  given  freely.  Xo  cases  do  worse  than 
those  in  which  the  mother  or  nurse  in  charge  can  not  be  made  to  appre- 
ciate the  value  of  starvation,  but  insists  upon  giving  food,  especially 
milk,  in  violation  of  the  rules  laid  down.  (8)  Great  care  is  required  dur- 
ing convalescence,  and  in  fact  during  the  remainder  of  the  summer,  to 
prevent  relapses;  these  usually  occur  from  errors  in  diet,  particular^ 
during  d&js  of  excessive  heat. 

Cholera  Infantum. — This  may  be  regarded  as  only  one  clinical 
type  of  acute  intestinal  intoxication,  yet  it  differs  from  the  others  suffi- 
ciently to  deserve  separate  consideration.  It  is  not,  however,  the  most 
frequent  form  met  with,  and  it  is  not  a  good  generic  name  for  the  dis- 
ease. As  yet  this  tj])e  has  not  been  connected  with  a  specific  form  of  in- 
toxication. Booker  found  the  cholera-infantum  t3'pe  of  diarrhoea  most 
frequently  associated  with  the  bacilli  of  the  proteiis  group.  Escherich 
has  shown  that  it  may  occur  from  streptococcus  infection.  The  peculiar 
symptoms  may  depend  upon  the  rapidity  of  absorption  and  the  other 
conditions  present  in  the  intestine,  or  possibly  upon  some  form  of  in- 
fection not  yet  determined.  Cholera  infantum  is  more  closely  con- 
nected with  impure  milk  than  is  any  of  the  other  forms  of  diarrhoea,  and 
may  be  due  to  some  poison  developing  in  the  milk  before  its  ingestion, 
or  in  the  stomach  or  intestines  after  the  milk  is  taken.  The  symptoms 
are  due  primarily  to  the  effects  of  the  poison  upon  the  heart,  the  nerve- 
centres,  and  the  vaso-motor  nerves  of  the  intestines ;  secondarily  to  the 
abstraction  of  fluid  from  the  various  organs  and  tissues  of  the  bodv. 
especially  the  nerve-centres. 

Cholera  infantum  rarely  occurs  in  an  infant  previously  healthv.  As 
a  rule,  there  is  some  antecedent  intestinal  disorder.  The  development 
of  the  choleriform  symptoms  is  usually  ver}'-  rapid,  and  a  child,  who 
perhaps  has  been  regarded  as  scarcely  ill  enough  to  require  a  physi- 


CHOLERA  INFANTUM.  377 

cian,  ma}^  be  brought,  in  the  course  of  five  or  six  hours,  to  death's 
door. 

Usually  there  are  general  symptoms,  such  as  prostration  and  a  stead- 
ily rising  temperature,  for  a  few  hours  before  the  vomiting  and  purging, 
or  these  sjanptoms  may  be  the  first  to  excite  alarm.  Vomiting  may  pre- 
cede diarrhoea,  or  both  may  begin  simultaneously.  The  vomiting  is  very 
frequent.  First,  whatever  food  is  in  the  stomach  is  vomited,  then  serum 
and  mucus,  and  finally  bilious  matter.  If  vomiting  subsides  for  a  time, 
it  is  almost  sure  to  begin  anew  with  the  taking  of  food  or  drink.  The 
stools  are  frequent,  large,  and  fluid,  and  in  the  course  of  half  a  day 
twelve  or  fifteen  may  occur.  If  less  frequent  they  are  proportionately 
larger.  They  are  of  a  pale  green,  yellow,  or  brownish  colour  in  the  be- 
ginning, but  as  they  become  more  frequent  they  often  lose  all  colour 
and  are  almost  entirely  serous.  The  sphincter  is  sometimes  so  relaxed 
that  small  evacuations  occur  every  few  minutes.  The  first  stools  are 
usually  acid,  later  they  are  neutral,  and  when  serous  they  may  be 
alkaline.  In  most  cases  they  are  odourless;  in  rare  instances  they 
are  exceedingly  ofi^ensive.  Microscopically  the  stools  show  large  num- 
bers of  epithelial  cells,  some  round  cells,  and  immense  numbers  of  bac- 
teria. 

Loss  of  weight  is  more  rapid  than  in  any  other  pathological  condition 
in  childhood.  Baginsky  records  a  case  in  which  it  reached  three  pounds 
in  two  days.  The  fontanel  is  depressed,  and  in  rare  instances  there  may 
be  overlapping  of  the  cranial  bones.  The  general  prostration  is  great 
almost  from  the  outset.  The  face,  better,  perhaps,  than  any  single  symp- 
tom, indicates  what  a  profound  impression  has  been  made  upon  the  sys- 
tem. The  eyes  are  sunken,  the  features  sharpened,  the  angles  of  the 
mouth  drawn  down,  and  a  peculiar  pallor  with  an  expression  of  anxiety 
overspreads  the  whole  countenance.  In  the  early  stages  the  nervous 
symptoms  are  those  of  irritation:  children  cry  loudly  or  moan,  and 
throw  themselves  fretfully  about  in  their  cribs,  the  excitement  sometimes 
bordering  upon  an  active  delirium.  Later,  these  symptoms  give  place  to 
dulness,  stupor,  relaxation,  and  coma  or  convulsions. 

The  temperature,  in  my  experience,  has  been  invariably  elevated,  and 
usually  in  proportion  to  the  severity  of  the  attack.  In  cases  recovering, 
it  has  generally  been  from  102°  to  103°  F.,  while  in  fatal  cases  it  has  risen 
almost  at  once  to  104°  or  105°  F.,  and  often  shortly  before  death  it  has 
reached  106°  or  even  108°  F.  Such  rectal  temperatures  may  occur  with 
a  clammy  skin  and  cold  extremities,  and  are  discovered  only  by  the  ther- 
mometer. The  pulse  is  always  rapid,  and  very  soon  it  becomes  weak, 
often  irregular,  and  finally  almost  imperceptible.  The  respiration  is 
irregular  and  rvcfiucnt,  and  may  l)e  stcrlorcnis.  Tlic  tongue  is  generally 
coated,  but  soon  ])ocomes  dry  and  reil,  and  is  often  jirotrudcd.  The  ab- 
domen is  generally  soft  and  sunken.     TJiere  is  almost  insatiable  thirst. 


3Y8  DISEASES  OF   THE  DIGESTIVE  SYSTEM. 

Everything  in  the  shape  of  fluids,  especially  ice-water,  is  drunk  with 
avidity,  even  though  vomited  as  soon  as  it  is  swallowed.  Very  little 
urine  is  passed,  sometimes  none  at  all  for  twenty-four  hours;  yet  this 
need  give  no  special  concern,  as  it  depends  upon  the  great  loss  of  fluid 
by  the  bowels. 

Symptoms  such  as  those  described  rarely  continue  more  than  one  day 
without  a  decided  change  either  for  better  or  worse.  In  the  fatal  cases 
there  is  hyperpyrexia,  a  cold,  clammy  skin,  absence  of  radial  pluse,  stu- 
por, coma  or  convulsions,  and  death.  The  diarrhoea  and  vomiting  may 
continue  until  the  end,  or  both  may  entire!}"  cease  for  some  hours  before 
it  occurs.  The  patients  may  pass  into  a  condition  resembling  the  algid 
stage  of  epidemic  cholera,  and  die  in  collapse.  In  other  cases,  after  the 
first  day  of  very  severe  symptoms,  the  discharges  diminish,  but  the 
nervous  S3anptoms  become  specially  prominent.  There  is  restlessness 
and  irritability  or  apathy  and  stupor.  The  fontanel  is  sunken ;  the  eyes 
are  half  open  and  covered  with  a  mucous  film;  respiration  is  irregular 
and  superficial,  sometimes  even  Che3me-Stokes ;  the  pulse  is  feeble,  irreg- 
ular, or  intermittent ;  the  extremities  are  cold ;  the  muscles  of  the  neck 
drawn  back;  the  abdomen  retracted;  no  desire  for  food  is  shown,  the 
patient  rousing  only  from  thirst.  The  temperature  is  not  elevated, 
but  normal  or  subnormal.  From  this  condition  recovery  may  take  place 
or  the  symptoms  may  merge  into  those  of  ileo-colitis ;  but  much  more 
frequent  than  either  of  the  foregoing  is  the  fatal  termination. 

These  nervous  symptoms  described  were  grouped  by  the  earliest 
writers,  first  by  Marshall  Hall,  under  the  term  spurious  hydrocephalus, 
or  hydrencephaJoid.  They  have  been  variously  explained  by  different 
writers  as  due  to  cerebral  ansemia,  cerebral  hyperaemia  (venous),  oedema 
of  the  meninges,  thrombosis  of  the  cerebral  sinuses,  and  uraemia.  In  but 
a  single  instance  have  I  met  with  post-mortem  changes  in  the  brain  which 
bore  any  proper  relation  to  the  symptoms.*  Although  I  have  examined 
the  brain  in  almost  all  my  autopsies  upon  patients  dj-ing  from  diarrhoeal 
diseases,  I  have  never  in  such  cases  seen  sinus  thrombosis,  and  but 
rarely  oedema.  Cerebral  hyperfemia  was  often  met  with  in  cases  dying 
in  convulsions,  but  not  with  any  regularity  otherwise.  Nor  have  my  ob- 
servations upon  the  kidneys  confirmed  the  observations  of  Kjellberg, 
whom  most  of  the  writers  since  his  day  have  quoted,  as  to  the  great  fre- 
quency of  nephritis.  A  scanty,  concentrated,  and  hence  irritating  urine 
is  the  rule,  and  a  small  amount  of  albumin  and  an  occasional  hyaline 

*  In  this  infant  the  cerebral  symptoms  were  so  marked  and  so  characteristic  that 
two  excellent  physicians  who  watched  the  case  unhesitatingly  made  a  diagnosis  of 
meningitis.  The  intestinal  symptoms  were  considered  of  secondary  importance.  The 
autopsy  revealed  follicular  ulcers  of  the  ileum,  moderate  parenchymatous  nephritis, 
and  an  extreme  degree  of  cerebral  ana?mia. 


CHOLERA   INFANTUM.  379 

cast  not  uncommon;  but  either  clinical  or  pathological  evidence  of  a 
serious  amount  of  nephritis  has  been,  in  my  own  experience,  extremely 
rare.  We  can  hardly  regard  either  the  renal  or  the  cerebral  changes  as 
an  explanation  of  the  nervous  symptoms  of  most  of  these  cases ;  they 
seem  rather  to  depend  upon  impeded  circulation,  due  to  a  thickening  of 
the  blood,  to  acute  inanition,  and  intestinal  toxemia. 

In  eases  going  on  to  recovery  the  vomiting  usually  ceases  first ;  then 
the  stools  become  less  frequent,  contain  more  solid  matter,  and  have 
more  colour.  Improvement  in  the  pulse,  a  fall  in  the  temperature,  and 
subsidence  of  the  nervous  symptoms  soon  follow.  The  disappearance  of 
the  nervous  symptoms  is  always  to  be  regarded  as  a  very  favourable  sign. 
The  discharges  gradually  assume  the  character  of  a  catarrhal  diarrhoea, 
which  continues  a  week  or  more.  Convalescence  is  never  very  rapid. 
Sometimes,  after  all  signs  of  improvement  have  continued  for  two  or 
three  days,  the  choleraic  discharges  return  with  great  severity,  and  the 
attack  proves  fatal. 

Of  the  cases  of  true  cholera  infantum  which  have  come  under  my 
notice,  fully  two-thirds  have  died.  The  result  depends  more  upon  the 
severity  of  the  attack  than  upon  anything  else. 

An  infrequent  complication  of  cholera  infantum  is  sclerema.  This 
condition  is  found  associated  with  muscular  contractions,  subnormal  tem- 
pergiture,  and  other  signs  of  the  most  extreme  depression.  These  cases 
are  invariably  fatal. 

Treatment. — Eestricting  the  term  to  the  class  of  cases  described 
above,  all  who  have  seen  much  of  the  disease  must  admit  that  the  results 
of  treatment  are  extremely  unsatisfactory,  and  that  the  most  severe  cases 
pursue  their  course  but  little,  if  at  all,  influenced  by  the  treatment  em- 
ployed. 

In  the  way  of  prophylaxis  much  can  be  done.  All  the  general  rules 
of  prevention  laid  down  in  the  previous  chapter  should  be  enforced  here. 
Special  emphasis,  however,  is  to  be  laid  upon  the  early  treatment  of  the 
milder  intestinal  derangements,  since  it  is  a  rule,  to  which  the  exceptions 
are  few,  that  such  symptoms  precede  for  some  days  the  occurrence  of  the 
choleriform  diarrhoea.  No  case  of  diarrhoea  in  summer  is  to  be  neglected. 
It  is  also  important  in  convalescence  from  ileo-colitis  that  vigilance 
should  never  be  relaxed  until  the  stools  are  quite  normal.  Especial  care 
is  necessary  in  regard  to  a  return  to  milk  after  attacks  of  serous  diar- 
rhoea. Under  sucli  conditions  milk  must  be  withheld  for  a  long  time,  at 
least  from  one  to  two  weeks.  Severe  and  fatal  relapses  often  follow  a 
violation  of  this  rule. 

The  best  view  of  the  treatment  will  be  gained  if  we  kee[)  in  mind  that 
we  are  not  treating  intestinal  catarrh,  nor  intestinal  inflammation,  al- 
though this  may  ensue,  but  that  we  are  treating  cases  of  poisoning;  that 
the  toxic  materials  cause  great  depression  of  the  heart  and  the  system 


380  DISEASES  OF   THE  DIGESTIVE   SYSTEM. 

generally  by  acting  on  the  nerve-centres,  and  by  paralyzing  tlie  vaso- 
motor nerves  of  the  intestines. 

The  main  indications  are :  ( 1 )  to  empty  the  stomach  and  intestine ; 
(3)  to  neutralize  the  effect  of  the  poison  upon  the  heart  and  nervous  sys- 
tem; (3)  to  supply  fluid  to  the  blood  to  make  up  for  the  very  great  drain 
of  the  discharges;  (4)  to  reduce  the  temperature;  (5)  to  treat  special 
symptoms  as  they  arise. 

For  the  first  indication  we  must  rely  upon  mechanical  means — stom- 
ach-washing and  intestinal  irrigation — for  there  is  no  time  to  ■wait  for 
the  action  of  cathartics.  For  the  second,  nothing  in  niy  hands  has  proved 
so  useful  as  the  hypodermic  use  of  morphine  and  atropine.  I  believe  this 
to  be  more  efficient  than  any  other  means  of  treatment  we  possess.  Mor- 
phine is  contra-indicated  where  the  purging  has  ceased  or  is  slight,  and 
Avhere  there  is  drowsiness,  stupor,  or  relaxation.  The  effects  of  the  dose 
should  always  be  carefully  watched ;  a  small  dose  repeated  is  better  than 
a  single  large  dose.  For  a  child  a  year  old,  not  more  than  gr.  -/q  of 
morphine  and  gr.  -g-^o-  of  atropine  should  be  the  initial  dose.  It  may  be 
repeated  in  an  hour  unless  the  desired  effects  are  produced;  these  are, 
arrest  of  the  vomiting  and  purging  (or  at  least  their  diminution),  im- 
provement in  the  heart's  action,  and  in  the  nervous  symptoms.  Here,  as 
in  shock,  we  find  morphine  our  most  reliable  heart  stimulant.  The  use 
of  opium  by  the  mouth  is  not  to  be  relied  upon,  oAving  to  the  uncerttwnty 
of  absorption  and  the  liability  to  produce  vomiting. 

For  the  third  indication,  it  is  useless  to  give  flviids  by  the  mouth. 
The  only  thing  that  can  be  depended  upon  is  the  injection  of  a  normal 
salt  solution  into  the  cellular  tissue  of  the  abdomen,  buttocks,  thighs, 
or  back.  At  least  half  a  pint  should  be  given  in  the  course  of  every 
twelve  hours.  A  very  much  larger  quantity  can  often  be  used  with  ad- 
vantage. This  causes  no  irritation,  and  is  absorbed  with  surprising 
rapidity.  A  simple  apparatus  for  making  the  injection  has  been  de- 
vised by  Dawbarn,  viz.,  to  attach  the  needle  of  a  hypodermic  syringe  by 
a  few  inches  of  rubber  tubing  to  the  nozzle  of  a  bulb  (Davidson's) 
syringe.  Only  a  sterilized  syringe  should  be  used,  and  care  must  be 
taken  to  prevent  the  entrance  of  air.  Special  apparatus  for  such  injec- 
tions is  also  sold  in  the  shops.  The  injection  is  made  slowlv,  and  the 
exact  amount  introduced  at  each  time  measured. 

Only  baths  are  to  be  relied  upon  for  the  reduction  of  temperature. 
They  may  be  continued  from  ten  to  thirty  minutes,  and  to  be  efficient, 
must  be  used  frequently — as  often  as  every  hour  if  symptoms  are  threat- 
ening. Iced  cloths  or  an  ice  cap  should  be  applied  to  the  head.  Cold- 
water  injections  are  a  valuable  accessory  to  the  treatment  by  baths.  A 
rectal  tube  should  be  used,  and  the  injection  carried  high  up  into  the 
colon,  the  water  being  allowed  to  flow  in  and  out  freely.  ISTothing  should 
be  allowed  by  the  mouth  except  ice  and  iced  champagne  or  brandy.    The 


ACUTE  ILEO-COLITIS.  38X 

stinmlants  must  be  given  in  small  quantities  and  frequentl3^  When 
stimulants  taken  by  the  mouth  are  vomited,  the}^  should  be  given  hyj^o- 
dermically.  Brandy,  ether,  or  camphor  may  be  used  freely.  During  the 
stage  of  most  acute  symptoms,  to  attempt  to  give  food  or  drugs  of  any 
kind  by  the  mouth  is  worse  than  useless.  After  the  stage  of  violent 
symptoms  has  subsided  and  reaction  is  established,  the  subsequent  man- 
agement in  respect  to  feeding  and  medication  should  be  the  same  as  in 
the  cases  considered  in  the  previous  chapter.  If  the  symptoms  described 
as  hijdrencephaJoid  are  present,  opium  is  to  be  avoided,  stimulants  by 
the  mouth  used  freeh',  and,  if  these  are  not  retained,  they  should  be 
given  hypodermically.  For  cold  extremities  and  subnormal  temperature, 
hot  mustard  baths  should  be  used  to  establish  reaction,  mustard  paste 
applied  all  over  the  body,  and  hot-water  bags  and  bottles  placed  about 
the  patient. 


CHAPTEK    YIII. 

DISEASES  OF   THE  INTESTINES.— {Continued.) 
ACUTE  COLITIS  AND   ILEO-COLITIS. 

Synonyms :  Entero-colitis,  enteritis,  enteritis  follienlaris,  dysentery, 
inflammatoiy  diarrhoea. 

The  terms  colitis  and  ileo-colitis  are  general  ones,  embracing  those 
forms  of  intestinal  disease  in  which  the  more  serious  lesions  are  pres- 
ent. In  gastro-enteric  intoxication  recovery  or  death  takes  place  before 
anything  more  than  superficial  changes  have  occurred,  while  in  ileo- 
colitis the  pathological  process  continues  until  there  have  been  produced 
marked  lesions,  often  involving  all  the  walls  of  the  intestine.  Ileo-colitis 
is  thus  to  be  regarded  as  a  condition  into  which  any  case  of  gastro- 
enteric intoxication  may  develop.  Sometimes  the  transition  is  so  grad- 
ual that  it  is  impossible,  by  symptoms,  to  draw  a  line  between  them. 
This  is  especially  true  of  the  cases  terminating  in  follicular  ulceration  of 
tlie  colon.  In  some  of  the  other  forms — acute  catarrhal  and  acute  mem- 
branous colitis — the  evidences  of  a  severe  intestinal  inflammation  are 
often  manifest  from  the  very  outset.  This  difference  is  probably  due 
to  a  difference  in  the  character  of  the  infection  and  its  virulence  in  the 
two  classes  of  eases.  The  extent  of  the  lesions  depends  very  much  upon 
the  duration  of  the  process.  It  has  seemed  wise,  with  our  present  un- 
derstanding of  these  cases,  to  drop  tlie  term  dysentery  as  a  generic  one, 
grouping  tliem  all  under  tlie  general  head  of  ileo-colitis  until  an  etio- 
logical classification  shall  .become  possible. 
26 


382  DISEi^SES  OF   THE   DIGESTIVE  SYSTEM. 

Etiology. — ]\rost  of  the  etiological  factors  discussed  in  the  previous 
chapter  apply  with  equal  force  to  the  cases  of  ileo-colitis.  It  may  be  sec- 
ondary to  any  of  the  infectious  diseases,  particularly  measles,  diphtheria, 
and  broncho-pneumonia.  As  to  contagion,  we  are  still  in  doubt  as  to 
the  degree  in  which  this  is  possible.  Infants  are  most  often  affected,  but 
the  disease  is  not  uncommon  up  to  the  fifth  year.  Attacks  are  more 
frec|uent  in  the  summer,  but  they  may  occur  at  any  season.  In  the  fall 
months,  some  outbreaks  seem  to  be  very  closely  connected  with  marked 
changes  in  the  temperature. 

From  the  investigations  thus  far  made  it  would  appear  that  no  one 
form  of  bacteria  is  responsible,  but  that  many  play  a  part  in  the  etiology 
of  this  disease.  Booker  found  the  deeper  lesions  usually  associated  with 
the  streptococcus ;  but  whether  the  latter  was  primary  or  a  secondary 
infection  was  not  easy  to  determine.  Escherich  and  others  found  the 
streptococcus  in  cases  regarded  as  primary.  The  bacillus  pyocyaneus  has 
been  found  in  some  of  ni}'  own  hospital  cases  and  elsewhere.  At  this 
age  amcebse,  though  occasionally  found  (see  page  -iOo),  do  not  appear 
to  be  a  frequent  etiological  factor. 

The  most  important  contribution  to  the  etiology  of  acute  ileo-colitis 
has  been  made  recently  Ijy  Flexner  and  his  pupils,  Duval  and  Bassett, 
who  demonstrated  the  presence  of  the  bacillus  of  Shiga  in  forty-two  of 
fifty-three  cases  of  acute  diarrhceal  disease  studied  in  one  institution  in 
a  single  summer.  That  the  presence  of  the  bacillus  of  dysentery  in  the 
discharges  was  not  an  accidental  finding  was  shown  by  the  fact  that  they 
obtained  the  characteristic  agglutination  reaction  with  the  organism  and 
the  blood  of  these  patients  in  dilutions  ranging  from  1  to  50  to  1  to 
1,000.  The  blood  reaction  occurred  in  some  cases  as  early  as  the  third 
day,  and  it  usually  became  well  established  from  the  seventh  to  the 
twelfth  day;  a  small  number  of  cases  did  not  react  until  the  third  or 
fourth  week,  and  some  not  at  all.  During  convalescence  the  reaction 
was  lost  or  greatly  weakened,  and  did  not  long  persist  after  recover}-. 
In  some  chronic  cases  it  continued  for  months.  The  clinical  type  of  the 
disease  in  which  the  bacillus  was  usually  found  was  acute  dysenteric 
diarrhoea  with  much  blood  and  mucus  in  the  stools.  Unpuljlished  con- 
firmatory observations  have  been  made  by  Park,  Dunham,  and  Wollstein. 

Lesions. — In  about  half  the  cases  only  the  colon  is  affected;  in  the 
remainder  the  disease  extends  into  the  ileum,  Init  usually  only  to  the 
distance  of  two  or  three  feet.  In  character  and  severity  the  lesions 
differ  greatly.  The  frequency  with  which  the  different  varieties  of  ileo- 
colitis were  found  in  eiglity-two  of  my  own  autopsies  was  as  follows: 

Follicular  ulceration 36 

Catarrhal  inflammation 26 

Catarrhal  inflammation  with  superficial  ulceration 6 

Membranous  inflammation ^ 

82 


ACUTE  ILEO-COLITIS.  383 

Acute  catarrhal  Ueo-colitis. — In  the  milder  cases  there  are  changes  in 
the  epithelium  and  infiltration  of  the  mucosa.  In  the  severer  cases  the 
suhniucosa  is  involved,  and  the  infiltration  of  the  mucosa  may  be  so  great 
as  to  lead  to  necrosis  and  the  formation  of  ulcers. 

Gross  appearances. — While  the  lower  ileum  and  the  colon  are  most 
seriously  affected,  it  is  not  uncommon  to  find  quite  marked  changes  in  a 
considerable  portion  of  the  small  intestine,  and  even  in  the  stomach.  In 
the  cases  of  short  duration,  the  lesions  are  sometimes  more  marked  in  the 
small  intestine  than  in  the  colon.  The  stomach  contains  undigested  food, 
and  mucus  which  is  commonly  stained  a  dark-brown  colour.  It  may  be 
dilated  or  contracted.  The  mucous  membrane  is  pale  or  congested ;  if 
the  latter,  it  is  usually  in  patches,  and  more  about  the  pyloric  orifice. 


Fig.  65. — Acute  catarrhal  inflammation  of  the  ileum. 

At  the  left  is  seen  the  edge  of  a  Peyer's  patch  (P)  greatly  swollen.  The  most  striking 
feature  of  the  lesion  is  the  loss  of  the  superficial  epithelium,  which  is  shown  in  all  parts  of  the 
specimen.  The  significance  of  this  depends  upon  the  fact  that  the  autopsy  was  made  but  two 
hours  after  death.  At  several  points,  F,  F,  the  tubular  follicles  have  loosened  and  fallen  out. 
The  mucosa,  A,  is  slightly  infiltrated  with  cells,  especially  near  the  Peyer's  patch.  The  sub- 
mucosa,  C,  and  muscular  coats,  i),  F,  are  normal.  F,  F,  are  small  veins.  History. — Infant,  nine 
months  old,  previously  healthy;  sick  three  days  with  severe  intestinal  symptoms;  temperature. 
103°  to  105°  F.  Avtnpsj/. — Acute  catarrhal  inflammation  of  ileum  and  colon ;  Peyer's  patches 
red  and  swollen.  The  specimen  is  taken  from  the  lower  ileum.  The  supei-ficial  character  of 
the  lesion  is  chiefly  due  to  the  short  duration  of  the  process. 

The  intestinal  contents  are  generally  green  in  colour,  and  thin.  The 
mucous  membrane  is  often  coated  with  tenacious  mucus.  The  small  in- 
testine is  distended  with  gas,  the  large  intestine  nearly  empty,  except  the 
transverse  colon.  The  mucous  membrane  may  appear  somewhat  swollen. 
In  the  small  intestine  there  are  occasionally  seen  swelling  and  axlema  of 
the  villi,  so  that  they  project  abnormally  and  give  a  plush-like  appearance. 
Congestion  is  a  constant  feature,  and  it  may  be  simply  upon  the  folds  of  the 
mucous  membrane,  or  about  the  solitary  lymph  nodules;  or  it  may  be  in- 
tense and  involve  the  whole  intestine  for  some  distance.  Small  ha?morrhagic 
areas  are  often  seen  here  and  there,  widely  scattered.  In  the  most  severe 
cases  there  are  marked  thickening  and  uniform  congestion,  and  the  appear- 
ance is  sometimes  much  like  that  seen  in  membranous  inflammation.    The 


384 


DISEASES   OF   THE  DIGESTIVE  SYSTEM. 


l^'mph  nodules  (solitary  follicles)  throughout  the  colon  are  usually  swollen, 
projecting  above  the  mucous  membrane  about  the  size  of  a  pin's  head, 
Peyer's  patches  may  be  normal,  or  they  may  be  swollen  and  congested, 
with  other  evidences  of  catarrhal  inflammation  in  the  surrounding  mucous 
membrane,  or  more  rarely  they  may  be  involved  when  the  rest  of  the  mu- 
cosa appears  healthy.  The  same  is  true  of  the  lymph  nodules  of  the  small 
intestine.  The  lymph  nodes  of  the  meseutery  are  usually  swollen  and 
acutely  congested,  but  they  may  appear  normal. 

Microscoj)ical  appearances. — In  interpreting  the  changes  found  in  the 
mucosa,  the  same  precautions  must  be  observed  as  stated  on  page  361. 

There  is  usually  loss  of  the  superficial  epithelium  and  of  that  lining 
the  tubular  glands  at  their  orifices.     Upon  the  surface  of  the  mucosa  and 


Fig.  66. — Acute  catarrhal  inflammation  of  the  ileum ;  severe  form. 

The  mucosa,  0,  is  everywhere  densely  infiltrated  with  round  cells,  compressing  the  tubular 
follicles,  and  in  places,  Z,  i,  almost  effacing  them.  Upon  the  surface  of  the  mucosa  is  a  thick 
layer  of  cells  and  mucus.  Beneath  this  the  epithelial  arches,  B,  B^  covering  the  villi  can  be 
seen.  The  lesions  are  almost  entirely  of  the  mucosa.  The  only  changes  in  the  submucosa,  E^ 
are  groups  of  cells  about  the  small  blood-vessels,  F,  V.  Hidory. — Infant  six  months  old ;  mod- 
erate diarrhoja  twelve  days ;  severe  symptoms  with  high  temperature  for  six  days.  There  was 
intense  inflammation  of  the  entire  colon  and  lower  three  feet  of  the  ileum.  Intestine  greatly 
congested  and  thickened.     Specimen  is  from  the  ileum. 


within  the  tubular  glands,  fine  granular  matter  is  seen  derived  from  the 
broken-down  epithelium.  The  goblet  cells  are  distended  with  mucus,  and 
do  not  stain  clearly.  The  lumen  of  the  tubular  glands  is  narrowed  from 
pressure  due  to  the  swelling  of  the  lymphoid  tissue  which  separates  them, 
which  is  partly  from  oedema,  and  partly  from  cell  infiltration  (Fig.  Cio). 
A  thick  layer  of  mucus  and  round  cells,  adhering  closely  to  the  surface, 
may  resemble  a  pseudo-membrane  (Fig.  6G).  In  fatal  cases  of  moder- 
ate severity  the  superficial  portion  of  the  mucosa  is  infiltrated  with 
round  cells  and  crowded  with  bacteria  (Plate  YIII,  C),  the  depth  to 
which  this  infiltration  extends  depending  upon  the  severity  and  dura- 


PLATE    IX. 


Extensive  Superficial  Ulceratiox  of  the  Colon. 

Female  child  nine  months  old ;  symptoms  of  acute  ileo-colitis  of  fifteen  days'  dura- 
tion;  temperature,  101°  to  104-5°  F.,  and  from  six  to  eight  stools  daily — thin,  green, 
and  yellow,  but  no  blood. 

Extensive  ulceration  throughout  the  colon,  most  marked  in  descending  portion, 
from  which  specimen  is  taken. 

A  A  are  small  cii-cular  ulcers ;  B  B,  larger  ones  from  coalescence  of  several  of 
these;  C  C,  large  areas  of  ulceration,  the  mucous  membrane  being  almost  entirely 
destroyed. 


ACUTE   ILEO-COLITIS.  385 

tion  of  the  process.  In  very  severe  cases  there  is  found  a  dense  infiltra- 
tion of  the  mucosa  and  of  the  submucosa  also,  which  in  places  extends 
quite  to  the  muscular  coat.  These  cases  closely  resemble  those  of  the 
membranous  variety,  lacking  only  the  exudation  of  fibrin.  The  lymph 
nodules  of  the  colon  are  swollen  to  a  greater  or  less  degree,  chiefly  from 
an  increase  in  the  number  of  lymphoid  cells.  This  swelling  may  be  the 
most  prominent  feature  of  the  lesion.  If  the  process  is  sufficiently  pro- 
longed, the  l3aiiph  nodules  may  break  down  and  ulcerate.  The  changes 
in  the  lymph  nodules  of  the  small  intestine  and  in  Peyer's  patches  are 
similar  to  those  seen  in  the  colon,  but  are  less  marked,  and  frequently 
absent  altogether.    Ulceration  in  Peyer's  patches,  is  extremely  rare. 

The  small  veins  and  capillaries  of  the  mucosa  and  submucosa  are 
usually  distended  with  blood ;  small  extravasations  are  very  common,  and 
occasionally  larger  ones  are  seen. 

Catarrhal  inflammation,  except  in  its  very  severe  form,  which  is  not 
frequent,  causes  no  lesions  that  can  not  readily  be  repaired.  The  most 
persistent  change  is  usually  the  sw^elling  of  the  lymph  nodules,  which  may 
last  a  long  time,  and  appears  to  be  an  important  factor  in  the  tendency  to 
relapses  and  recurring  attacks.  If  there  is  a  continuance  of  the  exciting 
cause,  or  the  patient's  constitution  is  a  bad  one,  the  process  may  become 
chronic. 

Catarrhal  inflximmation  ivith  superficial  ulceration. — In  the  most 
severe  form  of  catarrhal  inflammation  which  does  not  prove  fatal  in 
the  earlier  stages,  extensive  ulceration  occasionally  takes  place;  usually 
these  ulcers  are  seen  throughout  the  entire  colon,  and,  in  rare  cases,  a 
few  are  found  in  the  lower  ileum.  They  generally  begin  in  the  mucosa 
overlying  the  lymph  nodules,  and  while  they  have  a  wide  superficial  area, 
they  do  not  extend  deeper  than  the  mucosa.  The  small  ulcers  are  circu- 
lar and  usually  show  at  the  centre  a  small  granular  body — the  lymph 
nodule.  The  larger  ulcers  result  from  the  coalescence  of  several  small  ones, 
and  are  irregular  in  shape.  They  may  be  two  or  three  inches  in  diameter. 
Sometimes  for  a  considerable  distance  a  large  part  of  the  mucosa  may 
be  destroyed.  Often  the  entire  surface  presents  a  worm-eaten  appearance 
(Plate  IX).  On  microscopical  examination  there  is  seen,  in  the  greater 
part  of  the  ulcer,  complete  destruction  of  the  mucosa,  the  submucosa 
being  densely  packed  with  round  cells  quite  to  the  muscular  coat. 

Inflammatiou  of  tlic  lijnipli.  iwdales  ■with  ulceration  {follicular  ulcer- 
ation).— Follicular  ulcers  are  found  at  autopsy  in  about  one-third  of  the 
cases  (lying  IVoni  dian-lid'al  diseases.  They  are  rarely  seen  in  tliosc^  which 
have  lastetl  less  than  a  week,  and  not  often  before  the  middle  of  the 
second  week.  The  average  duration  of  the  disease  in  these  cases  is  about 
three  weeks. 

In  thirty-six  cases  in  which  follicular  ulcers  were  found  at  autopsy, 
they  were  present  in  the  small  intestine  alone  in  but  three  cases ;  in  the 


386 


DISEASES   OF  THE   DIGESTIVE   SYSTEM. 


small  intestine  and  in  tlie  colon  in  six  cases ;  in  the  remaining  twenty- 
seven  they  were  present  only  in  the  colon.  When  in  the  small  intestine 
they  were  seen  only  in  the  lower  ileum.  Ulceration  was  seen  a  few  times 
in  one  or  two  of  the  nodules  of  a  Peyer's  patch.  Ulceration  of  the  large 
intestine  involved  the  whole  colon  in  about  half  the  cases ;  while  in  the 
remainder  the  process  was  limited  to  its  lower  portion.  The  deepest  and 
also  the  largest  ulcers  were  usually  in  the  descending  colon  and  sigmoid 
flexure. 

In  the  early  stage  these  ulcers  appear  as  tiny  excavations  at  the  summit 
of  the  prominent  lymph  nodales.  Later,  the  whole  nodule  may  be  de- 
stroved,  and  a  small  round  ulcer  is  formed  from  one  twelfth  to  one  fourth 
of  an  inch  in  diameter  (Plate  X).  These  are  quite  deep  and  have  over- 
hanging edges ;  when  closely  set  they  give  the  intestine  a  sieve-like  ap- 


Fig.  67. — Lymph  nodule  of  the  colon  in  the  early  stage  of  ulceration — Follicular  ulcer. 

The  nodule,  i%  is  much  enlarged,  and  is  breaking  down  and  discharging  into  the  intestine. 
The  other  changes  are  not  markecl.  The  supei-ticiarepitheliuin  is  gone :  the  mucosa.  A^  shows 
a  slight  increase  of  cells,  and  in  the  submucosa,  C.  are  nests  of  cells  about  the  small  vessels,  V.  V. 
Jlisto?-!/.— Delicate  child,  thirteen  months  old ;  slight  diarrhoea  four  weeks :  severe  symptoms 
live  days.  The  colon  was  filled  with  ulcers  one  twelfth  of  an  inch  in  diameter,  one  of  which 
is  shown  in  the  illustration. 


pearance.  By  the  coalescence  of  several  of  them,  larger  ulcers  may  form 
which  are  an  inch  or  more  in  diameter.  At  the  bottom  of  these  larger 
ones  the  transverse  strige  of  the  circular  muscular  coat  are  often  plainly 
seen.     I  have  never  known  them  to  cause  perforation. 

Microscopical  appearances. — The  lymph  nodules  are  swollen,  principally 
from  the  accumulation  within  them  of  round  cells.  This  is  followed  by 
softening,  which  usually  begins  at  the  summit  of  the  nodule  and  ex- 


PLATE    X. 


Deep  Follicular  Ulcers  of  the  Colon. 

A  delicate  child,  fourteen  months  old,  sick  twelve  days ;  stools  green,  yellow,  brown, 
and  watery;  no  blood  :  temperature,  100    to  101"  F. 

The  small  intestine  was  normal ;  ulcers  throughout  colon.  The  specimen  is  from 
descending  colon  :  the  ulcers  are  deep,  and  most  of  them  extend  to  the  muscular  coat. 
(For  microscopical  appearance,  see  Fig.  68.) 


ACUTE   ILEO-COLITIS.  337 

tends  downward;  the  reticulum  breaks  down,  and  the  eelluhir  contents 
escape  into  the  intestine  (Fig.  67).  Softening  may  begin  at  the  centre 
of  the  nodule,  which  ruptures  like  an  abscess.  The  destruction  of  the 
whole  nodule  leaves  a  cavity,  which  is  the  follicular  ulcer.  At  first  the 
ulcers  correspond  in  size  to  the  nodule,  but  infiltration  of  the  adjacent 
tissue  soon  takes  place,  and  this  may  become  necrotic.  In  this  way 
the  ulcer  extends  chiefly  in  the  submucous  coat.     The  lesion  is  never 


■^^m 


5^    r 


>2>-= 


Fig.  68. — Deep  follicular  ulcer  of  the  colon. 

A  deep  ulcer  is  shown  at  F^  a  smaller  one  at  F'.  The  separation  of  the  mucosa  at  II  is  acci- 
dental. Ihere  is  no  trace  of  the  lymph  nodule  from  which  the  large  ulcer  had  its  origin.  The 
destructive  i^rocess  has  extended  laterally  in  the  submucosa,  C,  and  the  mucosa,  A^  is  falling  in 
to  fill  up  the  space.  In  the  vicinity  of  the  ulcers,  the  submucosa  is  densely  infiltrated  with 
round  cells,  Z",  Z",  which  also  are  seen  in  the  lymjth  spaces  between  the  bundles  of  circular 
muscular  fibres,  Z',  Z',  and  some  are  seen  in  the  longitudinal  muscular  coat,  Z,  Z.  History, — 
Thirteen  months  old,  delicate;  continuous  diarrhaml  symptoms  for  three  weeks.  Ulcers  found 
throughout  the  colon,  the  largest,  one  half  an  inch  in  diameter.  The  illustration  shows  one  of 
the  small  ones  like  those  in  Plate  X. 

limited  to  the  lymph  nodules ;  but  the  extent  of  the  other  changes  found 
depends  upon  the  severity  and  the  duration  of  the  process.  In  cases 
dying  after  an  illness  of  a  week  or  ten  days,  we  usually  find  only  moder- 
ate changes  in  the  mucosa,  and  in  the  submucosa  a  slight  infiltration  of 
round  cells,  especially  about  the  small  blood-vessels  (Fig.  67,  V,  V). 
In  those  which  have  lasted  three  or  four  weeks  the  ulcers  are  deeper,  and 
all  the  structures  of  the  intestine  in  their  neighbourliood  are  usually 
involved  (Fig.  68).  The  mucosa  is  densely  packed  with  round  cells,  as 
are  also  all  the  tissues  in  the  vicinity  of  the  ulcers;  even  the  muscular 
coat  may  bo  infiltrated.  The  ulcers,  however,  rarely  extend  deeper  than 
the  circular  layer. 

Follicular  ulceration  of  the  intestine  in  infancy,  usually  terminates 
fatally  if  the  process  is  an  extensive  one.  In  less  severe  cases,  recovery 
may  take  place,  the  ulcers  healing  by  grnniihii  ion  and  cicatrization  in  the 
course  of  from  four  to  eight  weeks. 

Acute  membranous  ileo-colitis. — This  is  the  most  severe  form  of  intes- 


388  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

tinal  inflammation  seen  among  children.  The  process  differs  quite  mate- 
rially from  that  described  as  occurring  among  adults.  In  only  one  of  my 
own  cases  was  it  associated  with  membranous  inflammation  of  any  other 
mucous  membrane,  in  that  case  with  membranous  gastritis.  The  most 
frequent  type  of  membranous  colitis  is  that  with  severe  acute  symptoms, 
both  constitutional  and  local,  with  a  duration  of  from  six  to  fourteen 
days.  In  young  infants  its  symptoms  and  course  are  very  irregular,  and 
it  may  be  found  at  autopsy  when  no  serious  intestinal  lesion  has  been 
suspected. 

Gross  appearances. — There  is  visible  to  the  naked  eye  usually  very  lit- 
tle pseudo-membrane  and  no  deep  sloughing.  The  lesion  affects  the 
last  two  or  three  feet  of  the  ileum  and  the  entire  colon,  sometimes  only 
tlie  colon.  It  is  exceedingly  rare  to  meet  with  any  marked  lesions  higher 
in  the  small  intestine.  The  most  marked  changes  are  near  the  ileo-csecal 
valve  or  in  the  sigmoid  flexure  and  the  rectum.  In  the  ileum  they  may 
be  quite  as  severe  as  in  the  colon  (Plate  XI).  The  intestinal  wall  is 
Arm  and  stiff,  and  is  two  or  three  times  its  normal  thickness.  It  is  not 
thrown  into  deep  folds,  as  is  the  healthy  intestine  when  empty.  It  is 
very  rare  to  find  false  membrane  that  can  be  stripped  off  in  patches  of 
any  considerable  size.  When  membrane  exists,  the  colour  is  a  yellowisli 
or  grayish  green,  and  the  surface  is  often  fissured,  giving  a  lobulated 
appearance.  In  the  parts  where  no  pseudo-membrane  can  be  seen,  the 
surface  is  usually  of  an  intense  red  colour  and  is  rough  and  granular,  in 
striking  contrast  to  the  normal  glistening  appearance.  Here  and  there 
small  extravasations  of  blood  may  be  seen.  In  the  regions  most  affected, 
the  normal  structures  of  the  mucous  membrane — the  villi.  Fever's 
patches,  and  solitary  follicles — can  not  be  distinguished.  In  a  single 
instance  I  found  an  exudation  of  fibrin  on  the  peritoneal  surface  of  the 
intestine  for  a  short  distance.  Except  in  the  lower  ileum  the  small  intes- 
tine shows  no  constant  changes,  and  none  are  usually  found  in  the 
stomach. 

Microscopical  changes. — These  (Fig.  69)  are  much  more  uniform 
than  the  gross  appearances.  The  most  characteristic  feature  is  the  exu- 
dation of  fibrin,  which  forms  a  distinct  pseudo-membrane  upon  the  sur- 
face of  the  intestine;  it  may  infiltrate  the  mucosa,  and  even  the  sub- 
mucosa.  Fibrin  is  seen  under  the  microscope  in  parts  of  the  specimen, 
which  to  the  naked  eye  show  no  distinct  pseudo-membrane,  but  only  a 
granular  appearance.  In  rare  cases  a  fibrinous  exudation  may  be  found 
upon  the  peritoneal  covering  of  the  intestine.  The  pseudo-membrane  is 
made  up  of  a  fibrinous  network  containing  small  round  cells,  some  red 
blood-cells,  and  bacteria,  chiefly  cocci.  The  mucosa,  and  usually  the  sub- 
mucosa,  are  densely  inflltrated  with  small  round  cells,  which  in  places 
may  be  so  numerous  as  to  efface  the  normal  elements  of  the  intestine. 
The  tubular  follicles  are  in  some  places  quite  destroyed,  not  a  vestige  of 


PLATE    XI. 


r    A 


Membranous  Inflammation  of  the  Ileum. 

A  delicate  child,  eleven  months  old ;  mild  diarrhaux  for  two  weeks  without  fever ; 
acute  severe  symptoms  for  twelve  days;  temperature,  100'  to  102-5"  F. ;  green  and 
mucous  stools  :  no  blood. 

The  lesions  involved  the  last  foot  of  iUnim  and  entire  colon.  Specimen  is  frum 
lower  ileum,  and  shows  the  abrupt  termination  of  the  l(>sion  ;  tlie  upper  part  shows 
normal  small  intestine;  A  is  a  Peyer's  patch;  B  is  the  inllamed  part  of  the  intestine; 
it  has  a  rougii  granular  appearance  and  is  much  thickened. 


ACUTE  ILEO-COLITIS.  389 

them  remaining.  In  otlier  places  tliey  are  compressed  and  distorted  by 
the  accumulation  of  cells.  The  great  thickening  of  the  intestine  is  due 
partly  to  the  cell  infiltration,  partly  to  the  fibrinous  exudation,  and  partly 
to  oedema.    All  the  blood-vessels,  both  in  the  mucosa  and  submucosa,  are 


M  «B  -ct* 


^>/? 

'^y 


Fig.  69. — Membranous  inflammation  of  the  colon. 

The  intestine  is  covered  with  a  pseudo-membrane,  J/,  which  is  composed  chiefly  of  granu- 
lar fibrin;  the  mucosa,  A,  is  densely  packed  with  round  cells,  and  the  tubular  follicles  have 
almost  disappeared,  traces  only  being  left  at  Z!,  T.  The  .submucosa,  C.  is  greatly  thickened, 
partly  from  cells,  but  chiefly  from  fibrin,  which  with  a  high  power  is  seen  to  be  even'where  in 
this  coat,  as  well  as  the  mucosa.  Nests  of  cells  are  seen  in  the  muscular  coats  at  Z,  L.  At  F\^ 
a  lymph  nodule  covered  by  pseudo-membrane,  but  breaking  down  at  its  centre.  F,  F,  are  small 
blood-vessels  with  nests  of  cells  about  them.  Ewtory. — Fourteen  months  old;  ill  nine  days  ; 
temperature  101°  to  105°  F. ;  all  stools  containing  blood.  Lesions  found  throughout  colon  and 
in  lower  ileum.  Intestine  greatly  thickened.  Specimen  is  from  ascending  colon,  where  lesion 
was  especially  severe. 

gorged  with  blood,  and  many  small  extravasations  are  seen.  A  necrotic 
process  with  the  formation  of  deep  ulcers  I  have  never  seen  associated 
with  membranous  colitis. 

Associated  lesions  of  ileo-coUtis. — The  most  important  one  is  bron- 
cho-pneumonia. It  is  found  in  quite  a  large  proportion  of  the  protracted 
cases,  and  not  infrequently  it  is  the  cause  of  death.  I  think  it  is  seldom 
due  to  an  infection  from  the  intestine,  although  such  a  thing  is  possible  in 
septicemic  cases.  It  occurs  rather  as  it  does  in  any  other  protracted 
exhausting  disease.  In  a  study  of  sixty  cases,  Spiegelbcrg  did  not  find 
bacteria  in  the  pulmonary  capillaries,  and  he  regards  infection  through 
the  blood  as  not  yet  proved.  Pulmonary  tuberculosis  is  not  infrequently 
met  with  in  hospital  cases,  having  no  relation  to  the  intestinal  disease. 
I  once  saw  a  pulmonary  abscess  complicating  an  attack  of  ulcerative 


390  DISEASES   OF   THE  DIGESTIVE   SYSTEM. 

colitis;  it  was  at  the  apex,  and  was  not  associated  with  suppuration 
elsewhere.  Peritonitis  is  infrequent.  I  have  met  with  it  but  once  or 
twice,  and  then  it  was  localized  and  of  the  plastic  variety.  Inflamma- 
tions of  the  other  serous  membranes — pleurisy,  pericarditis,  and  menin- 
gitis— are  all  very  rare. 

The  renal  lesions  of  ileo-colitis  have  been  the  subject  of  considerable 
discussion,*  some  observers  holding  that  nephritis  is  a  frecpient  conqDli- 
cation  of  the  severer  forms  of  diarrhcea,  while  others  have  held  it  to  be 
rare.  The  lesions  I  have  usually  found  in  my  own  cases  coincide  with 
those  described  by  others,  and  consist  in  marked  degeneration  of  the 
epithelium  of  the  tubes  with  but  few  glomerular  or  interstitial  changes. 
In  three  or  four  instances  only  have  I  found  well-marked  lesions  of  acute 
diffuse  nephritis  at  autopsy,  or  seen  its  symptoms  clinically.  I  believe 
it  to  be  a  very  infrequent  though  sometimes  a  most  serious  complica- 
tion. The  lesions  mentioned  as  usually  present  are  properly  classed 
as  acute  degeneration  rather  than  as  inflammation  of  the  kidney.  Its 
causes  are  chiefly  the  irritation  of  toxins,  intensified  no  doubt  by  the 
concentration  of  the  urine.  Degenerative  changes  may  be  found  also 
in  the  heart  muscle,  the  liver,  spleen,  and  even  in  the  central  nervous 
system. 

.  Considerable  attention  has  been  given  lately  to  a  study  of  the  blood 
in  intestinal  inflammations,  to  determine  how  frequently  and  in  what 
circumstances  a  general  blood  infection  (septicemia)  from  the  intestines 
occurs.  In  the  great  majority  of  the  cases  studied  under  proper  pre- 
cautions the  blood  is  sterile.  It  is  most  likely  to  become  infected  when 
there  are  serious  ulcerative  lesions;  but  sometimes,  especially  with 
streptococci,  when  only  superficial  lesions  are  present.  It  is  not  prob- 
able that  the  bacteria  in  the  blood  are  an  important  factor  in  producing 
lesions  in  other  organs. 

Symptoms. —  (1)  Catarrluil  cases  of  moderate  severity. — The  onset  is 
usually  sudden,  often  with  vomiting,  and  for  twelve,  sometimes  twenty- 
four  hours  the  symptoms  may  be  those  of  acute  indigestion:  vomiting, 
pain,  fever,  and  frequent  thin  green  or  yellow  stools,  which  are  partly 
faecal  and  contain  undigested  food.  Later  the  discharges  contain  blood 
and  mucus,  are  often  preceded  by  pain  and  accompanied  by  tenesmus. 
The  stools  are  very  frec{uent,  often  every  half  hour  and  proportionately 
small,  sometimes  less  than  a  tablespoonful  being  found  upon  the  nap- 
kin after  severe  straining  efforts.  The  mucus  may  be  clear  and  jelly- 
like, or  it  may  be  mixed  with  fecal  matter.  Blood  is  seen  in  some  cases 
in  almost  every  stool,  but  rarely  in  clots,  usually  streaking  the  mucus. 
These  stools  are  almost  odourless.     After  two  or  three  days  the  blood 

*  For  a  good  resiwie  of  the  subject,  see  J.  L.  Morse,  Arcliives  of  PiTcliatrics,  1899, 
p.  649. 


ACUTE   ILEO-COLITIS. 


391 


usually  disappears,  or  is  seen  only  as  traces  in  an  occasional  stool;  but 
niucus  is  still  present  in  large  quantities.  The  colour  of  the  discharges 
now  becomes  dark  brown  or  brownish-green.  Prolapsus  ani  is  frequent, 
and  may  occur  with  nearly  every  stool.  Abdominal  pain  is  present,  and 
is  often  quite  intense  just  before  the  stool;  and  frequently  there  is  ten- 
derness along  the  colon.  For  the  first  twenty-four  hours  the  tempera- 
ture is  usually  high,  from  102°  to  104°  F.  During  the  greater  part  of  the 
attack  it  ranges  from  99°  to  102°  F.  There  is  considerable  prostration; 
the  loss  in  weight  is  usually  marked  and  continuous ;  appetite  is  lost ; 
the  tongue  is  coated  and  the  general  appearance  of  the  children  indi- 
cates serious  illness,  although  no  really  grave  symptoms  are  present. 
Convalescence  is  always  slow,  and  it  may  be  months  before  the  child 
regains  its  lost  weight  (Fig.  70). 


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/ 

- 

/ 

1 

i 

S 

A 

1 

^ 

li 

1 

1 

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1 

L 

1 

Fig.  70. — Weight  curve  showing  loss  from  ileo-colitis. 

Well-nourished  infant;  attack  of  measles  at  A  (fortieth  week),  followed  by  ileo-colitis, 
which  thouLfJi  not  severe  continued  with  exacerbations  during  September  and  October.  At  B 
all  symptoms  liad  disappeared  except  occasional  mucus  in  the  stools.  Rapid  improvement  from 
this  time,  which  was  continued  during  the  winter,  the  child  being  sent  to  a  warm  climate;  it 
wa.s,  however,  live  and  a  half  months  before  the  weight  reached  the  normal  average  line. 

In  the  milder  cases  the  symptoms  point  to  inflammation  of  the  lower 
part  of  the  colon  only.  The  constitutional  symptoms  are  not  at  all 
marked.  The  temperature  may  not  be  above  101°  F. ;  the  tongue  may 
remain  clean  and  the  appetite  good ;  the  child  may  be  bright  and  active, 
and  hardly  seem  at  all  ill,  and  yet  have  from  six  to  eight  small  mucous 
and  bloody  stools  a  day. 

The  duration  of  the  acute  symptoms  is  usually  about  a  week,  and 
yet  in  such  cases,  even  though  the  child  was  pivviously  in  good  condition 
and  ]n-operly  treated,  recovery  is  slow.  The  first  symptom  of  improve- 
uicni  is  generally  the  disappearance  of  blood  from  the  stools,  which  at 
the  same  time  become  less  frequent,  and  the  pain  and  tenesmus  cease. 
Gradually  the  stools  assume  more  of  a  faecal  character,  but  mucus  is  likely 


392  DISEASES   OF   TKE  DIGESTIVE  SYSTEM. 

to  persist  for  two  or  three  weeks;  it  may  be  seen  in  all  stools,  or  only 
occasionally.  In  some  cases  both  the  mucus  and  blood  disappear  and  the 
stools  become  thin,  brown,  or  green,  like  those  of  an  ordinary  diarrhoea. 
Although  the  early  stage  of  very  acute  symptoms  may  last  but  a  few 
days,  if  there  is  a  continuance  for  two  or  three  weeks  of  the  brown,  mu- 
cous stools,  with  emaciation  and  slight  fever,  ulceration  is  probably 
present.  This  is  likely  to  occur  if  the  child  is  in  poor  condition,  if  its 
surroundings  are  bad,  or  if  it  is  improperly  treated  at  the  outset.  Ee- 
lapses  are  readily  excited,  but  cases  like  the  above  are  rarely  fatal  except 
in  delicate  infants.  This  is  the  most  common  form  of  ileo-colitis  which 
terminates  in  recovery. 

(2)  The  severe  catarrhal,  form. — The  symptoms  closely  resemble 
those  of  the  membranous  variety,  and  a  diagnosis  from  it  is  to  be  made 
only  by  the  absence  of  pseudo-membrane  from  the  stools.  The  most 
rapid  case  I  have  seen  lasted  only  three  days,  but  the  usual  duration  is 
from  one  to  two  weeks.  The  temperature  is  steadily  high;  the  stools 
continue  very  frequent  and  generally  contain  blood;  there  are  great 
prostration,  dry  tong-ue,  sordes  on  the  lips  and  teeth,  and  prominent 
nervous  symptoms.  Death  usually  occurs  from  exhaustion  and  profound 
sepsis  while  the  acute  symptoms  are  at  their  height.  If  the  patient  sur- 
vives this  stage,  the  case  may  drag  on  for  four  or  five  weeks,  very  much 
like  one  of  follicular  ulceration,  and  then  terminate  in  recovery  or  in 
death  from  slow  asthenia,  broncho-pneumonia,  or  from  an  acute  exacer- 
bation of  the  intestinal  symptoms.  The  autopsy  in  such  cases  usually 
reveals  the  presence  of  superficial  ulcers.  If  recovery  is  to  be  the  out- 
come, after  the  symptoms  have  been  nearly  stationary  for  a  long  time, 
there  is  seen  a  gradual  improvement  first  in  the  general  and  then  in  the 
local  conditions.  Convalescence  is  very  slow,  often  interrupted  by  re- 
lapses, and  it  may  be  months  before  the  patient  is  cpiite  well.  In  some 
cases  the  child  never  regains  its  former  vigour. 

(3)  Follicular  ulceration — ulcerative  inflammation  of  the  lymph 
nodules. — Follicular  ulceration  is  not  very  often  met  with  in  infants 
under  six  months  of  age.  Of  thirty-six  cases  in  which  the  diagnosis  was 
confirmed  by  autopsy,  all  but  four  were  between  the  ages  of  six  and 
twentv-one  months.  The  great  majority  of  these  children  were  in  poor 
condition  at  the  time  of  the  attack. 

To  understand  the  symptoms  of  these  cases,  it  must  be  remembered 
that  follicular  ulceration  is  a  terminal  process  which  may  follow  acute 
gastro-enteric  intoxication.  It  may  be  preceded  by  one  or  more  acute 
attacks,  or  by  a  protracted  subacute  attack.  On  account  of  the  feeble 
resistance  of  the  child  or  the  continuance  of  the  exciting  cause,  the 
pathological  process  gradually  extends  from  the  epithelium  to  the  lymph 
nodules  of  the  intestine,  chiefly  the  colon,  which,  as  already  described, 
pass  successively  through  the  stages  of  swelling,  softening,  and  ulcera- 


ACUTE  ILEO-COLITIS. 


393 


tion.  The  onset  of  the  illness  may  therefore  be  abrupt,  with  vom- 
iting and  high  fever;  or  gradual,  without  vomiting  and  with  very  little 
fever.  The  patient  may  be  ill  for  a  week  before  the  exact  type  which  the 
disease  is  assuming  can  be  positively  determined.  It  is  not  possible  to 
mark  the  transition  from  acute  gastro-enteric  intoxication  to  follicular 
ileo-colitis.  Usually  the  latter  may  be  assumed  to  exist  whenever,  after 
a  very  acute  onset,  there  is  a  continued  temperature  above  101°  F.,  and 
when  the  stools  habitually  contain  large  quantities  of  mucus  without 
blood. 

Vomiting  is  not  a  feature  of  these  cases ;  but  it  is  often  present  at  the 
onset.  Thronghont  the  attack  it  is  easily  excited  by  injudicious  feeding 
or  medication.    The  temperature  is  seldom  high,  except  at  first ;  its  usual 


DAY 

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Fig.  71. — Temperature  chart  of  ileo-colitis,  fatal  on  thirty-fourth  clay.    Autopsy  showed  follicu- 
lar ulcers  throughout  the  colon. 


range  is  from  99°  to  101°  F. ;  toward  the  close,  even  of  fatal  cases,  it  may 
be  scarcely  above  the  normal.  The  accompanying  chart  (Fig.  71)  is  a 
very  good  illustration  of  the  course  of  the  temperature  in  cases  begin- 
ning abruptly  and  ending  fatally. 

The  stools  are  seldom  very  frecjuent,  the  number  being  from  four 
to  eight  a  day.  The  most  constant  feature  is  the  presence  of  mucus, 
which  is  mixed  with  the  stools  and  usually  abundant.  Blood  is  not  gen- 
erally present,  and  a  large  amount  of  blood  is  extremely  rare.  It  was  ab- 
sent entirely  in  more  than  half  of  my  cases  in  which  the  diagnosis  was 
confirmed  by  autopsy.  A  small  quantity  of  blood  early  in  the  attack  is 
not  uncommon,  deisending  here  upon  congestion.  Large  haemorrhages 
from  ulcers  I  have  never  seen.  The  colour  of  the  stools  is  most  fre- 
quently dark  green  or  brown.  Fluid  stools  are  seen  only  during  ex- 
acerbations. The  odour  is  usually  offensive,  particularly  in  protracted 
cases.  The  microscope  shows  epithelial  cells  in  great  numbers,  and  very 
often  an  abundance  of  small  round  cells,  which  may  be  looked  upon  as 
the  most  constant  sign  of  ulceration. 

The  failure  in  nutrition  and  steady  loss  in  weight  are  very  constant  in 
these  cases.    As  emaciation  goes  on,  the  skin  hangs  in  loose  folds  on  the 


394  DISEASES  OF   THE  DIGESTIVE  SYSTEM. 

thighs ;  it  becomes  dry  and  scaly  and  loses  its  elasticity,  and  occasionally 
small  petechial  spots  are  seen  npon  the  abdomen.  The  skin  over  the  but- 
tocks becomes  excoriated,  and  bed-sores  form  over  the  heels,  the  sacrum, 
or  the  occiput.  The  abdomen  may  be  moderately  distended,  or  it  may  be 
relaxed  and  soft.  Tenderness  is  not  usually  present.  The  appetite  is 
lost,  and  in  most  cases  great  difficulty  is  experienced  in  getting  children 
to  take  a  proper  amount  of  nourishment.  Continued  aversion  to  food 
is  an  imfavourable  symptom.  Occasionally,  when  there  is  fever,  fluids 
are  taken  eagerly.  A  returning  appetite  is  always  an  encouraging  sign. 
The  mouth  is  often  dry,  the  tongue  coated,  sometimes  dr}^  and  brown; 
there  may  be  sordes  upon  the  lips  and  teeth.  Superficial  ulcers  form 
upon  the  mucous  membrane  of  the  mouth,  and  often  thrush  is  seen.  The 
urine  is  usually  diminished,  high-coloured,  and  loaded  with  urates.  Al- 
bumin and  casts  are  rarely  present.  In  only  two  or  three  eases  have  I 
seen  nephritis  severe  enough  to  be  a  factor  in  the  result.  Tenesmus  and 
prolapsus  ani  are  uncommon. 

The  average  duration  of  the  fatal  cases  is  about  three  weeks;  their 
course,  is  often  marked  by  exacerbations  and  remissions.  If  recovery 
takes  place,  convalescence  is  always  very  slow  and  relapses  are  easily 
excited. 

Very  few  of  these  cases  recover  completely.  Even  those  who  survive 
the  primary  illness  are  likely  to  suffer  from  intestinal  symptoms  for  many 
months.  Fatal  relapses  are  often  brought  on  by  injudicious  feeding 
when  the  children  are  apparently  almost  well.  The  general  health  is 
usually  so  undermined  that  the  patients  continue  to  suffer  from  all  the 
s3auptoms  of  malnutrition,  and  ultimately  succumb  to  an  attack  of  some 
intercurrent  acute  disease. 

The  diagnosis  of  ulceration  is  to  be  made  from  the  case  as  a  whole 
rather  than  from  any  special  symptoms.  If  a  delicate  infant  which  has 
previously  been  prone  to  diarrhoeal  attacks,  has  green  mucous  stools  with 
low  fever,  and  these  symptoms  continue  with  unabated  severity  for  ten  or 
twelve  days,  ulceration  is  probable.  If  such  symptoms  continue  for  three 
or  four  weeks  with  steadily  failing  strength  and  loss  of  weight,  the  diag- 
nosis is  almost  certain.  If,  on  the  contrary,  after  three  or  four  days  of 
acute  symptoms  there  is  improvement  in  the  stools  and  occasionally  some 
which  are  quite  faecal  in  character,  even  though  it  may  be  a  week  or  more 
before  the  mucus  disappears,  we  may  be  quite  certain  that  no  ulcers  have 
formed. 

(4)  The  memhranous  form. — This  is  the  gravest  form  of  inflamma- 
tion of  the  intestines  seen  in  children,  and  its  symptoms  are  more  often 
obscure  than  are  those  of  any  other  variety.  This  is  particularly  true 
when  it  affects  young  infants.  There  may  be  at  the  onset  and  throughout 
the  course  of  the  disease  severe  local  and  constitutional  symptoms ;  or 
with  well-marked  constitutional  symptoms,  the  local  symptoms  may  be 


ACUTE   ILEO-COLITIS. 


305 


DAY 

1 

2 

3 

4 

5 

6 

7 

8 

DATE 

JULY 

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Fig.  72. — Temperature  chart  of  membra- 
nous colitis :  fatal. 


slight  or  of  very  doubtful  character,  so  that  it  is  often  mistaken  for  some 
other  disease. 

In  the  first  form  it  closely  resembles  the  most  severe  eases  of  catar- 
rhal inflammation.     The  disease  begins  abruptly,  with  vomiting,  high 
temperature,  and  several  large,  fluid  stools.     The  vomiting  does  not 
often  continue  after  the  first  twenty- 
four  hours.     The  temperature  is   at 
first  from  102°  to  105°  F.,  and  its 
course  may  be  steadily  high  (Fig.  72), 
or  remittent.     The  abdomen  is  often 
tender  and  sometimes  swollen.    There 
is  severe  pain,  and  at  times  tenesmus, 
with  prolapse  of  the  rectum.     This  is 
intensely    congested,    and    sometimes 
shows    patches    of    pseudo-membrane 
upon  its  surface,  thus  establishing  the 
diagnosis. 

The  stools  often  resemble  those  of 
the  catarrhal  variety,  except  that 
blood  is  more  constantly  present  and 

usually  more  abundant,  but  the  only  positive  point  of  difference  is  the 
presence  of  shreds  or  flakes  of  pseudo-membrane.  If  the  stools  are 
thoroughly  washed  with  water  these  may  be  seen  as  small  gray  opaque 
masses,  which  are  then  easily  distinguished  from  the  transparent  mucus. 
Large  shreds  of  membrane  are  seldom  seen  in  children.  Both  blood 
and  mucus  sometimes  disappear  from  the  stools,  which  may  consist  only 
of  dirty  water.  Under  the  microscope  there  may  be  seen  epithelial  cells, 
red  blood-cells,  and  round  cells  in  great  numbers. 

The  presence  of  cerebral  symptoms  in  these  cases  of  membranous 
ileo-colitis  may  lead  to  great  obscurity  in  the  diagnosis.  This  is  most 
frequently  true  at  the  onset.  There  may  be  high  temperature,  great 
prostration,  vomiting,  stupor,  delirium,  and  even  convulsions ;  and  such 
symptoms  may  for  two  or  three  days  completely  mask  the  intestinal  con- 
dition. As  the  case  progresses,  however,  the  intestinal  symptoms  come 
more  and  more  into  prominence,  and  the  cerebral  symptoms  usually  sub- 
side. But  sometimes  this  is  not  the  case.  I  once  saw  a  case  closely 
watched  for  two  weeks  by  three  physicians  of  large  experience,  who  were 
agreed  in  the  diagnosis  of  a  coreI)ral  lesion,  but  not  as  to  its  nature, 
which  showed  at  autopsy  only  the  lesions  of  membranous  colitis.  There 
was  a  continuous  but  irregular  fever,  stupor,  retracted  abdomen,  opis- 
thotonus, unequal  pupils,  and  at  times  irregular  respiration.  Two  or 
three  days  before  death  the  first  blood  appeared  in  the  stools,  and  at 
the  same  time,  during  extensive  rectal  prolapse,  a  false  membrane  was 
seen. 


396 


DISEASES  OP   THE  DIGESTIVE  SYSTEM. 


MembranoiTS  colitis  is  also  obscure  when  it  affects  young  infants. 
Every  year  a  number  of  these  cases  are  seen  at  the  Babies'  Hospital. 
The  prominent  symptoms  are:  rather  high,  continuous  temperature, 
usually  ranging  between  101°  and  104°  F.,  but  following  no  distinct 
curve  (Fig.  73).;  wasting,  which  is  not  rapid  but  progressive;  frequent 


Day             8 

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Fig.  73. — Temperature  chart  of  membranous  colitis. 

Infant  fourteen  montlis  old,  Babies'  Hospital.  Symptoms  for  the  first  two  weeks  obscure, 
suggesting  first  pneumonia,  afterward  meningitis.  Intestinal  symptoms  for  the  last  two  weeks 
only,  never  very  severe;  stools  four  to  six  daily,  generally  green,  thin,  with  much  mucus  at 
times,  and  once  or  twice  traces  of  blood.  Culture  four  days  before  death  showed  streptococci 
and  colon  bacilli.  Autopsy :  No  lesion  of  importance  except  membranous  colitis  involving 
entire  colon ;  a  slight  catarrhal  enteritis. 

stools,  which  have  no  constant  or  striking  characteristics.  They  are 
usually  thin,  yellow  or  greenish  in  colour,  often  containing  no  mucus  or 
blood.  Occasionally  for  a  day  the  stools  may  be  almost  normal  in  ap- 
pearance. In  number  they  average  five  or  six  a  day,  but  often  for  days 
only  two  or  three.  Outside  of  a  hospital  where  autopsies  are  regularly 
made  these  cases  would  pass  as  excellent  examples  of  infantile  typhoid. 
In  many  cases  the  diagnosis  wavered  between  obscure  pneumonia,  tuber- 
culosis, and  typhoid,  and  was  settled  only  at  the  autopsy. 

The  duration  of  membranous  ileo-colitis  is  usually  from  one  to  three 
weeks.  Death  takes  place  from  sepsis,  exhaustion,  or  from  complica- 
tions. It  is  probable  that  almost  every  case  of  the  severity  described  ter- 
minates fatally  when  it  occurs  in  an  infant.  In  older  children  the  prog- 
nosis is  much  better  as  to  life,  but  in  them  the  acute  attack  may  be  fol- 
loAved  by  the  chronic  form  of  the  disease. 

Diagnosis. — Ileo-colitis  is  to  be  distinguished  chiefly  from  typhoid 
fever,  intussusception,  and  meningitis.  Typhoid  (see  chapter  on 
Typhoid)  is  distinguished  by  the  slower  invasion,  more  constant  tem- 
perature, enlargement  of  the  spleen,  tympanites,  and  most  of  all  by  the 
Widal  reaction  and  the  eruption.  The  fact  that  the  disease  is  epidemic 
is  also  to  be  considered.  Acute  colitis  should  not  be  confounded  with  in- 
tussusception ;  yet  the  records  of  intussusception  show  that  a  very  large 
proportion  of  the  cases  were  regarded  in  the  beginning  as  cases  of  dysen- 
tery. In  intussusception,  although  we  have  a  sudden  onset  with  acute 
pain,  tenesm.us,  vomiting,  and  marked  prostration,  there  is  rarely  fever. 
The  later  symptoms — absolute  constipation,  tumour,  tympanites,  rising 


ACUTE   ILEU-COLITIS.  -<j7 

temperature,  stercoraceous  vomiting,  and  collapse — have  nothing  in  com- 
mon with  colitis.  The  membranous  form  may  be  confounded  with  men- 
ingitis, and  in  some  cases  a  differential  diagnosis  is  impossible  except  by 
the  course  of  the  disease.  Marked  looseness  of  the  bowels,  even  though 
the  stools  have  no  characteristic  appearance,  should  always  make  one 
doubt  meningitis. 

A  diagnosis  between  the  different  varieties  of  ileo-colitis  is  not 
always  possible.  Follicular  ulceration  is  distinguished  by  its  lower 
temperature,  rather  subacute  course,  infrequency  of  blood  in  the 
stools,  and  by  the  fact  that  it  is  usually  preceded  by  one  or  more 
attacks  of  acute  gastro-enteric  intoxication,  upon  which  its  peculiar 
symptoms  are  gradually  ingrafted.  In  the  catarrhal  form,  the  symptoms 
of  an  acute  inflammation  of  the  colon  are  usually  manifest  from  the 
outset — bloody  stools,  pain,  tenderness,  tenesmus,  and  fever.  In  the 
membranous  variety  such  symptoms  are  sometimes  seen;  but,  as  a  rule, 
the  local  symptoms  are  less  pronounced,  while  the  constitutional  symp- 
toms, especially  those  relating  to  the  nervous  system,  are  usually 
marked.  The  course  is  usually  shorter  and  more  intense  than  in  the 
follicular  form.  Death  often  takes  place  in  ten  or  twelve  days,  during 
the  period  of  most  acute  symptoms. 

Prognosis. — This  is  much  worse  in  infants  than  in  older  children.  It 
is  especially  bad  in  cities,  among  the  poorer  classes,  and  in  institutions. 
It  is  rendered  unfavourable  by  previous  rickets  or  malnutrition,  and  by 
the  existence  of  any  complication,  especially  broncho-pneumonia.  The 
particular  symptoms  in  a  case  which  make  the  prognosis  unfavourable 
are  continued  high  temperature,  frequent  vomiting,  rapid  wasting,  an 
excessive  amount  of  blood  in  the  stools,  severe  nervous  symptoms,  and 
very  weak  pulse.  Summer  cases  are  never  out  of  danger  until  the  end 
of  the  hot  season,  on  account  of  the  great  liability  to  relapses  and 
recurrent  attacks. 

Prophylaxis. — What  has  been  said  regarding  general  prophylaxis  in 
the  previous  chapter,  applies  equally  well  to  cases  of  ileo-colitis.  Special 
emphasis  should  be  placed  upon  the  necessity  of  energetic  early  treatment 
of  all  the  milder  forms  of  diarrhoea,  and  particularly  the  cases  of  acute 
gastro-enteric  intoxication,  in  order  that  the  process  may  be  arrested  be- 
fore serious  anatomical  changes  have  taken  place — a  thing  which  is  often 
possible.  Equal  stress  should  be  laid  u])on  the  importance  of  prompt  and 
radical  treatment  at  the  very  beginning  ol'  the  cases  with  a  sudden  onset. 

Hygienic  Treatment. — Tlie  gcnci'al  ])lan  Toeommeiided  in  the  previ- 
ous chapter  should  be  followed  here.  A  change  of  air  is  desirable  for 
most  cases  as  soon  as  the  acute  inflamuuitory  symptoms  have  subsided. 
In  the  protracted  cases  wliicli  drag  on  a  subacute  course,  this  change  will 
often  do  more  than  anything  else.  Plenty  of  pure  fresh  air  is  neces- 
sary in  all  cases.    The  indications  for  bathing  are  the  same  as  in  other 


398  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

cases  of  acute  diarrhoea.  It  is  undesirable  to  crowd  these  patients  in 
institutions,  as  they  always  do  better  when  separated. 

The  diet  during  the  acute  stage  should  be  the  same  as  in  cases  of 
acute  gastro-enteric  intoxication.  In  the  protracted  cases  the  diet  pre- 
sents great  difficulties,  as  the  children  have  little  or  no  appetite,  and 
soon  come  to  refuse  everything  in  the  shape  of  food  that  is  offered. 
In  infancy,  the  articles  which  are  most  to  be  depended  upon  are 
skimmed  milk  which  has  been  completely  peptonized,  animal  broths, 
and  liquid  beef  peptonoids.  In  some  cases  rice  or  barley  water  are  well 
borne;  in  others,  some  of  the  malted  foods,  although  these  often  in- 
crease the  number  of  stools  and  have  to  be  stopped  on  that  account. 
Food  which  leaves  little  residue  should  always  be  chosen.  Infants, 
when  very  ill,  are  much  more  likely  to  take  too  little  than  too  much  food. 
A  careful  record  should  be  kept  of  the  amount  actually  taken  in  each 
twenty-four  hours.  When  this  is  much  below  the  requirements  of  nutri- 
tion, gavage  may  be  tried.  Sometimes  all  food  and  stimulants  may  be 
advantageously  given  in  this  way.  In  no  case  should  food  be  given 
oftener  than  every  two  hours,  and  usually  the  interval  should  be  three 
hours,  water  and  stimulants  being  allowed  between  the  feedings.  In 
older  children  the  diet  during  the  acute  stage  should  be  much  the  same 
as  in  infants.  At  a  later  period,  raw  beef,  kumyss,  or  matzoon  will  be 
found  useful,  and  during  convalescence,  eggs,  boiled  milk,  or  milk  gruels 
made  with  rice  or  barley.  Special  care  should  be  given  to  the  diet  for 
a  long  time.  For  months  after  an  acute  attack  the  intestines  are  very 
easily  deranged.  Relapses  are  excited  by  changes  in  the  temperature, 
by  great  fatigue  or  exhaustion,  but  most  of  all  by  improper  feeding. 
Especially  in  older  children  should  such  articles  be  avoided  as  oatmeal, 
potatoes,  corn,  tomatoes,  and  all  fruits.  I  have  seen  a  single  peach  given 
to  a  child  two  years  old,  excite  a  dangerous  relapse,  and  a  few  raisins 
a  fatal  one. 

Medicinal  and  Mechanical  Treatment. — Cases,  the  early  stage  of 
which  is  marked  by  vomiting  and  thin  diarrhoeal  stools,  are  to  be  managed 
at  the  outset  according  to  the  plan  outlined  in  the  previous  chapter — viz., 
free  purgation,  irrigation  of  the  colon,  and  stopping  all  food.  When 
the  symptoms  of  acute  inflammation  are  evident  from  the  outset,  as 
shown  by  the  frequent  bloody  and  mucous  stools  with  tenesmus  and 
pain,  the  measures  to  be  depended  upon  are  castor  oil  or  saline  cathar- 
tics and  irrigation  of  the  colon,  and  later  opium  and  bismuth  by  the 
mouth.  Castor  oil  should  be  administered  in  a  full  dose  at  the  out- 
set— one  drachm  at  six  months,  two  drachms  at  one  year,  and  half  an 
ounce  at  four  years.  Its  primary  efi^ect  is  to  clear  the  intestines,  and  its 
secondary  effect  is  soothing.  The  salines  may  be  used  as  described  in  the 
previous  chapter.  (See  page  373.)  If  the  stomach  is  at  all  irritable, 
calomel,  one-fourth  srrain  everv  hour  for  five  or  six  doses,  mav  be  substi- 


ACUTE   ILEO-COLITIS.  399 

tuted.  Opium  is  usually  required  on  account  of  the  pain  and  tenesmus. 
The  dose  should  be  regulated  by  the  severity  of  these  symptoms  and  by 
the  frequency  of  the  stools.  The  deodorized  tincture  and  paregoric  are, 
I  think,  preferable  to  other  preparations.  Dover's  powder  may  be  used 
if  the  stomach  is  not  irritable.  Eepeated  small  doses  are  better  than  a 
single  large  dose.  It  is  very  important  that  opium  should  be  withheld 
for  at  least  twelve  hours  after  the  initial  purgative.  As  the  pathological 
process  is  principally  in  the  colon,  and  most  severe  in  the  lower  half  of 
the  colon,  it  can  often  be  much  more  effectively  treated  by  injections 
than  by  drugs  given  by  the  mouth.  Irrigation  of  the  colon  is  one  of  our 
most  valuable  means  of  treatment  in  these  cases.  It  should  be  used  in 
conjunction  with  the  measures  already  referred  to.  For  general  purposes 
a  saline  solution  at  100°  to  104°  F.  should  be  employed  (common  salt  or 
borax  one  drachm  to  water  one  pint) .  One  or  two  quarts  should  be  given 
at  one  time;  it  should  be  injected  high  into  the  colon  through  a  long 
rectal  tube,  and  early  in  the  disease  repeated  at  least  twice  a  day. 
When  the  tenesmus  is  very  great  and  blood  abundant,  small  injections 
of  either  hot  water  (106°  to  110°  F.)  or  ice  water  may  be  used,  and 
later  astringent  injections.  The  most  useful  astringents  are  tannic  acid 
and  hamamelis,  weak  solutions — a  drachm  of  tannic  acid  or  two  drachms 
of  the  fluid  extract  of  hamamelis  to  a  pint  of  water — are  to  be  pre- 
ferred. Whether  injections  are  to  be  used  continuously  or  not  will  de- 
pend much  upon  the  patient.  If  they  are  well  borne,  they  may  be  given 
once  or  twice  a  day  during  the  attack ;  but  if  at  every  attempt  to  give 
them  the  child  struggles,  screams,  and  resists,  they  may  do  more  harm 
than  good.  Complete  rest  is  a  very  important  part  of  the  treatment. 
In  conjunction  with  opium,  benefit  is  often  seen  from  the  continued  use 
of  castor  oil  in  small  doses — i.  e.,  ten  drops  in  emulsion  every  two  or 
three  hours. 

For  cases  not  influenced  by  the  measures  mentioned,  or  those  not 
seen  at  the  outset,  bismuth  should  be  tried,  but  it  is  of  no  use  whatever 
unless  large  doses  are  administered.  One  or  two  drachms  of  the  sulv 
nitrate  should  be  given  in  twentA'-four  hours  to  a  child  a  year  old,  aud 
proportionate  doses  to  older  children.  This  should  be  suspended  in 
mucilage.  Tenesmus  and  pain  are  sometimes  relieved  by  the  injection 
of  three  or  four  ounces  of  a  starch  solution  to  which  from  five  to  ten 
drops  of  laudanum  are  added.  Severe  tenesmus,  when  not  controlled 
thus,  and  when  associated  with  prolapsus  ani,  is  sometimes  immediately 
relieved  by  a  suppository  containiug  from  one-fourth  to  one-half  grain 
of  cocaine. 

Stimulants  are  needed  in  nearly  all  cases.  There  are  no  valid  objec- 
tions to  their  use  even  in  the  youngest  infant.  The  feeble  digestion  and 
assimilation  of  these  patients  very  frequently  compel  us  to  use  alcohol. 
Stimulants  are  indicated  by  a  weak  pulse,  cold  extremities,  and  great 


400  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

general  prostration,  no  matter  at  what  stage  in  the  disease  these  symp- 
toms are  seen.  Old  brandy  is  usually  to  be  preferred.  Generally  not 
more  than  thirty  drops  every  two  hours  are  needed  for  an  infant  one 
year  old,  but  for  short  periods  a  much  larger  quantity  may  be  required. 
Brandy  should  always  be  diluted  with  at  least  eight  parts  of  water. 

In  cases  where  symptoms  have  lasted  two  or  three  weeks,  and  the 
active  symptoms  have  subsided,  where  the  temperature  is  scarcely  above 
100°  F.,  and  the  stools  reduced  to  four  or  five  a  day,  it  is  wise  to  stop  all 
medication  and  attend  only  to  food  and  stimulants,  with  irrigation  of  the 
colon  every  tAvo  or  three  days.  One  is  often  surprised  at  this  stage  to  find 
that  patients  do  better  without  drugs  than  with  them.  The  prevailing 
tendency  is  to  overdose  cases  of  this  type.  Careful  attention  to  diet, 
judicious  stimulation,  occasional  irrigation  of  the  bowel,  with  change  of 
air,  will  do  much  more  than  any  amount  of  medication. 

During  convalescence  general  tonics  are  required,  such  as  arsenic, 
iron,  nux  vomica,  and  wine.  Cod-liver  oil  should  be  deferred  until  the 
stomach  and  appetite  are  quite  normal  and  the  stools  free  from  mucus. 
It  should,  however,  be  continued  throughout  the  succeeding  winter 
months. 

CHRONIC  ILEO-COLITIS. 

The  severe  forms  of  chronic  ileo-colitis  follow  acute  ileo-colitis,  usu- 
ally the  catarrhal  or  follicular  form,  as  the  membranous  is  so  severe 
that  the  patients  rarely  survive  the  acute  stage.  There  may  be  only  a 
chronic  catarrhal  inflammation  of  the  mucous  membrane,  or  ulcers  may 
be  present. 

The  milder  forms  are  usually  the  result  of  chronic  intestinal  indi- 
gestion. 

Lesions. — Catarrhal  form. — In  its  milder  form  it  is  quite  common, 
but  in  its  severe  form  it  is  exceedingly  rare.  There  may  be  changes  in 
a  large  part  of  the  small  intestine  and  in  the  stomach,  as  well  as  in  the 
lower  ileum  and  colon. 

The  gross  appearance  of  the  intestine  often  differs  very  little  from 
the  normal.  The  mucous  membrane  is  usiially  of  a  dull  gray  or  slate 
colour.  Pigmentation  may  occur  as  striae  in  the  mucous  membrane,  but 
more  frequently  it  is  limited  to  Peyer's  patches  and  the  solitary  lymph 
nodules;  these,  as  well  as  the  mesenteric  lymph  nodes,  are  generall}'^ 
swollen. 

The  microscopical  changes  are  usually  marked.  The  lesion  is  chiefly 
one  of  the  mucosa  (Fig.  74).  The  important  features  are  a  disappear- 
ance of  very  many  of  the  tul)ular  glands,  and  in  the  small  intestine  of 
the  villi  also.  There  is  a  very  marked  coll  proliferation  in  the  adenoid 
tissue  of  the  mucosa,  and  if  the  disease  has  existed  long  enough  there  may 
be  a  production  of  new  connective  tissue.     The  solitary  lymph  nodules 


CHRONIC   ILEO-COLITIS. 


401 


show  usually  nothing  but  cell  h3^perplasia.  The  lesions  are  not  uniformly- 
distributed,  but  occur  in  patches  throughout  the  intestine.  When  present 
in  the  stomach,  they  are  of  the  same  kind  as  those  described  in  the  intes- 
tine, although  rarely  so  severe.  In  milder  cases  the  gross  appearances 
may  show  very  little  change  to  the  naked  eye,  except  swelling  of  the 


Fig.  74. — Chronic  catarrhal  inflammation  of  the  ileum. 

The  lesions  affect  the  mucosa,  A,  almost  exclusively.  It  is  somewhat  thickened  ;  there  is 
extensive  destruction  of  the  tubular  follicles,  remains  being  seen  at  'J\  T\  there  is  a  great  in- 
crease in  the  cells,  and  some  new  connective  tissue  in  the  mucosa.  Large  new  blood-vessels 
are  seen  at  (7,  C.  History. — Delicate  child,  thirteen  months  old ;  diarrhoeal  symptoms  for  four 
months ;  during  the  first  two  weeks  there  w^as  high  fever ;  at  death  weighed  eight  pounds. 
The  gross  changes  at  the  autopsy  were  very  slight.     The  section  is  from  the  middle  ileum. 

lymph  nodules.  Under  the  microscope  there  may  be  found  more  or  less 
extensive  cell  infiltration  of  the  mucosa,  but  rarely  any  destructive 
changes  or  new  connective  tissue. 

Ulcerative,  form. — This  is  rather  rare,  for  the  reason  that  in  infancy 
a  very  large  proportion  of  the  cases  die  during  the  acute  stage. 

The  ulcers  are  nearly  always  of  the  follicular  variety;  occasionally 
they  are  broad  and  shallow.  If  the  patient  dies  after  an  illness  of  from 
six  to  eight  weeks,  the  appearances  do  not  differ  essentially  from  those 
described  in  acute  cases.  If  life  is  prolonged  from  two  to  four  months, 
ulcers  are  found  in  various  stages  of  repair.  Follicular  ulcers  require 
from  one  to  three  months  for  cicatrization,  and  the  broad  superficial 
ulcers  even  a  longer  time.  It  is  very  doubtful  whether  stricture  ever 
results  from  these  ulcers  in  children.  The  mucous  membrane  shows 
almost  invariably  evidences  of  more  or  less  extensive  chronic  catarrhal 
inflammation.  Among  the  very  rare  lesions  are  cysts  of  the  colon.  Fully 
developed  cysts  I  have  seen  but  once.  The  child  had  an  attack  of  acute 
ileo-colitis,  which  became  chronic,  lasting  about  five  months.  He  never 
regained  his  health,  and  died  one  year  later  from  intercurrent  disease. 
In  the  descending  colon  and  rectum,  about  twenty  cysts  the  size  of  a  pea, 
and  many  smaller  ones,  were  found.  They  had  a  thin,  translucent  cover- 
ing. On  section,  a  thick,  transparent,  gelatinous  material  escaped.  They 
were  situated  in  the  submucosa,  and  were  undoubtedly  produced  by  the 
dilatation  of  some  of  the  tubular  glands  whose  orifices  had  been  oblit- 
erated. 


402  DISEASES  OP   THE  DIGESTIVE  SYSTEM. 

Associated  lesions. — The  important  ones  are  in  the  lungs,  the  most 
common  being  hypostatic  congestion,  subacute  or  chronic  broncho-pneu- 
monia, more  rarely  pulmonary  tuberculosis.  It  is  rare  to  find  the  lungs 
perfectly  healthy.  The  liver  is  often  found  extremely  fatty  in  cases  asso- 
ciated with  great  wasting,  but  in  no  case  have  I  seen  hepatic  abscess. 
The  kidneys  usually  show  a  more  or  less  intense  cloudy  swelling,  and 
sometimes  there  may  be  well-marked  nephritis.  Dropsical  effusions  into 
the  serous  cavities  are  very  rare. 

Symptoms. — In  the  milder  cases  there  are  only  the  sj^mptoms  of 
chronic  intestinal  indigestion  with  the  constant  presence  of  mucus  in  the 
stools,  usually  in  large  amount. 

The  severe  cases  are  usually  seen  in  autumn,  and  are  generally  the 
secjuel  of  acute  attacks  occurring  during  the  summer. 

The  signs  of  active  inflammation  have  passed  away;  the  tem- 
perature is  usually  normal;  there  is  no  pain  or  tenderness.  There  is, 
however,  no  improvement  in  the  general  condition,  and  either  the  weight 
remains  stationary,  or  the  child  continues  to  lose  slowly  until  it  is  little 
more  than  a  skeleton.  The  face  is  pinched,  the  eyes  sunken,  and  the 
cheeks  hollow.  The  hps  are  pale,  often  fissured,  and  bleed  readily.  The 
fontanel  is  depressed.  The  body  is  so  small  that  the  head  seems  much 
too  large.  The  skin  hangs  in  loose  folds  on  the  thighs.  The  mouth  is 
often  the  seat  of  thrush,  of  catarrhal,  herpetic,  or  rarely  of  ulcerative 
stomatitis.  The  tongue  may  be  heavily  coated,  but  is  more  often  dry, 
glazed,  and  red. 

Although  they  seldom  cry  for  food,  as  a  rule  these  children  will  take 
nearlv  evervthing  given  them,  and  in  almost  unlimited  amount.  Xot- 
withstanding  that  it  is  retained,  the  more  they  are  fed  the  more  rapid 
seems  the  wasting.  Vomiting  is  not  common,  and  seldom  occurs  except 
from  overloading  the  stomach  or  during  acute  exacerbations. 

The  stools  are  rarely  frequent,  five  or  six  a  day  being  the  average; 
often  there  may  be  only  two  or  three  a  day  for  a  week  at  a  time.  They 
are  thinner  than  normal,  Irat  are  not  often  fluid.  They  contain  mucus 
of  a  green  or  brownish  colour,  usually  in  large  quantity;  but  rarely  blood. 
The  stools  are  sometimes  green,  often  greenish  brown,  sometimes  a  pale 
gray.  They  are  always  large  in  proportion  to  the  amount  of  food  taken. 
Undigested  food  is  always  present  in  quantity,  and  upon  the  diet  de- 
pends very  much  the  gross  appearance  of  the  stool,  the  odour  of  which 
is  almost  always  offensive.  Pus  is  often  found  under  the  microscope, 
but  is  rarely  visible  to  the  naked  eye.  Xothnagel  and  Baginsky  have 
called  attention  to  a  form  of  stools  which  they  believe  to  be  characteristic 
of  wide-spread  inflammation  of  the  mucous  membrane  with  atrophy  of 
the  tubular  glands  :  they  are  of  nearly  normal  consistence,  homogeneous, 
dark  green  or  brown  colour,  and  usually  off'ensive ;  they  sometimes  al- 
ternate with  stools  of  a  watery  character;  under  the  microscope  nuclei 


CHRONIC  ILEO-COLITIS.  403 

are  foimd,  but  no  imchaiiged  epithelial  cells ;  the  food  remains  are  some- 
times unrecognisable,  owing  to  decomposition. 

Prolapsus  ani  is  not  so  frequent  as  in  the  acute  cases;  but  when  it 
occurs  it  is  generally  more  difficult  to  control.  Flatulence  and  colic  are 
prominent  symptoms  in  some  cases,  but  absent  altogether  in  many  others. 
As  a  rule,  there  is  neither  abdominal  pain  nor  tenderness.  The  abdomen 
is  usually  distended,  and  in  most  cases  the  enlargement  is  uniform,  but 
sometimes  there  is  marked  epigastric  prominence,  which  is  more  often 
from  dilatation  of  the  transverse  colon  than  of  the  stomach.  Although 
the  mesenteric  glands  are  enlarged,  they  can  not  be  felt  through  the 
abdominal  walls.  The  skin  is  dry  and  scaly,  and  in  the  worst  cases  fre- 
quently covered  with  small  petechise  over  the  abdomen  and  lower  extrem- 
ities. About  the  anus,  and  over  the  sacrum,  thighs,  genitals,  and  some- 
times feet,  there  are  excoriations,  and  not  infrequently  ulcerations.  The 
temperature  is  elevated  only  during  exacerbations,  or  from  inflammatory 
complications.  A  subnormal  temperature  is  frequently  met  with.  I  have 
occasionally  seen  it  95°  F.  in  the  rectum.  The  urine  often  contains  an 
excessive  amount  of  indican.  Dropsy  is  often  present  without  albu- 
minuria. The  weight  is  stationary,  or  steadily  falls  to  an  almost  in- 
credible degree.  I  have  seen  one  infant  weighing  but  eight  pounds  at 
thirteen  months;  another,  thirteen  pounds  at  two  years  and  foiir 
months.  Ulcers  of  the  cornea  are  not  uncommon.  Nervous  symptoms 
are  always  present.  The  children  are  cross  and  irritable,  sleep  badly,  and 
frequently  have  a  low,  whining  cry,  which  is  continued  much  of  the  time. 
Sometimes  they  are  dull,  apathetic,  and  quite  indifEerent  to  their  sur- 
roundings. Persistent  opisthotonus  is  occasionally  seen;  and  there  may 
be  contractions  of  the  extremities,  but  rarely  general  convulsions. 

The  duration  of  the  disease  is  from  two  months  to  a  year.  Compara- 
tively few  patients  survive  more  than  four  months.  The  progress  is 
irregular,  and  marked  by  periods  of  improvement,  during  which  for  a 
time  the  patient  may  hold  his  own,  or  even  gain  in  weight.  Any  trivial 
cause  may  excite  a  relapse,  and  the  downward  progress  is  rapid.  Death 
often  occurs  during  one  of  these  exacerbations,  or  it  may  be  due  to  bron- 
cho-pnounionia,  tuberculosis,  or  slow  asthenia. 

Diagnosis. — It  is  important  to  distinguish  the  cases  with  marked 
cachexia  and  slow  convalescence,  although  ultimately  resulting  in  com- 
plete recovery,  from  those  which  present  at  a  certain  stage  almost  iden- 
tical symptoms,  and  yet  go  on  steadily  downward,  terminating  fatally. 
The  difference  in  these  cases  is  really  a  difference  in  the  character  and 
extent  of  the  lesions.  The  first  group  are  probably  cases  of  superficial 
catarrhal  inflammation,  or  of  follicular  inflammation  which  has  not  gone 
on  to  ulceration,  these  lesions  being  capable  of  repair.  The  second 
group  are  the  cases  of  ulceration,  in  which  complete  recovery  from  the 
lesions  is  impossible,  and  repair  only  partial,  if  indeed  any  occurs.    In 


404  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

distinguishing  between  these  groups  the  most  important  guide  is  the 
nature  of  the  symptoms  during  the  antecedent  acute  attack.  The  longer 
the  acute  symptoms  have  lasted  and  the  higher  the  temperature,  the 
greater  is  probably  the  extent  of  the  lesions,  and  the  more  severe  their 
character. 

The  diagnosis  of  chronic  ileo-colitis  from  general  tuberculosis  is 
often  difficult.  Tuberculosis  is  more  likely  to  be  met  with  in  institutions, 
among  the  poor  of  cities,  and  in  children  previously  delicate  and  with  a 
tuberculous  family  history.  In  chronic  ileo-colitis  the  wasting  and 
anaemia  follow  the  intestinal  symptoms,  and  are  usually  just  in  propor- 
tion to  their  severity.  For  the  differential  diagnosis  of  the  pulmonary 
conditions,  see  the  chapter  on  Tuberculosis.  Fever  is  rarely  absent  in 
general  tuberculosis  or  in  tuberculous  ulceration  of  the  intestine  if  ex- 
tensive, though  it  is  not  high  and  its  course  is  very  irregular.  It  is  ab- 
sent in  chronic  ileo-colitis,  except  from  complications  and  from  the 
occasional  acute  exacerbations. 

Prognosis. — The  prognosis  depends  upon  the  child's  previous  condi- 
tion, upon  the  duration  of  the  intestinal  symptoms,  upon  our  ability  to 
carry  out  proper  treatment,  upon  the  presence  of  complications;  but, 
most  of  all,  upon  the  severity  and  extent  of  the  intestinal  lesions.  The 
possibility  of  error  always  exists  in  estimating  the  gravity  of  the  lesions, 
so  that  no  case  should  be  considered  hopeless.  The  most  unpromising 
cases  sometimes  end  in  complete  recovery.  If,  however,  continuous 
symptoms  have  existed  for  eight  or  ten  weeks  without  any  sign  of  im- 
provement, recovery  is  extremely  doubtful.  The  patient  may  linger  for 
two  or  three  months  longer,  but  visually  only  to  be  carried  off  by  the  first 
acute  disturbance  which  occurs. 

Treatment. — No  greater  mistake  is  made  than  to  give  these  children 
week  after  week  the  various  diarrhoea-mixtures,  with  the  expectation 
that  ultimately  the  formula  which  exactly  meets  the  particular  case  will 
be  found.  Drugs  are  to  be  used  only  for  the  relief  of  special  symptoms. 
Thus  a  dose  of  opium  may  be  needed  when  the  movements  are  unusually 
frequent,  or  castor  oil,  or  calomel  occasionally  when  the  stools  are  partic- 
ularly offensive.  The  essential  and  important  part  of  the  treatment  con- 
sists in  injections,  careful  feeding,  stimulation,  and  change  of  air.  As- 
tringent enemata,  however,  are  of  some  value.  They  should  not  be  given 
continuously,  but  from  time  to  time  should  be  omitted  for  a  week  or  two 
to  see  what  the  condition  of  the  stools  is  without  them.  I  have  seen 
several  cases  of  the  milder  variety  where  the  constant  use  of  such  injec- 
tions seemed  to  be  an  important  factor  in  keeping  up  the  production  of 
mucus.  The  colon  should  first  be  washed  witli  a  large  amount  of  a  tepid 
salt  or  borax  solution,  and  then  four  or  five  ounces  of  the  astringent  solu- 
tion injected,  and  held  in  place  by  compressing  the  buttocks  for  half 
an  hour. 


AMCEBIC  COLITIS.  4O5 

Alcoholic  stimulants  must  be  given  in  almost  all  cases,  and  the}'  may 
be  continued  for  a  long  time  with  advantage.  Old  port  or  sherry  will 
sometimes  do  better  than  brandy  or  whisky.  The  diet  mentioned  in  the 
later  stages  of  the  acute  cases  should  be  continued.  The  predigested 
foods  are  useful,  especially  completely  peptonized  milk ;  also  are  beef 
preparations  as  bovinine,  and  the  liquid  beef  peptonoids,  and  in  some 
cases  raw  scraped  beef,  also  the  whites  of  fresh  eggs,  partially  cooked. 
Fats  and  starchy  foods  should  be  excluded  entirely  or  given  in  very  small 
quantities.  It  is  usually  better  to  give  the  carboh3'drates  in  the  form  of 
the  malted  foods.  Kumyss  and  matzoon  are  useful.  The  diet  must  be 
closely  watched  and  directed  according  to  its  effect  upon  the  stools. 
Much  information  may  be  obtained  by  thoroughly  washing  the  stools 
and  examining  the  residue.  ISTutrition  may  be  promoted  by  inunctions 
of  cocoa  butter,  cod-liver  oil,  or  some  other  form  of  fat. 

The  patient  should  first  be  put  in  the  best  possible  surroundings ;  in 
no  disease  is  a  change  of  air  more  to  be  desired  than  in  this.  These  cases 
are  trying  ones  to  the  physician ;  for  unless  he  can  absolutely  control  the 
matter  of  diet,  it  is  almost  useless  to  attempt  to  do  anything.  Still,  by 
careful  study  of  the  individual  case  and  attention  to  minute  details,  suc- 
cess may  sometimes  be  achieved  even  when  the  outlook  seemed  at  the 
outset  the  most  hopeless.  The  danger  of  relapses  and  second  attacks 
continues  long  after  the  primary  attack  has  subsided. 

AMCEBIC  COLITIS. 

Amoebic  colitis  is  rare  in  children ;  it  is  particularly  so  in  infants, 
probably  owing  to  the  fact  that  nearly  all  the  water  taken  at  this  age  is 
boiled.  Most  of  the  cases  in  children  thus  far  reported  have  been  ob- 
served in  warm  climates,  although  Amberg  *  has  recorded  five  which 
occurred  in  Baltimore,  the  youngest  being  two  years  and  eight 
months  old. 

The  symptoms  in  the  few  cases  that  have  been  reported  in  children 
have  differed  in  no  important  particular  from  the  disease  as  seen  in 
adults.  In  exceptional  cases  the  onset  may  be  abrui)t  and  the  attack 
may  run  an  acute  course,  terminating  fatally  in  two  to  throe  weeks. 
Such  cases  are  characterized  by  much  abdominal  pain  and  tenderness, 
frequent  mucous  and  bloody  stools  containing  auurl)a\,  and  some  fever, 
whicb.  however,  seldom  reaches  102°  F. 

j\fore  frequently  this  acute  onset  is  followed  by  a  subacute  or  chronic 
form  of  the  disease,  or  the  disease  may  be  subacute  from  the  beginning. 
The  protracted  cases  are  the  type  of  the  disease  most  frequently  seen. 
They  are  very  obstinate  to  treatment.  Periods  of  constipation  and  ap- 
parent recovery  often  alternate  with  exacerbations  in  which  the  bloody 

*  See  Bulletin   of  Johns   Hopkins   Hospital,  December,  1901,  for  references  to 
literature. 


406  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

and  mucous  stools  return,  with  pain,  tenesmus,  and  slight  fever.  The 
duration  may  be  from  a  few  months  to  one  or  two  years.  Death  may 
finally  occur  from  exhaustion  with  extreme  wasting,  or  from  some  com- 
plication, such  as  hasmorrhage,  abscesses  of  the  liver  being  very  rare  in 
children.  The  diagnosis  from  other  forms  of  colitis  is  made  only  by  the 
discovery  of  amoebae  in  a  freshly  voided  stool. 

The  general  treatment  is  the  same  as  for  other  forms  of  acute  or 
subacute  colitis.  The  special  treatment  for  the  purpose  of  destroying 
the  amoebae  is  the  use  of  injections  of  quinine  which  may  be  employed 
in  solutions  varying  in  strength  from  1  to  5,000  to  1  to  250. 

AMYLOID  DEGENERATION  OF  THE  INTESTINES. 

This  is  rarely  met  with  in  infants.  It  is  not  so  infrequent  in  older 
children,  where  it  is  associated  with  amyloid  changes  in  the  liver,  spleen, 
and  kidneys,  usually  as  a  result  of  prolonged  suppuration  in  connection 
with  bone  tuberculosis.  It  is  sometimes  met  with  in  syphilis.  The  ileum 
is  the  part  of  the  intestine  most  affected.  The  process  begins  in  the  walls 
of  the  arterioles  and  capillaries,  particularly  of  the  villi,  and  later  in- 
volves the  vessels  of  the  submucosa ;  subsequently  the  epithelium  may  be 
affected.  The  mucous  membrane  in  these  cases  is  pale,  rather  translu- 
cent. The  condition  is  recognised  by  the  application  of  the  iodine  test; 
the  affected  villi  become  of  a  brownish-red  or  mahogany  colour. 

Amyloid  degeneration  produces  no  definite  symptoms.  Diarrhoea  is 
frequent  but  by  no  means  constant.  The  anaemia  and  waxy  cachexia 
which  are  present  are  probably  dependent  much  more  upon  the  associated 
lesions  of  the  liver  and  kidneys  than  upon  the  changes  in  the  intestines. 

TUBERCULOSIS  OP  THE  INTESTINES  AND  MESENTERIC   LYMPH 
NODES  (MESENTERIC   GLANDS). 

These  two  conditions  are  usually,  but  not  invariably,  associated,  and 
may  be  conveniently  considered  together. 

Frequency. — In  one  series  of  109  autopsies  upon  tuberculous  cases 
from  my  own  hospital  records  the  intestines  were  involved  in  37  per 
cent.  In  a  second  series  of  103  autopsies  they  were  involved  in  54  per 
cent.  The  great  majority  of  the  patients  were  under  three  years  of  age. 
In  131  autopsies  upon  tuberculous  cases  published  in  the  Pendlebury 
Hospital  Reports,  the  intestines  were  involved  in  50  per  cent.  These 
patients  were  mainly  between  four  and  fourteen  years  old.  In  209  autop- 
sies upon  tuberculous  children,  chiefly  infants,  reported  by  Mltller,  the 
intestines  were  involved  in  28  per  cent.  In  1,346  autopsies  collected  by 
Biedert  there  were  intestinal  lesions  in  31-6  per  cent.  These  figures 
show  that  tuberculosis  of  the  intestines  is  not  one  of  the  most  frequent 
forms  in  children,  and  that  it  is  rather  less  frequent  in  infancy  than  at 


TUBERCULOSIS  OF  THE  INTESTINES.  407 

a  later  age.  It  is  most  common  from  the  third  to  the  eighth  year.  The 
mesenteric  lymph  nodes  were  tuberculous  in  about  5U  per  cent  of  my 
own  autopsies,  and  in  59  per  cent  of  the  Pendlebury  cases;  occurring 
thus  in  both  series  with  slightly  greater  frequency  than  tuberculosis  of 
the  intestines. 

Etiology. — In  the  great  majority  of  cases  the  mesenteric  lymph  nodes 
are  infected  from  the  intestines.  It  is  possible,  but  I  believe  exceptional, 
for  the  infection  to  occur  through  the  general  circulation.  With  tuber- 
culous ulcers  of  the  intestine,  the  lymph  nodes  are,  I  think,  invariably 
found  by  inoculation  in  animals  to  be  tuberculous;  although  they  may 
not  yet  be  caseous.  The  infection  of  the  intestinal  mucous  membrane 
is  from  bacilli  in  the  canal.  Much  stress  has  been  laid  upon  tuberculous 
milk  as  a  means  by  which  children  are  infected.  There  is  little  patho- 
logical support  to  be  found  for  the  view  that  children  often  contract  the 
disease  in  this  way.  In  119  autopsies  upon  tuberculous  children,  chiefly 
infants,  there  was  not  found  one  in  which  the  most  advanced,  and  there- 
fore presumably  the  primary,  lesion  was  in  the  intestines  or  stomach. 
In  127  autopsies,  also  upon  tuberculous  infants,  Northrup  found  the 
most  advanced  lesion  in  the  intestines  in  but  a  single  case.  While  in- 
fection from  milk  is  possible,  it  is  certainly  extremely  infrequent.  In 
my  own  autopsies,  intestinal  lesions  have  been  found,  with  but  one  excep- 
tion, only  in  marked  cases  of  generalized  tuberculosis.  In  not  more  than 
one-fourth  of  the  cases  in  which  such  lesions  were  present  were  they 
severe.  They  were  usually  associated  with  an  advanced  pulmonary  pro- 
cess, and  were  doubtless  due  to  swallowing  tuberculous  sputum. 

Lesions. — Intestines. — The  usual  seat  is  the  small  intestine,  chiefly 
the  jejunum  and  lower  ileum.  With  extensive  disease  the  large  intes- 
tine may  also  be  involved,  most  frequently  the  csecum,  and  exceptionally 
it  alone  may  be  affected.  Tuberculous  ulcers  may  be  found  in  the  ap- 
pendix. 

The  early  deposits  appear  as  tiny  yellow  nodules,  generally  widely 
scattered  and  affecting  Peyer's  patches.  Usually,  however,  ulcers  are 
present,  and  often  only  ulcers  are  seen.  Their  size  and  number  vary 
greatly;  there  may  be  only  five  or  six  tiny  ulcers,  or  there  may  be  forty 
or  fifty,  the  largest  being  two  or  three  inches  in  diameter.  They  very 
frequently  involve  Peyer's  patches.  The  typical  tuberculous  ulcer  is  of 
irregular  shape,  with  rounded  borders  and  with  its  longest  diameter  at 
right  angles  to  the  intestinal  axis.  When  large,  it  may  nearly  encircle 
the  gut.  The  ulcers  are  excavated;  they  have  overhanging,  infiltrated 
edges  of  a  deep  red  colour.  The  surface  is  covered  with  granulations. 
In  those  which  have  partially  healed  a  distinct  puckering  of  the  intes- 
tine occurs,  which  is  especially  noticeable  upon  the  peritoneal  surface. 
The  small  ulcers  involve  the  mucosa  only;  the  larger  and  older  ones  the 
submucosa  and  the  muscular  coats,  and  not  infrequently  also  the  serous 


408  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

coat.  Perforation  may  occur,  but  rarely  into  the  general  peritoneal  cav- 
ity, as  a  localized  plastic  inflammation  precedes  it.  There  may  be  ad- 
hesions of  adjacent  intestinal  coils,  and  fistulge  may  form,  owing  to  ulcer- 
ation at  their  point  of  contact.  With  these  severe  cases  there  is  always 
associated  more  or  less  extensive  tuberculous  peritonitis,  frequently  of 
the  ulcerative  variety.  Like  other  tuberculous  processes,  the  infiltration 
and  ulceration  may  cease  at  any  stage,  and  cicatrization  follow.  If  the 
ulcers  have  been  large  ones,  there  is  always  some  narrowing  of  the  lumen 
of  the  intestine.  Stricture  rarely  results,  because  the  patients  die  from 
the  general  disease  before  it  has  had  time  to  occur.  Monti  has  reported 
a  case  of  obstruction  at  the  ileo-ctecal  valve,  due  to  an  old  tuberculous 
cicatrix,  in  an  infant  of  twenty-one  months. 

Mesenteric  hjmpli  nodes. — Usually  these  tuberculous  lymph  nodes  are 
from  half  an  inch  to  an  inch  in  diameter;  occasionally  they  may  reach 
the  size  of  a  hens  egg.  From  a  fusion  of  several  of  them,  tumours  of 
considerable  size  may  be  formed.  I  have  seen  one  such  mass  as  large  as 
the  head  of  a  child  at  birth. 

The  process  is  the  same  as  that  which  occurs  in  other  lymph  nodes  of 
the  body.  There  is  a  tuberculous  inflammation,  followed  by  caseation, 
softening,  and  abscess,  or  by  calcification.  Localized  peritonitis  is  found 
in  all  the  marked  cases ;  this  is  usually  plastic,  but  may  be  suppurative 
when  due  to  the  rupture  of  an  abscess.  Pressure  upon  the  vena  cava 
may  lead  to  dropsy  in  the  lower  extremities.  Ollivier  has  reported  a  case 
in  which  thrombosis  of  the  vena  cava  occurred.  Pressure  upon  the  portal 
vein  may  lead  to  ascites  and  dilatation  of  the  superficial  abdominal  veins. 
There  may  be  pressure  upon  the  thoracic  duct. 

Symptoms. — The  symptoms  of  intestinal  tuberculosis  are  exceedingly 
irregular.  Ulcers  are  very  frequently  found  at  autopsy  when  there  have 
been  no  marked  intestinal  symptoms ;  this  is  especially  true  of  the  small 
ulcers  usually  seen  in  infants.  On  the  other  hand,  diarrha?a  is  not  un- 
common in  cases  of  advanced  general  tuberculosis  where  no  ulcers  are 
present.  It  is  the  most  frequent  symptom,  and  may  be  exceedingly  obsti- 
nate. The  stools  do  not  differ  essentially  from  those  in  chronic  ileo- 
colitis, except  in  the  occurrence  of  ha?morrhages  and  in  the  presence  of 
tubercle  bacilli.  Haemorrhages  are  not  very  frequent,  but  they  may  be  so 
large  as  to  be  the  cause  of  death.  This  occurred  in  one  of  my  cases,  an 
infant  nine  months  old,  the  blood  coming  from  a  single  ulcer  in  the 
ileum.  Hsemorrhage  is  more  common  in  older  children.  In  some  cases 
localized  abdominal  pain  or  tenderness  is  present.  In  advanced  cases 
the  symptoms  of  intestinal  ulceration  are  usually  mingled  with  those  of 
peritonitis,  and  there  are  also  present  the  enlarged  mesenteric  Ij^mpli 
nodes,  which  may  aid  in  the  diagnosis.  In  the  vast  majority  of  cases, 
these  nodes  are  recognised  only  by  deep  palpation.  The  tumours  are 
generally  felt  as  irregular  nodular  masses,  lying  close  against  the  spine. 


CHRONIC  INTESTINAL  INDIGESTION.  409 

not  movable,  and  sometimes  tender  on  pressure.  Other  tumours  from 
deposits  in  the  peritonaeum  may  be  present  anywhere  in  the  abdomen; 
they  may  be  superficial  or  deep.  The  other  symptoms  are  due  to  the 
complications  already  mentioned  and  to  tuberculosis  elsewhere. 

Diagnosis. — The  only  positive  evidence  of  intestinal  tuberculosis  is 
the  discovery  of  the  bacilli  in  the  stools.  In  the  absence  of  this  evidence, 
the  disease  is  differentiated  from  simple  ileo-colitis,  first,  by  the  signs  of 
tuberculosis  elsewhere  in  the  body,  especially  in  the  lungs,  these  being 
almost  invariably  involved;  secondl}',  by  the  slow  onset  and  gradual 
development 'of  the  symptoms,  while  in  chronic  ileo-colitis  an  acute  at- 
tack has  almost  invariably  preceded.  Large  haBmorrhages  always  suggest 
tuberculosis. 

The  large  mesenteric  glands  are  recognised  only  as  abdominal  tu- 
mours. 

Prognosis. — This  depends  altogether  upon  the  extent  of  the  tubercu- 
lous disease  elsewhere,  as  it  is  extremely  rare  for  the  intestinal  lesion  to 
be  the  cause  of  death.  Once  formed,  the  ulcers  probably  remain,  cica- 
trization being  very  rare,  and  then  only  partial. 

Treatment. — The  only  symptom  which  ordinarily  demands  treatment 
is  the  diarrhoea.  When  severe,  this  is  to  be  managed  much  as  in  cases  of 
ileo-colitis,  except  that  irrigation  of  the  colon  is,  of  course,  not  called  for. 
The  chief  reliance  must  be  upon  diet  and  internal  medication.  The 
drugs  which  are  most  useful  are  bismuth,  opium,  and  creosote,  which 
should  be  given  in  pills  coated  with  shellac. 


CHAPTER   IX. 

DISEASES  OF  TEE  INTESTINES.— {Continued.) 

CHRONIC   INTESTINAL  INDIGESTION. 

As  the  larger  and  more  complex  part  of  the  process  of  digestion  goes 
on  in  the  intestine,  so  intestinal  indigestion  is  a  more  common  and  more 
complicated  disturbance  than  gastric  indigestion.  In  many  cases  we  find 
the  two  associated,  but  in  perhaps  the  majority  the  symptoms  relate  en- 
tirely to  the  intestinal  process.  The  conditions  seen  in  young  infants  are 
so  different  from  those  in  older  children  that  the  cases  may  be  best  con- 
sidered separately. 

In  Young  Infants. — The  general  causes  are  the  same  as  those  men- 
tioned in  connection  with  chronic  gastric  indigestion :  they  are  constitu- 
tional debility,  either  congenital  or  acquired,  unfavourable  surroundings, 
and  previous  attacks  of  acute  disease.  Chronic  intestinal  indigestion  is 
especially  common  during  the  first  six  months,  and  is  seen  both  in  nurs- 


410  DISEASES   OF   THE   DIGESTIVE  SYSTEM. 

ing  infants  and  in  those  who  are  artifieially  fed.  In  the  ease  of  breast-fed 
infants,  the  mother  is  often  highly  nervous,  delicate,  and  anemic,  and 
may  be  taking  large  quantities  of  fluids  of  every  description,  for  the  pur- 
pose of  maintaining  an  abundant  flow  of  milk.  "Why  it  is  that  the  milk 
causes  so  much  disturbance  can  not  always  be  discovered  even  b}'  the  most 
careful  analysis.  The  difficulty  seems  to  be  most  frequently  with  the 
proteids,  which  are  often  in  excess.  Sometimes,  proteids  differing  in 
character  from  those  normally  present  seem  to  be  produced,  as  the  stools 
show  that  they  are  not  digested.  The  microscope  in  some  cases  reveals 
the  presence  of  many  colostrum  corpuscles  in  the  milk.  In  another  group 
of  cases,  where  the  condition  of  the  nurse  is  all  that  can  be  desired,  the 
trouble  is  simply  that  the  milk  is  too  rich;  it  being  then  high  both  in  fat 
and  proteids.  It  may  come,  although  rarely,  from  the  fact  that  the  child 
gets  too  much,  being  nursed  either  too  frequently  or  for  too  long  a  time. 

In  infants  who  are  being  fed  upon  cow's  milk,  the  most  common  cause 
is  that  the  proteids  are  too  high;  this  is  usually  the  mistake  when  in- 
fants are  fed  upon  plain  milk  which  has  been  simply  diluted.  In  other 
cases  the  fat  or  sugar  may  be  excessive,  as  in  many  of  the  milk-and-cream 
mixtures  in  vogue.  Xext  to  this  mistake  in  proportions,  is  that  of  over- 
feeding. Another  very  important  cause  is  the  use  of  farinaceous  foods 
too  early,  and  in  excess. 

Lesions. — Strictly  speaking,  chronic  indigestion  is  a  functional  dis- 
order without  anatomical  changes.  When  the  condition  has  lasted  for 
many  weeks  or  months,  as  often  happens,  there  may  result  a  low  grade  of 
catarrhal  inflammation  in  the  colon,  frequently  attended  b}*  hyperplasia 
of  the  lymph  nodules  of  the  mucous  membrane  (Plate  XII),  and  some- 
times by  a  similar  process  in  the  mesenteric  Ijmiph  nodes.  Chronic  indi- 
gestion may  be  the  principal  and  the  only  symptom  in  cases  of  chronic 
ileo-colitis  which  follow  acute  attacks. 

Symptoms. — The  general  symptoms  are  those  of  malnutrition,  or  in 
the  more  severe  form,  those  of  marasmus.  These  have  already  been  fully 
described,  and  need  only  be  mentioned  here.  The  most  important  are 
stationary  or  falling  weight,  ansemia,  poor  circulation,  often  subnormal 
temperature,  almost  constant  fretfulness  and  crying,  with  very  little 
quiet  sleep.  The  tongue  is  usually  coated  and  the  appetite  often  good, 
these  infants  taking  food  whenever  given,  and  in  an  almost  unlimited 
quantity.  There  are  few  cases  in  which  occasional  vomiting  does  not 
occur,  but  it  is  rarely  persistent.  So  far  as  the  intestinal  condition  is 
concerned,  the  cases  may  be  divided  into  those  with  diarrhoea  and  those 
with  constipation.  It  may  happen  that  the  same  eliild  will  suffer  for  a 
long  time  from  diarrhoea  and  then  from  constipation,  or  the  reverse;  but 
usually  one  condition  or  the  other  is  habitual.  The  diarrhoeal  stools 
are  thin,  green,  and  almost  invariably  contain  curds,  either  in  large  lumps 
or  small,  flaky  masses.    They  vary  in  number  from  three  to  ten  in  twenty- 


PLATE    XII. 


Chronic  Hyperplasia  of  the  Tjymph  Nodules  (Solitary  Follicles) 
OF  the  Colon. 

Child  ten  moiitlis  old  ;  death  from  pneumonia  without  intestiiuil  symptoms, 
five  months  old,  nearly  all  stools  were  green  or  brown  and  contained  mucus. 
The  condition  shown  existed  throughout  the  colon. 


Until 


CHRONIC   INTEriTIXAL   INDIGESTION.  411 

four  hours.  They  are  commonly  passed  without  pain^  akhough  there 
may  be  flatulence.  The  stools  have  usually  a  sour,  unpleasant  odour,  but 
they  are  rarely  foul.  They  may  be  irritating  to  the  skin,  and  cause 
troublesome  excoriations  or  intertrigo.  In  some  cases  the  stools  contain 
but  little  solid  matter,  the  character  being  that  of  yellowish-green  water. 
In  most  of  the  cases,  after  the  process  has  lasted  two  or  three  weeks, 
mucus  is  present,  and  may  then  become  a  constant  feature. 

If  there  is  constipation,  the  stools  are  usually  gray  or  white;  they 
are  smooth  and  pasty  or  like  hard  balls  passed  after  much  straining,  often 
coated  with  mucus  and  sometimes  streaked  with  blood.  Often  the  bowels 
will  not  move  for  days  except  after  the  use  of  laxatives  or  enemata.  The 
latter  often  have  but  little  effect,  as  the  rectum  may  be  empty.  Con- 
stipated cases  are  especially  prone  to  suffer  much  from  flatulence  and 
colic,  the  attacks  of  which  may  be  very  severe. 

The  duration  of  these  symptoms  is  indefinite.  There  is  little  or  no 
tendency  to  spontaneous  improvement,  and  they  may  drag  on  for  several 
months  or  until  the  problem  of  diet  is  solved.  The  progress  of  these 
cases  is  marked  by  frequent  exacerbations,  during  which  there  is  vomit- 
ing, and  usually  fever.  Such  symptoms  are  generally  dependent  upon 
intestinal  toxaemia.  A  low  irregular  fever  may  continue  for  days  or  even 
weeks.  Although  the  general  symptoms  of  failing  nutrition  are  present 
in  most  cases,  a  mild  degree  of  chronic  intestinal  indigestion  with  fre- 
quent loose  movements  may  sometimes  last  for  months,  during  wliieh 
the  patients  may  gain  steadily  in  weight  and  give  every  indication  of 
being  well  nourished.  This  is  much  more  common  in  nursing  infants 
than  in  those  who  are  artificially  fed. 

Diagnosis, — It  is  not  generally  difficult  to  determine  that  an  infant  is 
suffering  from  chronic  intestinal  indigestion;  but  one  should  endeavour 
to  go  further  in  his  diagnosis  and  discover  which  of  the  elements  of  the 
food  is  causing  the  chief  disturbance.  Thus,  in  an  infant  fed  on  cow's 
milk,  we  wish  to  know  whether  it  is  the  proteids,  the  fat,  or  the  sugar;  or. 
in  another  case,  whether  it  is  the  starch  of  some  proprietary  food.  Much 
valuable  information  may  be  gained  from  a  careful  history  of  what  has 
already  been  tried  in  the  case;  often  some  gross  error  can  be  detected  in 
the  formula  used  or  in  the  preparation  of  the  food.  Dilliculty  with  the 
proteids  is  usually  shown  by  colic,  constipation  more  often  than  dianlKea. 
and  by  curds  in  the  stools;  often  there  is  vomiting.  DifTiculty  witii  tlie 
fat  is  often  indicated  by  loose  movements,  usually  of  a  yellow  or  yellow- 
ish-green colniir  ;ii)(l  sour  odoui'.  Sometimes  they  are  white,  smooth  and 
formed,  witii  a  i)ecuiiarly  offensive  odour;  there  may  be  vomiting  or  the 
regurgitation  of  food  in  small  quantities.  Dilliculty  \\ith  the  sugar  is  less 
common  than  w  itli  either  the  proteids  or  the  fat,  but  there  may  be  flatu- 
lence, colic,  and  diarrhoea,  with  thin,  sour,  irritating  stools.  Difficulty 
with  the  starch  leads  to  much  flatulence  and  colic,  diarrhoea  alternating 


412  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

with  constipation,  and  offensive  stools.  One  may  find  the  foregoing 
symptoms  in  any  combination,  for  in  protracted  cases  the  trouble  is  rarely 
limited  to  a  single  element  in  the  food.  If  one. is  feeding  cow's  milk,  the 
best  way  to  arrive  at  a  diagnosis  is  to  begin  with  what  would  be  a  proper 
formula  for  a  healthy  infant  somewhat  younger,  and  watch  the  stools 
closely  for  two  or  three  days.  The  proportion  of  the  offending  element 
should  then  be  reduced  until  the  symptoms  it  is  causing  disappear.  By 
carefully  modifying  milk  in  this  way,  a  diagnosis  can  usually  be  reached 
in  a  few  days.    "Without  it,  all  treatment  is  haphazard  experimentation. 

Prognosis. — This  depends  almost  entirely  upon  how  early  the  cases 
come  under  treatment  and  how  they  are  managed.  There  is  very  little 
tendency  to  spontaneous  improvement  or  recovery.  The  existence  of 
chronic  intestinal  indigestion  is  one  of  the  most  important  predisposing 
causes  of  more  serious  forms  of  intestinal  disease,  and  in  that  consists  its 
chief  danger. 

Treatment. — Drugs  have  no  part  in  the  treatment  of  these  cases,  ex- 
cept now  and  then  for  particular  symptoms,  such  as  diarrhoea,  constipa- 
tion, or  colic.  These  infants  are  cured  by  proper  dietetic  and  hygienic 
measures,  and  by  these  alone.  The  problem  of  diet  has  already  been  dis- 
cussed in  the  chapter  on  Infant  Feeding.  For  the  general  management 
of  the  case,  which  is  not  less  important,  the  reader  is  referred  to  the 
chapter  on  Malnutrition. 

In  Older  Childre^t. — Chronic  intestinal  indigestion  is  exceedingly 
common  in  children  from  the  first  to  the  fifth  year;  it  is,  however, 
seen  throughout  childhood.  With  younger  children,  solid  food  has  gen- 
erally been  used  too  early  and  in  too  large  quantities.  The  articles  from 
which  most  trouble  is  seen  are  imperfectly  cooked  cereals,  vegetables  of 
all  kinds,  but  especially  potato.  Often  the  diet  is  composed  almost  en- 
tirely of  farinaceous  foods  and  bread.  Children  suffering  from. rickets 
are  much  more  prone  to  chronic  intestinal  indigestion  than  are  others, 
but  it  is  seen  in  many  in  whom  there  is  no  trace  of  rickets,  and  in  all 
grades  of  society — quite  as  often  among  the  better  class  as  in  dispensary 
practice,  although  in  the  former  the  type  is  usually  less  severe.  ;. 

Symptoms. — The  clinical  picture  which  these  cases  present  is  a  very 
common  one,  and  the  symptoms  are  quite  imiform.  The  patients  are 
generally  very  thin,  with  very  small  extremities,  a  small  amount  of  fat, 
and  a  large  protuberant  abdomen.  There  is  much  flatulence,  and  in  cases 
of  long  standing  there  is  marked  tympanites.  Such  children  are  pale, 
anaemic,  and  sallow  in  complexion ;  they  have  dark  rings  under  the  eyes ; 
they  are  easily  fatigued  on  slight  exertion ;  they  are  very  cross,  irri- 
table, and  emotional  to  an  unnatural  degree.  They  are  hard  to  amuse, 
hard  to  control,  and  altogether  exceedingly  difficult  patients  to  deal  with. 
Their  growth  is  retarded  if  the  symptoms  have  lasted  long.  They  are 
much  below  the  average  in  height  and  weight.    Even  when  not  rachitic 


CHRONIC  INTESTINAL  INDIGESTION.  413 

they  walk  late,  and  their  general  development  is  very  slow.  The  sleep  is 
always  unnatural  and  disturbed;  they  can  rarely  be  made  to  sleep  with 
any  regularity  during  the  day,  and  at  night  they  toss  about  their  cribs, 
waking  frequently,  crying  out  and  often  grinding  their  teeth,  this  some- 
times leading  to  the  diagnosis  of  intestinal  worms.  They  perspire  very 
readily,  and  suffer  from  cold  extremities. 

The  bowels  are  usually  constipated,  the  stools  being  of  a  light  gray 
colour  or  perfectly  white.  The}'  are  always  formed  and  generally  lumpy. 
The  odour  from  the  discharges  is  usually  extremely  foul.  In  other  cases 
there  is  chronic  diarrhoea.  The  stools  are  not  very  frequent,  rarely  ex- 
ceeding four  or  five  a  day,  but  they  are  large,  thin,  gray,  green,  or  brown 
in  colour,  very  offensive,  and  always  contain  undigested  food.  They  are 
often  excited  by  the  taking  of  food.  From  time  to  time,  in  many 
patients,  large  quantities  of  mucus  are  passed  from  the  intestine ;  in 
some  cases  this  comes  to  be  a  constant  feature  of  the  disease.  It  results 
from  an  intestinal  catarrh,  which  has  been  set  up  by  the  irritation  from 
the  hard  fgecal  masses  or  from  the  chronic  functional  derangement. 
Large  quantities  of  gas  are  expelled  per  anum.  Pain  is  not  a  very  com- 
mon sjmiptom  in  most  cases,  although  in  a  few  patients  a  localized  pain 
of  considerable  severity  may  be  complained  of  at  certain  times,  lasting 
for  a  day  or  more.  The  appetite  is  capricious,  and  usually  poor,  though 
some  patients  will  eat  everything  offered.  Because  of  the  disinclination 
to  take  simple  food,  the  most  indigestible  and  highly  seasoned  articles  are 
often  given,  with  the  effect  of  increasing  the  severity  of  the  symptoms. 
The  tongue  may  be  coated;  but  unless  the  stomach  is  also  affected  it 
is  usually  clean  and  the  breath  is  not  offensive. 

The  nervous  symptoms  which  these  patients  present  are  exceedingly 
varied,  and  often  of  the  most  puzzling  character.  In  many  cases  they  are 
so  severe  and  so  persistent  as  to  lead  to  the  diagnosis  of  organic  disease  of 
the  brain.  In  addition  to  the  condition  of  general  nervous  irritability, 
there  may  be  opisthotonus,  tetany,  fainting  attacks  resembling  some- 
what the  seizures  of  petit  mal,  exaggerated  reflexes,  attacks  of  dulness  or 
sometimes  stupor,  with  retracted  abdomen,  irregular  pulse  and  respira- 
tion, and  other  symptoms  strongly  suggestive  of  tuberculous  meningitis. 
Convulsions  are  not  very  uncommon.  They  are  usually  accompanied  by 
fever,  and  may  be  repeated  at  intervals  of  a  few  minutes.  Headache  and 
frequent  attacks  of  vomiting,  which  are  perhaps  to  be  interpreted  as  in- 
stances of  migraine,  are  occasionally  seen.  In  fact,  there  is  almost  no 
end  to  the  complexity  of  these  cases  and  the  combinations  of  nervous 
symptoms  which  they  may  present.  Most  of  these  are  toxic  in  their 
origin.    The  skin  shows  frequently  eruptions  of  erythema  or  of  urticaria. 

Slight  fever,  also  of  toxic  origin,  is  sometimes  present  for  many 
weeks,  the  temperature  usually  varying  between  99°  and  100  -5°  F. 
Sometimes  for  several  days  it  may  be  normal,  and  occasionally  may  rise 


414  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

to  102°  or  103°  F.  during  a  slight  exacerbation  in  the  symptoms.  The 
urine  of  most  of  these  patients  contains  a  great  excess  of  indican;  the 
amount  present  indicates  very  acciirately  the  degree  of  intestinal  putre- 
faction present,  and  often  fluctuates  regularly  with  the  nervous  symp- 
toms. 

Intercurrent  attacks  of  acute  indigestion,  with  diarrhoea  and  vomit- 
ing, are  common  and  quite  easily  excited.  The  course  and  duration  of 
these  symptoms  are  indefinite.  In  the  most  severe  forms,  if  untreated, 
the  patients  gradually  waste  until  they  die  from  exhaustion,  or  fall  easy 
victims  of  any  acute  disease  which  they  may  happen  to  contract.  There 
is  but  little  tendency  to  spontaneous  recover}^ 

Prognosis. — This  depends  upon  the  duration  of  the  symptoms,  the 
general  condition  of  the  patient  at  the  time  treatment  is  begun,  and  upon 
how  thoroughly  it  can  be  carried  out.  The  symptoms,  in  the  great 
majority  of  cases,  have  existed  for  several  months  at  the  time  the  case 
comes  under  observation.  Generall}'',  the  greater  the  mistakes  in  feeding 
have  been,  and  the  greater  the  violation  of  hygienic  and  dietetic  rules, 
the  better  the  prognosis.  A  child  who  has  developed  chronic  intestinal 
indigestion  of  a  severe  type,  in  spite  of  the  fact  that  the  hygienic  sur- 
roundings were  good,  and  where  the  dietetic  errors  were  not  flagrant,  is 
not  nearly  so  hopeful  a  subject  for  treatment  as  one  whose  hygienic  sur- 
roundings have  been  poor  and  whose  diet  has  been  especially  bad.  In 
cases  like  the  latter,  a  removal  of  the  causes  and  the  institution  of  proper 
methods  of  treatment  almost  invariably  result  in  immediate  and  striking 
improvement,  unless  the  general  vitality  of  the  patient  has  been  reduced 
to  a  very  low  point.  In  the  other  cases,  where  the  mistakes  have  been 
less  marked,  and  the  condition  is  due  more  to  constitutional  than  to  local 
causes,  the  improvement  is  slower  and  less  striking.  Thus,  as  a  rule, 
hospital  patients  improve  more  rapidly  than  those  seen  in  private  prac- 
tice, because  their  previous  treatment  has  been  so  much  worse. 

Treatment. — In  no  class  of  cases  that  the  physician  is  called  upon  to 
treat  are  results  more  satisfactory  than  in  many  of  those  of  chronic  intes- 
tinal indigestion,  where  the  intelligent  co-operation  of  the  parents  or  a 
trained  nurse  can  be  secured.  If  the  parents  themselves  are  lax  in  disci- 
pline, and  are  unable  to  control  the  child,  an  efficient  trained  nurse  should 
be  secured,  into  whose  hands  the  exclusive  management  of  the  child 
should  be  placed.  The  essential  part  of  the  treatment  is  diet  and  gen- 
eral management.  In  the  second  and  third  years  the  most  important 
thing  is  to  stop  all  starchy  food  for  a  considerable  time,  and  put  the 
patient  upon  an  exclusive  diet  of  rare  beef  or  beef  juice  and  milk.  The 
milk  for  many  of  the  patients  must  be  peptonized,  as  the  casein  of  cow's 
milk  is  often  very  difficult  of  digestion  even  for  children  three  years  old. 
By  some  the  fat  also  can  not  be  digested,  and  skimmed  milk  should  then 
be  used;  in  very  obstinate  cases  it  should  be  peptonized  for  two  hours; 


CHRONIC   INTESTINAL   INDIGESTION.  415 

in  the  majority  of  cases,  however,  it  is  sufficient  to  peptonize  it  from  fif- 
teen to  twenty  minutes.  After  a  few  weeks  some  carbohydrates  may  be 
added,  preferably  in  the  form  of  one  of  the  malted  foods,  which  may  be 
continued  until  the  child  can  digest  some  form  of  starch.  The  number 
of  feedings  should  not  be  more  than  four  a  day  during  the  second  year, 
and  three  or  four  a  day  for  children  during  the  third  and  fourth  years. 
The.se  should  always  be  at  regular  intervals,  and  nothing  whatever  given 
between  meals.  The  meat  should  be  rare  scraped  beefsteak  or  mutton; 
from  one  to  three  tablespoonfuls  may  be  allowed  once  a  day.  The  juice 
of  fresh  fruit,  especially  oranges,  may  after  a  time  be  given  once  a  day, 
one  hour  before  meals.  Kumyss  and  matzoon  are  often  of  very  great 
value  in  children  who  are  not  fond  of  milk,  or  who  become  tired  of  the 
diet.  Although  at  first  they  are  taken  with  difficulty,  in  many  cases  a 
fondness  for  them  is  very  soon  acquired. 

After  improvement  has  been  going  on  for  two  months,  bread  may  be 
added,  at  first  in  small  quantities  and  once  a  day.  This  should  preferably 
be  stale  bread,  cut  thin  and  dried  in  the  oven  until  it  is  crisp,  and  given 
without  butter.  Two  or  three  times  a  week  raw  oysters  may  be  tried. 
Mutton,  chicken,  or  beef  broth,  without  vegetables,  may  be  given  occa- 
sionally in  the  place  of  one  of  the  milk  feedings.  After  this  diet  has  been 
kept  up  for  three  or  four  months,  if  improvement  continues,  one  of  the 
green  vegetables  may  be  added  once  a  day,  preferably  either  spinach, 
stewed  celery,  or  asparagus.  After  two  or  three  months  more  of  contin- 
ued improvement,  thoroughly  cooked  rice  or  macaroni  may  be  given  twice 
a  week.  With  these  articles  of  diet  one  can  get  along  very  comfortably 
for  a  year,  and  no  larger  variety  should  be  given  until  all  the  symptoms 
have  disappeared.  When  starchy  food  is  first  allowed,  it  should  be 
only  in  small  quantities,  and  usually  with  some  preparation  of  diastase. 
Potato  and  oatmeal  should  bo  forbidden  for  a  long  time.    . 

Intestinal  irrigation  is  useful  in  some  cases  in  which  there  is  much 
mucus  passed.  But  it  should  not  be  forgotten  that  continued  irrigation 
often  keeps  up  the  production  of  mucus.  Astringents  should  not  be  used, 
but  only  a  warm  saline  solution,  and  this  not  regularly.  It  should  be 
omitted  from  time  to  time  to  see  whether  the  discharge  of  mucus  is  not 
less  without  it.     It  is  of  most  value  during  exacerbations. 

The  constipation  can  sometimes  be  controlled  by  the  diet.  Calomel 
frcf[uently  seems  to  exert  a  very  marked  influence,  even  when  the  con- 
stipation is  not  severe.  It  is  often  wise  to  administer  a  full  dose  every 
five  or  six  days.  In  some  patients  castor  oil  acts  more  satisfactorily. 
It  is  sometimes  objectionable,  hoAvever,  froiii  its  tendency  to  aggravate 
the  constipation.  As  laxatives  in  this  condition  I  have  found  tlie  great- 
est satisfaction  from  the  use  of  preparations  of  cascara  and  the  com- 
pound licorice  powder.     Abdominal  massage  is  also  useful. 

Drugs  directed  against  the  process  of  putrefaction  are  extremely  un- 


416  DISEASES  OF   THE  DIGESTIVE  SYSTEM. 

satisfactory  even  in  older  children^  but  sometimes  diminution  in  the 
amount  of  flatiilence  follows  the  use  of  subgallate  of  bismuth^  carbonate 
of  creosote,  salol,  or  salicylate  of  soda.  General  tonics  are  required, 
and  may  add  materially  to  the  improvement  of  the  patients.  Altogether 
the  best  one  is  nux  vomica.  It  may  be  given  in  combination  with  the 
bitter  wine  of  iron  just  before  meals  three  times  a  day.  This  increases 
the  appetite  and  acts  favourably  upon  the  constipation.  Cod-liver  oil, 
particularly  in  the  early  stage,  is  badly  borne.  It  should  be  withheld 
in  all  cases  until  very  marked  improvement  in  the  condition  of  the 
digestion  is  assured. 

Relapses  are  easily  excited  by  indiscretion  in  diet,  and  parents  should 
be  impressed  at  the  very  beginning  with  the  necessity  of  adhering  rigidly 
to  the  diet  prescribed,  for  a  long  period.  It  very  often  happens  that  the 
improvement  which  is  seen  after  one  or  two  months  of  careful  treatment 
is  so  marked  as  to  lead  the  parents  to  the  belief  that  a  cure  has  been  ac- 
complished, so  that  they  relax  their  vigilance  and  allow  improper  articles 
of  food  which  are  almost  certain  to  induce  a  relapse.  If  the  case  is  an 
aggravated  one,  and  the  symptoms  of  long  standing,  it  is  wise  to  tell 
parents  at  the  outset  that  a  year's  treatment  is  the  minimum  in  which 
anything  permanent  can  be  accomplished. 

The  general  treatment  of  the  patient  must  not  be  overlooked.  Proper 
clothing,  regular  exercise  in  the  open  air,  cool  sleeping  rooms,  massage, 
sponging  every  morning  with  cold  water,  are  all  of  very  great  importance, 
and  contribute  almost  as  much  to  the  results  obtained  as  the  special 
measures  adopted.     (See  chapter  on  Malnutrition.) 

The  improvement  in  the  nervous  symptoms  of  the  patient  is  one  of 
the  first  things  noticed,  and  is  often  marked  in  a  few  da3rs  after  the 
beginning  of  treatment.  From  an  irritable,  fretful,  peevish  child  the 
patient  is  sometimes  totally  changed  in  disposition  in  a  few  weeks,  so 
as  to  become  quiet,  affectionate,  docile,  and  playful. 

INTESTINAL  COLIC. 

The  term  colic  is  applied  to  any  severe  paroxysmal  pain  occurring  in 
the  intestines.  It  may  be  due  to  many  causes.  The  colic  of  lead  and 
arsenic  poisoning  are  both  very  rare  in  children;  but  colicky  pains  are 
present  in  appendicitis,  intussusception,  ileo-eolitis,  and,  in  fact,  in  all 
the  severe  forms  of  intestinal  inflammation.  Colic  may  be  due  to  swal- 
lowing certain  substances,  especially  foreign  bodies  and  the  seeds  of 
fruits;  and  in  rare  cases  it  may  be  excited  by  the  presence  of  round- 
worms when  they  are  numerous.  In  all  the  conditions  mentioned,  colic 
is  only  one  of  the  symptoms,  although  it  may  be  a  very  prominent  one. 

The  special  and  peculiar  colic  of  infancy  is  that  which  is  associated 
with  flatulence,  and  is  due  to  indigestion.     Here  it  is  a  symptom  only, 


INTESTINAL  COLIC.  417 

but  may  be  a  most  troublesome  one.  This  form  of  colic  belongs  essen- 
tially to  the  first  six  months  of  life,  and  is  more  frequent  during  the  first 
three  months.  It  may  be  seen  at  any  time  when  digestion  is  very  feeble. 
Many  young  infants  suffer  from  colic  a  large  part  of  the  time ;  others 
have  only  occasional  attacks,  which  are  often  repeated  at  a  certain  time 
in  the  day,  usually  toward  evening. 

The  flatulence  to  Avhich  the  colic  is  usually  due  may  be  from  decom- 
position in  the  food  or  intestinal  secretions,  or  in  both.  It  is  seen  quite 
as  often  in  nursing  infants  as  in  those  who  are  artificially  fed.  Any  of 
the  elements  of  the  milk  may  be  a  cause  of  colic,  but  in  fully  four-fifths 
of  the  cases  it  is  the  proteids.  The  colic  of  nursing  infants  is  nearly  al- 
ways due  to  the  fact  that  the  milk  is  excessive  in  proteids,  or  else  that 
these  are  digested  with  special  difficulty.  If  cow's  milk  is  the  food,  it  is 
the  proteids  which  are  usually  at  fault.  It  is  rare  that  the  quantity  of 
sugar  present  in  cow's  milk  is  sufficient  to  be  a  cause  of  colic ;  but  this 
may  happen  when  sugar  has  been  added,  more  frequently  with  cane 
sugar  than  with  milk  sugar.  It  is  extremely  rare  for  the  fat  to  be  a 
cause  of  colic.  In  infants  whose  food  consists  largely  of  farinaceous 
substances,  colic  is  also  very  common. 

As  a  result  of  the  decomposition  taking  place  in  the  intestine,  gas  ac- 
cumulates, and,  the  intestines  lacking  sufficient  muscular  force  to  expel 
it,  distention  follows.  To  this  in  part  the  pain  is  due.  But  spasm  of  the 
muscular  walls  of  the  intestine  is  also  an  element  in  producing  the  pain. 
In  some  of  the  most  severe  cases  it  is  possible  that  the  spasm  may  be 
accompanied  by  a  slight  transient  intussusception.  Colic  may  occur 
without  flatulence,  as  in  cases  when  it  follows  cold  feet  or  chilling  the 
surface.  In  these  cases  also,  muscular  spasm  appears  to  be  the  principal 
factor  in  causing  the  pain.  Intestinal  colic  may  occur  alone,  or  it  may 
alternate  with  or  accompan}^  gastric  colic. 

Symptoms. — These  are  in  most  cases  so  typical  as  to  bo  easily  recog- 
nised. They  are  always  more  severe  in  delicate  and  highly  nervous  chil- 
dren. In  the  severe  attacks  there  is  contraction  of  the  features,  the  loud 
paroxysmal  cry,  subsiding  for  a  few  moments  and  then  beginning  with 
renewed  intensity,  drawing  up  of  the  lower  extremities,  and  in  male  in- 
fants contraction  of  the  scrotum.  With  these  symptoms  the  abdomen  is 
usually  found  tense  and  hard.  With  the  expulsion  of  the  gas,  the  symp- 
toms subside  at  once,  and  the  child  usually  falls  asleep.  In  the  most 
severe  attacks  there  may  be  considerable  prostration,  cold  extremities, 
and  perspiration.  When  the  symptoms  are  less  severe  there  is  only  con- 
tinual fretfulness,  and  the  child  can  not  sleep.  \\\\rn  colic  is  habitual 
there  are  very  few  honrs  in  the  twenty-four  wlicii  (lie  cliild  seems  to  be 
entirely  comfortal)lc.  hi  iiui'sin.u-  iiifaiils  llici'c  ni;iy  ;il  times  be  difficulty 
in  distinguishing  the  cry  of  colic  from  tl);i(  of  liuiigcr,  as  infants  suffering 
from  colic  will  usually  take  food  eagerly,  and  this  is  often  followed  by 


418  DISEASES  OF   THE  DIGESTIVE  SYSTEM. 

temporary  relief.  In  colic,  however,  the  pain  soon  returns,  and  often  is 
more  severe  than  before.  The  cry  of  colic  is  usually  violent  and  parox- 
ysmal ;  that  of  hunger  is  apt  to  be  prolonged  and  continuous,  and  is  not 
accompanied  by  the  other  symptoms  mentioned  as  indicating  abdominal 
pain.  In  older  children  the  less  frequent  causes  of  colic  mentioned  at 
the  beginning  of  this  article,  especially  appendicitis,  should  be  borne 
in  mind. 

Treatment. — When  colic  is  due  to  flatulence  of  the  intestine,  nothing 
given  by  the  mouth  has  much  effect  in  relieving  the  symptoms.  Certainly 
food  should  not  be  given.  The  purpose  of  treatment  during  the  attack  is 
to  assist  the  child  to  get  rid  of  the  gas ;  as  this  is  usually  in  the  colon,  the 
most  efficient  means  is  by  massage  or  enemata.  At  first  an  injection  of 
four  or  five  ounces  of  lukewarm  water  should  be  used.  If  this  is  not  suc- 
cessful, two  ounces  of  cold  water  with  half  a  teaspoonful  of  glycerin  may 
be  tried.  This  rarely  fails  to  start  peristalsis  and  expel  the  gas.  In  con- 
junction with  these  measures,  dry  heat  should  be  applied  to  the  abdomen 
by  means  of  hot  fiannels  or  a  hot-water  bag,  and  the  feet  should  be  well 
warmed.  In  cases  of  colic  not  associated  with  flatulence,  where  the  pain 
is  probably  the  result  of  muscular  spasm,  opium  in  some  form  is  required 
in  addition  to  heat  or  counter-irritation.  The  treatment  between  the 
attacks  and  the  treatment  of  habitual  colic  should  be  directed  toward 
the  indigestion,  upon  which  they  depend. 

CHRONIC   CONSTIPATION. 

Constipation  may  be  said  to  exist  whenever  the  stools  are  less  fre- 
quent, harder,  and  drier  than  normal.  During  the  first  six  months  in- 
fants usually  have  two  movements  a  day.  Many,  however,  have  only  one ; 
but  if  this  is  normal  in  character  the  child  is  not  constipated.  In  other 
cases,  although  there  are  two  and  even  three  stools  a  day,  they  may  all  be 
small,  dry,  and  hard,  having  all  the  characters  of  constipated  stools,  and 
the  case  should  be  treated  accordingly. 

Etiology. — The  causes  of  chronic  constipation  are  many  and  far- 
reaching.  It  may  be  due  to  a  diminution  in  the  secretion  of  the  intestinal 
glands  or  of  the  liver.  The  movements  are  then  hard,  dry,  very  light- 
coloured,  and  are  associated  with  much  flatulence  and  other  signs  of 
intestinal  indigestion.  Very  often  the  principal  factor  in  constipation  is 
insufficient  muscular  contraction  in  the  intestine.  The  fa?cal  masses  are 
then  propelled  so  slowly  and  remain  so  long  in  the  intestine  that  the  fluid 
portion  is  absorbed,  the  residue  becoming,  in  consequence,  so  dry  and 
hard  that  it  is  difficult  to  expel.  In  other  cases  constipation  depends 
upon  the  fact  that  there  is  insufficient  volume  to  the  stools,  as  may  be 
the  case  when  the  food  given  leaves  very  little  residue.  Constipation  may 
depend  upon  local  causes,  as,  for  example,  where  an  evacuation  of  the 
bowels  is  resisted  on  account  of  pain  from  fissure  of  the  anus  or  from 


CHRONIC   CONSTIPATION.  419 

haemorrhoids.  Although  not  the  primary  cause,  this  condition  may  be 
suflicient  to  Ivcep  up  the  constipation  indefinitely.  It  may,  in  rare  cases, 
be  due  to  a  congenital  condition,  such  as  a  narrowing  of  the  large  intes- 
tine at  some  point.  The  most  important  causes  of  constipation  may  be 
grouped  under  two  heads :  diet,  and  conditions  giving  rise  to  muscular 
atony. 

Diet. — In  breast-fed  infants  the  trouble  is  usually  a  lack  of  fat  and 
an  excess  of  proteids  in  the  milk.  In  those  who  are  artificially  fed  it  is 
often  because  the  fat  is  too  low,  and  sometimes  because  both  the  fat  and 
the  proteids  are  too  low,  the  stool  lacking  volume.  In  other  cases  the 
cause  of  constipation  is  indigestion,  in  still  others  the  use  of  "  sterilized  " 
milk.  During  the  second  and  third  years  the  cause  may  be  too  much 
cow's  milk,  particularly  that  which  has  been  boiled,  or  the  use  of  an  ex- 
cessive amount  of  starchy  food.  As  during  the  first  year,  the  trouble 
with  cow's  milk  is  that  it  contains  too  much  casein,  the  digestibility  of 
which  has  often  been  rendered  more  difficult  by  the  boiling.  In  older 
children  the  cause  may  be  an  excess  of  starchy  food  and  a  lack  of  suffi- 
cient green  vegetables,  meat,  and  fruit. 

Muscular  atony. — The  most  common  cause  of  muscular  atony  is 
habit ;  in  a  large  number  of  cases  lack  of  proper  training  is  the  principal 
etiological  factor.  If  the  inclination  to  have  a  stool  is  regularly  disre- 
garded it  soon  ceases  to  be  felt.  The  ordinary  irritation  from  ftecal 
masses  produces  no  response  whatever.  The  longer  such  a  condition 
continues  the  more  obstinate  does  it  become.  This  is  an  important  factor 
in  all  cases.  Another  potent  cause  of  muscular  atony  is  rickets.  In  this 
disease  the  muscular  walls  of  the  intestine  suffer  like  the  muscles  of  the 
extremities,  and  become  incapable  of  doing  their  work.  Again,  any  form 
of  malnutrition  in  which  there  is  feeble  muscular  tone  may  cause  or 
aggravate  constipation.  It  is  often  seen  as  a  sequel  to  acute  attacks  of 
diarrhoeal  diseases,  particularly  when  these  have  been  prolonged.  "Want 
of  sufficient  muscular  exercise  is  a  frequent  cause.  There  are  many  chil- 
dren who  rarely  suffer  from  constipation  in  summer  when  they  have 
plenty  of  out-of-door  exercise,  who  very  often  do  so  in  winter  when  such 
exercise  is  wanting.  A  loss  of  muscular  tone  is  not  an  infrequent  result 
of  the  prolonged  and  indiscriminate  use  of  purgative  drugs  or  enemata. 

Symptoms. — In  many  cases  no  symptoms  are  present  except  the  local 
ones,  the  general  health  being  excellent  and  the  nutrition  in  no  way 
disturbed.  In  the  majority,  however,  there  are  symptoms  of  greater  or 
less  severity,  depending  somewhat  upon  the  cause  of  the  constipation. 
There  may  be  simply  flatulence  and  colicky  pains,  or  the  irritation  of 
the  hardened  faacal  masses  may  produce  a  sliglit  catarrhal  inflammation 
of  the  sigmoid  flexure  and  tbo  rectum,  so  iliat  imieus  and  sometimes 
traces  of  blood  may  be  passed  with  the  stool.  Ila-inorrlioids  may  develop 
even  in  infancy,  and  frequently  tlie  constant  straining  leads  to  the  pro- 


420  DISEASES   OF  THE  DIGESTIVE  SYSTEM. 

diiction  of  hernia.  In  man}^  cases  there  are  from  time  to  time  nervous 
symptoms  resulting  from  the  absorption  of  various  toxic  materials  from 
the  intestine.  There  may  be  headache,  clulness,  fretfulness,  disturbed 
sleep,  and  often  associated  signs  of  intestinal  indigestion.  The  urine 
often  contains  indican  in  excess,  and  there  ma}^  be  slight  fever. 

Diagnosis. — This  includes  the  discovery  of  the  cause  and  the  principal 
seat  of  the  constipation.  To  arrive  at  the  former  the  most  careful  and 
thorough  investigation  should  be  made  of  the  child's  diet  and  habits.  It 
is  desirable  to  determine  whether  the  seat  of  trouble  is  the  rectum,  the 
upper  part  of  the  colon,  or  the  small  intestine.  If  a  suppository  is  al- 
most immediately  followed  by  a  normal  stool,  one  may  be  sure  that  the 
rectum  only  is  at  fault,  and  that  it  needs  but  a  little  extra  stimulus  to 
make  it  do  its  work.  This  is  common  in  infants  who  are  too  young  to 
make  any  voluntary  efforts.  In  such  cases  there  are  no  other  symptoms 
present.  In  others,  the  white  or  gray  stools,  marked  flatulence,  offensive 
breath,  and  general  irritability,  leave  no  doubt  of  the  fact  that  the  trou- 
ble is  in  the  small  intestine  and  depends  upon  indigestion. 

Treatment. — This  is  always  difficult,  and  in  obstinate  cases  must  be 
continued  for  a  long  time.  The  co-operation  of  an  intelligent  mother 
or  nurse  is  absolutely  indispensable.  To  establish  the  habit  of  regular 
stools  should  be  the  first  step,  for  without  this  regularity  nothing  can 
be  done.  Even  in  infants  only  a  few  months  old  proper  habits  are  often 
easily  formed  if  the  child  is  put  upon  the  chamber  or  chair  invariably  at 
the  same  hour.  When  a  local  stimulus  is  required  in  addition  an  oiled 
glass  rod  or  a  glutin  suppository  may  be  inserted.  An  older  child  must 
be  taught  to  heed  the  first  impulse  to  evacuate  the  bowel.  Eegular 
habits  can  hardly  be  formed  unless  the  same  time  each  day  is  chosen 
for  the  movement.  That  to  be  preferred  is  soon  after  the  morning  meal,, 
as  taking  food  into  the  stomach  usually  starts  a  peristaltic  wave  which 
is  continued  throughout  the  intestine.  With  older  children  breakfast 
should  be  early  enough  to  allow  ample  time  for  this  duty  before  the 
other  engagements  of  the  day;  and  nurses  should  be  impressed  with 
the  importance  of  the  early  formation  of  proper  habits  on  the  part  of 
their  charges.  Stretching  the  sphincter  under  an  anesthetic  is  some- 
times of  great  benefit,  especially  where  tonic  spasm  is  present. 

Food. — With  nursing  infants  who  get  good  breast-milk  constipation 
is  rare.  Where  the  milk  is  low  in  fat  and  high  in  proteids,  constipation  is 
not  uncommon.  For  the  measures  by  which  such  milk  can  be  improved,, 
see  chapter  on  Breast  Feeding. 

In  feeding  cow's  milk,  constipation  is  overcome  by  getting  the  exact 
proportions  of  proteids  and  fat  which  are  suited  to  the  infant.  With 
most  infants  during  the  early  weeks  from  2  to  3  per  cent  fat  and  1  per 
cent  proteids  succeed  best;  with  those  a  little  older,  from  3  to  4  per  cent 
fat  and  1*5  per  cent  proteids.     During  the  last  half  of  the  first  year  4 


CHRONIC   CONSTIPATION.  421 

per  cent  fat  and  from  3  to  3  per  cent  proteids  will  be  found  satisfactory. 
(See  Infant  Feeding.)  To  feed  an  infant  two  or  three  months  old  upon 
2  per  cent  fat  and  2  per  cent  proteids — which  is  what  is  usually  given 
when  cow's  milk  is  simply  diluted  once  with  water — almost  invari- 
ably produces  constipation.  With  most  infants  during  the  first  year, 
constipation  may  be^,  if  not  cured,  at  least  prevented  by  such  modifi- 
cations. 

During  the  second  year,  children  who  suffer  from  constipation  should 
have  both  cream  and  water  added  to  the  milk,  to  reduce  the  proteids 
without  lowering  the  fat.  Suitable  proportions  can  be  obtained  by  add- 
ing two  tablespoonfuls  of  cream  to  two-thirds  of  a  glass  of  milk,  and 
filling  up  the  glass  with  water.  Further  improvement  may  be  brought 
about  by  substituting  malted  for  starchy  foods  and  adding  more  meat 
broth  or  beef -juice  which  are  quite  laxative  on  account  of  their  extract- 
ives and  salts.  Fruits  are  valuable  in  all  these  cases;  but  only  the  juice 
should  be  given  until  a  child  is  eighteen  or  twenty  months  old.  That  of 
almost  any  fresh  fruit  may  be  employed.  After  two  years  pulpy  fruits 
may  be  given;  baked  apples,  oranges,  stewed  prunes,  and  in  summer, 
fresh  peaches,  plums,  and  pears,  may  be  given  in  small  quantities;  but 
all  fruits  with  seeds  should  be  avoided. 

For  older  children  who  are  on  a  mixed  diet  the  amount  of  starchy 
food  should  be  moderate,  oatmeal  being  perhaps  the  best  cereal.  Milk 
should  be  given  rather  sparing!}-,  and  even  then  may  be  advantageously 
modified  as  for  the  second  year.  It  is  sometimes  advisable  to  stop  milk 
altogether  and  give  only  cream,  from  four  to  eight  ounces  of  which  may 
be  allowed  daily.  It  may  be  used  with  the  breakfast  cereal,  mixed  with 
potato  or  rice,  added  to  soups  or  broths,  and  taken  in  various  other  ways. 
All  bread  should  be  made  from  whole  wheat  or  unbolted  flour.  Meat  and 
broth  may  be  allowed  freely,  also  green  vegetables,  one  of  which  should 
be  given  every  day.  All  fruits  allowed  infants  may  be  used,  but  in  larger 
quantities,  and  in  addition  raw  apples.  Of  the  dried  fruits,  only  dates, 
prunes,  and  figs  are  admissible,  and  these  are  better  stewed  than  raw. 
Fresh  fruit  is  preferably  given  in  the  morning,  oranges  being  especially 
useful  when  taken  on  rising. 

Either  hot  or  cold  water,  when  taken  an  hour  before  breakfast,  may  be 
of  considerable  benefit  to  older  children.  The  sparkling  waters,  like 
Vichy  or  Apollinaris,  are  often  better  than  plain  water. 

Massage,  when  properly  employed,  is  useful  in  conjunction  with  other 
measures,  but  rarely  succeeds  alone.  It  should  be  given  for  five  or  ten 
minutes  after  retiring  and  just  before  rising.  The  hand  must  he  warm, 
but  no  oil  used,  the  purpose  being  not  to  make  friction  upon  the  skin,  but 
to  move  the  skin  and  abdominal  walls  upon  the  intestines.  This  should 
be  done  with  a  circular  motion,  changing  the  point  from  time  to  time 
until  the  whole  abdomen  has  been  thoroughly  covered.     In  addition  to 


422  DISEASES  OF   THE  DIGESTIVE  SYSTEM. 

this  a  general  kneading  of  the  abdomen  may  be  employed.  Only  slight 
pressure  should  be  made  until  the  child  becomes  accustomed  to  the  process, 
when  quite  deep  pressure  will  be  tolerated.  The  intestinal  coils  may  often 
be  felt  contracting  under  the  hand  during  massage.*  In  general  torpor 
of  the  intestines  massage  is  useful,  and  when  properly  done  may  affect  the 
small  as  well  as  the  large  intestine. 

A  proper  amount  of  active  muscular  exercise  is  necessary  and  should 
be  made  a  part  of  the  treatment  in  every  case.  Yale  (New  York)  has 
called  attention  to  the  importance  of  posture  during  the  stool,  he  having 
found  that  in  many  cases  a  cure  was  effected  simply  by  substituting  a  low 
seat  on  a  nursery  chair  or  closet  for  the  high  one  previously  used.  The 
low  seat  afforded  the  child  an  opportunity  to  strain  to  some  purpose,  while 
the  higher  one  with  the  legs  dangling,  made  this  almost  impossible. 

Stcppositories. — In  many  cases,  particularly  in  young  infants  who  are 
not  old  enough  to  initiate  the  muscular  effort,  a  slight  stimulus  to  the  rec- 
tum is  all  that  is  required.  The  cone  of  oiled  paper  has  a  great  reputa- 
tion in  domestic  practice  and  is  not  objectionable.  It  may  be  of  assistance 
in  establishing  the  habit  of  a  daily  movement  at  a  regular  time.  Soap  sup- 
positories produce  a  more  marked  irritation  ;  although  their  immediate 
effect  is  quite  satisfactory,  they  should  not  be  continued  indefinitely.  They 
are,  however,  less  objectionable  than  glycerin  suppositories.  The  lat- 
ter, for  an  immediate  effect,  are  convenient  and  usually  efficient ;  but 
their  prolonged  use,  especially  in  infants,  is  likely  to  set  up  a  catarrhal 
proctitis.  The  gluten  suppositories  produce  less  irritation  and  are  conse- 
quently slower  in  their  effect,  but  they  have  not  the  disadvantages  of  the 
soap  or  glycerin.  Medicated  suppositories  are  certainly  one  of  our  most 
efficient  measures ;  if  drugs  must  be  employed,  they  are  perhaps  open  to 
the  fewest  objections  when  used  in  this  way.  The  following  are  the  best 
drugs  for  this  purpose,  the  dose  being  that  for  a  child  of  two  or  three 
years  :  ext.  nux  vomica,  gr.  -^-^ ;  ext.  belladonna,  gr.  -^  ;  ext.  hj^oscyamus, 
gr.  ^ ;  sulphur,  gr.  ij  ;  purified  aloes,  gr.  J  ;  aloin,  gr.  -^.  A  good  com- 
bination is  aloin,  gr.  -^j  ;  ext.  belladonna,  gr.  -^^  ;  ext.  nux  vomica,  gr.  -^^ ; 
ol.  theobrom.,  gr.  x.  In  obstinate  cases  this  may  be  used  niglit  and  morn- 
ing, and  later  at  night  only.  After  some  improvement  has  occurred  the 
aloin  may  be  omitted.  Many  of  the  proprietary  suppositories  contain  the 
ingredients  mentioned,  particularly  belladonna,  the  dose  of  which  is  often 
considerably  larger  than  should  be  given.  Suppositories  are  chiefly  use- 
ful when  the  trouble  is  the  rectum  and  lower  colon;  but  very  little  is 
to  be  expected  from  them  when  it  is  higher  in  the  intestine. 

Ene7nata. — These  should  be  restricted  to  cases  in  which  only  temporary 
relief  is  desired.  An  injection  of  an  ounce  of  sweet  oil  may  facilitate  the 
passage  of  very  hard  and  dry  stools,  and  larger  injections  of  soap  and  water 


*  See  Karnitzky,  Archiv  fiir  Kinderheilkunde,  Bd.  xii,  p.  6G. 


CHRONIC  CONSTIPATION.  423 

may  be  used  to  break  up  hard  ftecal  accumulations.  For  immediate  effect 
an  injection  of  one  draclim  of  glycerin  in  half  an  ounce  of  water  is  perhaps 
the  most  efficient  means  at  our  command.  Cases  of  fsecal  impaction  are 
rarely  met  with  in  children.  They  are  to  be  managed  as  in  adults,  by 
repeated  injections  of  warm  water  or  of  ox-gall,  and  sometimes  by  me- 
chanical removal.  For  continuous  use  enemata  are  not  to  be  advised,  for 
larger  and  larger  quantities  are  required  to  produce  the  effect. 

Medicinal  treatment. — This  is  the  least  important  part  of  the  manage- 
ment of  chronic  constipation.  No  plan  is  worse  than  to  give  some  active 
purgative  every  third  or  fourth  day  and  trust  matters  to  take  care  of  them- 
selves the  rest  of  the  time.  The  most  valuable  drugs  are  those  which 
stimulate  the  muscular  walls  of  the  intestine,  such  as  cascara,  nux  vomica, 
belladonna,  and  hyoscyamus.  These  are  particularly  useful  in  atonic  con- 
stipation associated  with  rickets  and  following  diarrhoeal  diseases,  but  they 
are  valuable  in  all  cases.  With  most  drugs  the  ^Drolonged  use  of  small 
doses  is  better  than  the  occasional  use  of  large  ones.  Calomel  is  indicated 
in  cases  attended  with  dry,  very  white  stools  and  marked  flatulence; 
one  fourth  to  one  half  grain  of  the  tablet  triturates  may  be  given  for  two 
or  three  successive  nights  in  conjunction  with  other  means.  Cascara  may 
be  used  either  in  the  form  of  the  elixir,  dose  from  one  half  to  one  drachm, 
or  the  fluid  extract,  from  one  to  five  drops.  Rhubarb,  either  in  the  form 
of  the  syrup  or  the  mixture  of  rhubarb  and  soda,  may  be  given  occa- 
sionally, but  it  is  not  adapted  to  continuous  use.  Of  salines,  phosphate 
of  soda  is  best  for  continuous  use  in  infants.  All  the  preparations  of 
malt  possess  slight  laxative  properties,  and  are  useful  in  conjunction  with 
dietetic  and  other  medicinal  means ;  either  Trommer's  extract  of  malt 
or  maltine  may  be  employed.  Castor  oil  should  seldom  be  given  for 
chronic  constij)ation.  The  frequent  use  of  small  quantities  of  olive  oil 
is  often  a  good  means  of  treatment  in  the  case  of  young  iufants,  the  oil 
being  added  to  the  food. 

Summary. — The  treatment  of  constipation  is  palliative  and  curative. 
The  palliative  measures  are  drugs,  suppositories,  injections,  and  enemata. 
Cure  is  accomplished  only  by  diet,  massage,  exercise,  and  the  formation  of 
regular  habits.  An  average  case  of  chronic  constipation  in  a  child  four 
years  old  maybe  managed  as  follows  :  Massage  for  eight  minutes,  morning 
and  night ;  the  juice  of  half  an  orange  and  a  glass  of  Alchy  immediately 
upon  rising ;  a  breakfast  of  oatmeal  with  one  ounce  of  cream,  dried  bread 
with  butter,  an  q^^,  half  a  glass  of  milk  with  cream  and  water  added  ; 
a  dinner  of  soup,  one  starchy  vegetable — e.  g.,  potato  with  cream,  and 
one  green  vegetable,  beef-steak,  baked  apple  or  prunes,  dried  bread  and 
butter,  and  water  to  drink  ;  for  supper,  cream-toast,  eg^,  dried  bread  and 
butter,  or  Graham  crackers,  half  a  glass  of  milk  with  cream  and  water 
added  ;  a  suppository  containing  nux  vomica  and  hyoscyamus  given  at 
bedtime. 


424  DISEASES   OF   THE   DIGESTIA'E  SYSTEM. 

Hypertrophy  and  Dilatation  of  the  Colon. — It  is  probable  that  in  many 
cases  of  chronic  constipation,  especially  among  rachitic  infants,  a  consid- 
erable degree  of  dilatation  of  the  colon  occurs.  However,  it  seems  to  be 
but  a  temporary  condition,  disappearing  by  the  third  or  fourth  year. 

There  is  another  form  of  dilatation  which  may  be  permanent ;  it  is 
associated  with  a  marked  degree  of  hypertrophy  of  the  muscular  walls  of 
the  colon.  The  reported  cases  thus  far  are  few  in  number,  but  have  been 
observed  both  in  infants  (Hirschsprung,*  Myaf)  and  in  older  children 
(Osier,  Hughes t).  The  prominent  symptoms  are  two:  obstinate  con- 
stipation, which  in  most  of  the  cases  has  continued  from  early  infancy, 
and  is  sometimes  so  severe  that  the  patients  have  gone  for  two  weeks 
without  a  movement  of  the  bowels ;  and  distention  of  the  abdomen,  which 
may  be  extreme,  but  w^hich  may  disappear  and  the  abdomen  become  per- 
fectly flat  after  the  tseces  and  flatus  have  been  discharged.  There  is  usu- 
ally emaciation,  and  from  time  to  time  there  may  be  diarrhoea.  Death 
may  occur  in  infancy,  or  the  patients  may  live  to  adult  life. 

In  the  cases  which  have  come  to  autopsy  there  has  been  found  an 
enormous  dilatation  of  the  large  intestine,  chiefly  of  the  transverse  colon 
and  the  sigmoid  flexure.  In  one  case  (Hughes'),  in  a  boy  of  three  years, 
the  colon  was  four  inches  in  diameter,  and  held  fourteen  ^^ints  of  water. 
In  none  of  the  cases  was  there  stricture  at  any  point.  The  mucous  mem- 
brane has  invariably  been  found  ulcerated,  this  clearly  being  a  secondary 
process.  The  muscular  walls  have  been  greatly  hypertrophied.  The  con- 
dition is  without  doubt  a  congenital  one.  Treatment  is  palliative  only. 
In  some  of  the  cases  the  condition  seems  to  have  been  aggravated  by  the 
use  of  large  enemata. 

INTUSSUSCEPTION". 

Intussusception  consists  in  the  invagination  of  one  portion  of  the 
intestine  into  another.  It  occurs  most  frequently  in  infancy,  being  at 
this  age  the  most  common  cause  of  acute  intestinal  obstruction.  The 
accident  is  not  a  common  one,  but  the  life  of  the  patient  generally  depends 
upon  its  prompt  recognition. 

Varieties. — Usually  the  upper  part  of  the  intestine  is  invaginated  into 
the  lower,  although  the  reverse  is  occasionally  seen.  Intussusceptions  may 
occur  at  any  point  in  the  intestinal  tract.  Those  of  the  small  intestine 
are  called  enteric ;  those  of  the  colon,  colic ;  and  those  occurring  at  the 
ileo-csecal  valve,  ileo-ccBcal  (Fig.  75).  Of  90  cases  under  ten  years  of  age, 
in  which  the  variety  was  determined  by  autopsy  or  operation,  75  were 
ileo-c£ecal,  9  colic,  and  6  enteric.      In  the  ileo-c»cal  form  a  few  inches 

*  Hirschsprung,  Jahrbuch  fiir  Kinderh.,  Bd.  xxvii,  p,  1. 

f  Mya,  Revue  Mensuelle  des  Maladies  de  I'Enfance,  vol,  xii,  p,  633. 

X  Osier,  Archives  of  Pa?diatrics,  vol,  xi,  p.  112. 


INTUSSUSCEPTION. 


425 


of  the  ileum  pass  through  the  ileo-ctpcal  valve,  and  then  invagination  of 
the  colon  occurs.  Cases  in  which  the  ileum  passes  through  the  valve,  hut 
without  invagination  of  the  colon,  are  sometimes  classed  separately  as  an 
ileo-colic  variety. 

Intussusceptions  of  the  di/ing,  as  the}^  have  heen  called,  are  met  with 
in  my  experience  in  ahout  eight  per  cent  of  all  autopsies  made  upon  in- 
fants; they  are  not  often  found  in  children  over  two  3^ears  of  age.  They 
are  descending,  enteric,  easily  reducible,   and   multiple — usually   from 


Fig.  75. — lleo-ctecal  intussusception.     A  specimen  removed  from  a  cliild  in  the  New  York 

Infant  Asylum. 

eight  to  twelve  invaginations  being  present.  They  are  more  frequently 
in  the  jejunum  than  in  the  ileum.  They  usually  involve  but  two  or  three 
inches  of  the  intestine,  but  may  include  ten  or  twelve  inches.  They  are 
found  in  autopsies  upon  patients  dying  of  all  varieties  of  disease,  and 
are  probably  produced  in  tlie  death  agony.  These  intussusceptions  are 
without  syni])toms,  and  are  of  no  clinical  importance. 

Etiology. — Of  358  collected  cases  under  ten  years,  the  following  are 


426  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

the  ages  reported  :  under  four  months,  28  cases ;  from  four  to  six 
months,  113;  seven  to  nine  months,  71  ;  ten  to  twelve  months,  18;  one 
to  two  years,  32  ;  two  to  ten  years,  96.  Three  fourths  of  the  cases 
which  occur  in  childhood  are,  therefore,  in  the  first  two  years,  and  one 
half  of  them  between  the  fourth  and  ninth  months.  The  greater  fre- 
quency in  infancy  is  attributed  to  the  thinness  of  the  intestinal  walls,  the 
greater  mobility  of  the  caecum  and  ascending  colon,  and  the  presence 
of  other  intestinal  derangements  at  this  age. 

Males  are  more  often  affected  than  females.  Of  268  cases  in  which 
the  sex  was  mentioned,  there  were  174  males  and  94  females.  For  this 
fact  there  is  no  explanation.  The  exciting  causes  of  an  attack  are  ex- 
tremely obscure.  The  great  majority  of  cases  occur  in  children  who  were 
apparently  in  perfect  health.  Some  previous  intestinal  disorder  was  pres- 
ent in  about  three  per  cent  of  the  cases  I  have  collected — diarrhoea,  dysen- 
tery, colic,  chronic  indigestion,  and  constipation,  all  being  mentioned.  In 
four  cases  the  intussusception  was  ascribed  to  injury  of  the  abdomen. 
The  association  with  the  general  diseases  is  too  infrequent  to  be  of  any 
importance. 

Lesions. — ISTothnagel's  vivisection  experiments  *  have  shown  conclusively 
that  intussusceptions  are  formed  by  the  irregular  action  of  the  muscular 

walls  of  the  intestine.     They  can  be 
produced  or  released  at  will  by  vary- 
ing the  application  of  the  electrical 
-p^^  ^g  current.     In  the  artificial  intussus- 

ception there  is  first  a  contraction 
of  a  certain  part  of  the  intestine,  and  if  this  ceases  abruptly  the  normal 
gut  below  this  point  turns  upward  and  folds  over  upon  the  contracted 
portion,  thus  forming  a  minute  intussusception  (Fig.  76).  When  once 
begun,  the  intussusception  increases  solely  at  the  expense  of  the  external 
layer    (Fig.  77).     Thus,  while   the  apex  of  the  tumour  D  remains  un- 


FiG.  77. — Mechanism  of  intussusception.     (Treves.) 

changed,  the  part  of  the  sheath  at  A  passes  to  B  and  then  to  C,  so  that 
the  lower  part  of  the  intestine  is  drawn  over  the  upper,  rather  than  the 
upper  crowded  into  the  lower.  The  mechanism  of  the  invagination  was 
apparently  the  same  when  a  part  of  the  intestine  was  first  paralyzed  by 

*  Beitrage  zur  Physiologie  und  Pathologic  des  Darms,  Berlin,  1884.  A  full  abstract 
is  to  be  found  in  Treves's  Intestinal  Obstruction,  London,  1884,  to  which  I  am  indebted 
for  many  points  in  this  article. 


INTUSSUSCEPTION.  42T 

crushing,  as  in  the  cases  in  which  a  spasm  of  the  intestine  was  first  pro- 
duced. 

There  is  no  doubt  that  pathological  intussusceptions  are  produced  in 
the  same  way  as  in  these  experiments.  As  the  invagination  takes  place^ 
the  mesentery  is  drawn  in  with  the  bowel,  and  always  lies  between  the 
sheath  and  the  inner  layer.  To  allow  intussusception  to  occur,  the  mes- 
entery must  be  unduly  long,  stretched,  or  lacerated.  Its  attachment  to 
the  spine  causes  the  intussusception  to  describe  an  arc  of  a  circle,  the  con- 
cavity of  which  is  always  toward  the  spine.  It  also  causes  a  puckering 
of  the  tumour.  Invagination  does  not  necessarily  produce  either  obstruc- 
tion or  strangulation,  but  usually  both  are  present,  and  are  the  chief 
Causes  of  the  symptoms.  Traction  upon  the  mesentery  leads  to  obstruc- 
tion in  its  vessels,  causing  congestion,  oedema,  haemorrhages,  and  even 
gangrene.  Obstruction  is  chiefly  due  to  swelling.  It  may  be  due  to 
dragging  of  the  mesentery,  which  brings  the  apex  of  the  tumour  against 
the  side  of  the  gut,  or  to  bending  of  the  intussusception. 

The  great  cause  of  irreducibility  in  the  first  two  or  three  days  is  swell- 
ing. I  have  several  times  seen  at  autopsy  or  operation  the  intussuscep- 
tion easily  reduced,  except  the  last  two  or  three  inches  of  the  caecum  or 
ileum,  which  was  swollen  to  the  thickness  of  from  a  fourth  to  half  an 
inch.  Adhesions  may  prevent  reduction,  but  rarely  before  the  fourth  day ;. 
they  are  often  absent  as  late  as  the  sixth  or  seventh  day.  They  are  usually 
between  the  internal  and  middle  layers  of  the  intussusceptum,  and  are  due 
to  local  peritonitis.  In  chronic  cases,  however,  they  form  the  principal 
obstacle  to  reduction.  Other  causes  of  irreducibility  are  twisting  of  the 
tumour  and  pinching  of  the  prolapsed  intestine,  especially  of  the  ileum 
by  the  ileo-c£ecal  valve. 

Gangrene  and  sloughing  of  the  gangrenous  portion  of  the  intestine 
occur  much  more  often  in  acute  than  in  chronic  cases.  Portions  of 
intestine  were  passed  per  anum  in  24  of  362  cases  under  ten  years,  or 
about  six  per  cent;  but  only  two  of  these  were  in  infants.  Toward  the 
end  of  the  second  week  is  the  time  when  the  separation  of  the  sloughs  is 
to  be  looked  for.  The  amount  of  intestine  discharged,  varies  from  a  few 
inches  to  several  feet.  Two  cases  are  on  record  in  which  the  entire  colon 
was  passed,  the  patients  recovering,  but  dying  several  months  later  from 
other  causes.  At  the  autopsies  the  ileum  was  found  attached  to  the  lower 
part  of  the  rectum  just  above  the  anus.  In  acute  cases  gangrene  occurs 
about  the  upper  end  of  the  tumour,  and  the  intestine  usually  comes  away 
in  one  large  mass.  In  chronic  cases  shreds  of  intestine  may  be  discharged 
for  several  weeks. 

Symptoms. — The  clinical  picture  of  a  case  oL'  iulussusccplion  is  a 
striking  one,  and  when  acute  the  symptoms  are  so  uniform  that,  once 
seen,  it  can  scarcely  be  overlooked  a  second  time.  The  patient, 
usually  between  six  and  twelve  months  of  age,  is  taken  suddenly  ill 


428  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

with  severe  pain  and  vomiting;  the  pain  recurring  paroxysmally  every 
few  minutes,  and  the  vomiting  being  first  of  the  contents  of  the  stom- 
ach, and  afterward  bilious.  There  may  be  one  or  two  loose  fsecal  stools, 
then  only  blood  or  blood  and  mucus  are  passed  without  any  admixture  of 
faeces.  The  general  symptoms  are  those  of  great  prostration,  or  even  col- 
lapse— pallor,  feeble  23ulse,  apathy,  and  normal  or  subnormal  tempera- 
ture. The  abdomen  is  relaxed.  A  tumour  is  present  in  the  left  iliac 
fossa,  or  it  is  felt  per  rectum.  Later  there  is  tympanites ;  the  vomiting  and 
pain  continue ;  there  is  a  steady  increase  in  the  prostration,  and  toward 
the  end  a  rapidly  rising  temperature,  which  may  reach  105°  or  106°  F. 
before  death  occurs  from  collapse.  If  the  symptoms  continue  longer  the 
signs  of  peritonitis  are  added.  In  subacute  cases  the  onset  is  less  abrupt, 
and  pain,  vomiting,  and  constipation  less  constant  and  less  severe ;  but 
the  same  symptoms  are  present.  In  chronic  cases  the  onset  is  with  vague, 
indefinite  intestinal  symptoms ;  pain,  vomiting  and  bloody  discharges  are 
usually  wanting;  there  are  progressive  wasting  and  more  or  less  diar- 
rhcea,  but  only  the  presence  of  the  tumour  leads  to  the  recognition  of 
the  condition. 

Onset. — Of  193  cases  under  ten  years  in  which  data  upon  this  point 
could  be  obtained,  the  onset  was  sudden  in  181  and  gradual  in  12  cases. 
By  far  the  most  frequent  symptoms  of  onset  are  pain  and  vomiting.  In 
a  smaller  number  of  cases  the  initial  symptom  is  diarrhoea  or  a  discharge 
of  blood  and  mucus. 

Pain. — This  is  rarely  continuous,  but  is  intermittent,  recurring  in 
paroxysms  like  those  of  ordinary  colic,  but  of  great  severity.  No  pain  in 
infancy  is  to  be  compared  with  it.  The  child  often  shrieks  so  as  to  be  heard 
all  over  the  house.  Pain  is  a  prominent  symptom  in  over  three  fourths 
of  the  cases,  and  is  very  rarely  absent.  It  is  generally  more  marked  for 
the  first  two  days,  but  may  continue  throughout  the  attack.  In  a  few 
cases  the  pain  is  localized,  being  usually  referred  to  the  region  of  the  um- 
bilicus. 

Vomiting  is  more  marked  at  the  onset,  but  may  continue  throughout 
the  attack.  Like  pain,  it  is  more  frequent  in  the  acute  cases.  It  is  due 
to  intestinal  obstruction.  Vomiting  is  present  in  fully  four  fifths  of  all 
cases.  Usually  it  is  persistent  and  uncontrollable ;  it  is  often  projectile. 
If  food  is  given,  vomiting  often  occurs  as  soon  as  it  reaches  the  stomach. 
Stercoraceous  vomiting  occurs  in  about  fifteen  per  cent  of  the  cases  in 
children  under  ten  years,  but  is  not  common  in  infancy.  It  is  rarely  pres- 
ent before  the  third  or  fourth  day.  Although  a  bad  sign,  it  is  not  by 
any  means  a  fatal  one,  as  nearly  one  half  the  cases  in  which  it  has  been 
noted  have  recovered  ;  it  is  to  be  regarded,  as  indicating  complete  intes- 
tinal obstruction  rather  than  strangulation. 

Tumour. — This  is  one  of  the  most  important  symptoms  for  diagnosis 
because  of  its  frequency  and  its  peculiar  character.     It  is  present  early  in 


INTUSSUSCEPTION. 


429 


the  disease,  often  in  a  few  hours  after  the  initial  symptoms.  The  follow- 
ing table  shows  the  frequency  with  which  a  tumour  was  present  in  the 
different  varieties,  and  the  position  which  it  occupied  in  each.  The  an- 
atomical variety  was  determined  either  by  autopsy  or  operation. 

The  Relation  between  the  Tumour  and  the  Different  Varieties  of  Intussus- 
ception in  188  Cases  under  Ten  Years. 


SEAT   OF  INTUSSUSCEPTION. 

Seat  of  Tumour. 

Ileo-  . 
caecal. 

Ileo- 
colic. 

Colic. 

Enteric. 

Not 
stated. 

Total. 

Hegion  of  caecum 

"i 

3 
3 
4 
25 
9 

i 

3 

'i 

i 

7 
1 

1 

i 

1 

7 
12 
13 
18 

8 
28 
12 

'2 

11 

"       "  ascending  colon 

"       "  transverse  colon.. .  . 

"       "  descending  colon . . . 

"       "  sigmoid  flexure  .... 

Rectal 

13 
16 
21 
13 
61 

Protruding  from  anus 

Umbilical  region 

22 
1 

Movable 

3 

Site  unknown 

1 

Total 

46 
10 

4 
2 

9 

3 

1 

100 
18 

162 

No  tumour  felt 

26 

Tumour  was  thus  made  out  during  life  in  eighty-six  per  cent  of  the 
cases;  and  in  the  great  majority  of  these  it  was  discovered  at  the  first 
careful  examination. 

It  will  be  noted  that  in  one  half  of  the  cases  the  tumour  was  either 
felt  in  the  rectum  or  protruded  from  the  anus,  and  that  in  over  two  thirds 
it  had  advanced  as  far  as  the  descending  colon  or  beyond.  The  tumour 
may  reach  the  rectum  in  a  surprisingly  short  time,  even  when  the  invagi- 
nation begins  at  the  ileo-csecal  valve.  In  one  of  my  own  cases  it  was  felt 
in  the  rectum  in  less  than  twelve  hours  from  the  onset.  The  usual  de- 
scription, "  sausage-shaped,"  is  accurate  when  the  invagination  is  large,  the 
tumour  then  being  from  four  to  six  inches  long  and  about  an  inch  and  a 
half  in  diameter.     It  is  often  curved. 

During  manipulation,  or  during  an  attack  of  pain,  the  tumour  may  be- 
come more  prominent  and  may  be  distinctly  erectile.  To  the  touch  the 
rectal  tumour  closely  resembles  the  os  uteri,  the  central  opening  being  the 
apex  of  the  intussusception.  When  protruding  from  the  body,  the  tu- 
mour is  rarely  more  than  two  inches  long.  It  is  usually  of  a  deep  purplish 
colour,  and  may  be  gangrenous.  It  has  been  mistaken  for  prolapsus  ani, 
polypus,  and  even  haemorrhoids.  In  a  case  which  came  subsequently 
under  my  observation,  the  tumour  was  discovered  by  the  mother  before 
the  physician  had  suspected  the  condition. 

Condition  of  the  bowels.— BXoo&y  stools  are  a  very  constant  symptom. 
Of  186  cases  under  ten  years  in  which  this  condition  of  the  bowels  was 
29 


430  DISEASES    OF   THE   DIGESTIVE   SYSTEM. 

noted,  blood  in  the  stools  was  present  in  seventy-six  per  cent.  There  are 
very  often  two  or  three  thin,  diarrhceal  movements,  and  then  only  blood 
and  mucus  are  passed  with  no  trace  of  faeces  and  with  no  faecal  odour. 
The  amount  of  blood  varies  from  a  quantity  sufficient  to  stain  the  mucus 
to  an  ounce  of  semifluid  blood.  It  rarely  occurs  without  some  mucus. 
Such  discharges  frequently  follow  attacks  of  severe  colicky  pain,  and  may 
occur  several  times  in  an  hour.  They  may  continue,  or  after  a  day  or  two 
they  may  be  succeeded  by  absolute  stojspage.  Diarrhoea  throughout  the 
attack  is  rare  in  children,  particularly  so  in  infants.  It  belongs  generally 
to  chronic  cases.  Constipation  is  complete  in  most  of  the  acute  cases, 
neither  gas  nor  faeces  being  passed  ;  a  fact  which  the  discharge  of  blood 
and  mucus  may  lead  one  to  overlook. 

Tenesmus  is  very  common  if  the  tumour  is  rectal.  Relaxation  of  the 
sphincter  is  met  with  in  a  considerable  proportion  of  the  cases  when  the 
tumour  is  in  the  sigmoid  flexure,  or  rectum. 

During  the  first  twenty-four  or  forty-eight  hours  the  abdominal  walls 
are  soft  and  relaxed,  and  may  even  be  retracted.  Usually  there  is  then 
little  resistance  to  abdominal  palpation.  After  the  second  or  third  day 
there  is  usually  t3'mpanites;  but  this  does  not  necessarily  mean  that 
peritonitis  exists.  Localized  tenderness  is  a  symptom  of  some  impor- 
tance when  a  tumour  is  absent.  Scanty  urine  has  been  noted  in  a  few 
cases,  but  is  of  no  special  value  in  showing  the  seat  of  obstruction. 

In  the  acute  cases  the  general  symjjtoms  are  very  striking.  They  are 
the  ordinary  ones  of  severe  shock — marked  prostration,  pallor  with  an- 
anxious  expression  of  the  face,  general  muscular  relaxation,  cold  extrem- 
ities, cold  perspiration,  and  often  a  subnormal  temperature.  Early  there 
is  marked  restlessness,  and  even  convulsions  may  occur.  Later  there  are 
ai3athy,  dulness,  and  semi-stupor.  The  temperature  during  the  first  twenty- 
four  hours  is  usually  not  elevated,  and  is  frequently  subnormal.  Toward 
the  close  of  the  disease  it  rises  rapidly  to  103°,  104°  F.,  or  even  higher, 
quite  independently  of  peritonitis.  A  rapidly  rising  temperature  is  always 
a  bad  symptom,  and  usually  betokens  death  within  twenty-four  hours. 
Wasting  is  seen  in  the  chronic  cases,  and  may  be  quite  rapid. 

Course,  Duration  and  Termination. — Of  198  cases  under  ten  years,  155 
were  classed  as  acute,  lasting  less  than  seven  days;  33  as  subacute,  last- 
ing from  one  to  four  w^eeks ;  10  were  chronic,  lasting  over  four  weeks. 
Nearly  all  the  cases  occurring  in  infancy  are  acute.  The  duration  of  the 
disease  in  92  fatal  cases  was  as  follows :  less  than  twent3^-four  hours,  2 
cases ;  two  to  four  days,  44  cases ;  five  to  seven  da3's,  23  cases ;  one  to  two 
weeks,  18  cases ;  two  to  three  weeks,  6  cases.  Thus  one  half  the  cases 
died  upon  the  third,  fourth,  or  fifth  day.  Of  57  cases  terminating  in 
recovery,  66  per  cent  were  reduced  in  the  first  or  second  day.  (See  table, 
page  432.) 

Spontaneous  reduction  is,  without  doubt,  possible  in  intussusception^ 


INTUSSUSCEPTION.  431 

Treves  and  others  are  of  the  opinion  that  this  happens  much  more  fre- 
quently than  is  generally  supposed,  and  that  many  cases  of  severe  colic  are 
really  cases  of  slight  intussusception.  There  are  seen  in  both  conditions 
the  tendency  to  vomit,  the  paroxysmal  pain,  the  constitutional  depression, 
and  often  the  sudden  cessation  of  the  symptoms,  especially  under  the 
influence  of  opium ;  but  to  make  a  positive  diagnosis  of  invagination  in 
such  cases  is  impossible.  Intussusception  may  be  cured  spontaneously  by 
sloughing  of  the  invaginated  part,  the  continuity  of  the  intestine  being 
preserved  by  adhesions.  Such  a  result  is  rare  at  all  ages,  and  is  almost 
never  seen  in  infancy.  Even  though  recovery  from  the  attack  takes  place, 
complete  restoration  to  health  is  very  rare. 

The  most  frequent  cause  of  death  in  acute  cases  is  shock.  Peritonitis 
is  not  found  at  autopsy  or  operation  so  often  as  might  be  expected.  In 
58  autopsies,  it  was  seen  but  twenty  times,  and  in  seven  of  these  it  was 
limited  to  the  intussusception.  In  but  7  cases  was  there  perforation.  In 
chronic  cases  death  is  usually  from  exhaustion  or  complications. 

Diagnosis. — This  usually  presents  no  difficulty  in  acute  cases  provided 
the  physician  has  the  condition  in  mind.  The  great  majority  of  such 
cases  present  nearly  all  the  classical  symptoms — viz.,  sudden  onset,  re- 
curring colicky  pains,  frequent  vomiting,  bloody  and  mucous  stools 
without  faecal  matter,  general  prostration  or  collapse,  and  low  tempera- 
ture. The  records  show  that  the  most  common  error  is  to  regard  the  case 
for  the  first  few  days  as  one  of  gastro-enteritis  or  ileo-colitis,  the  physi- 
cian's attention  being  engrossed  by  the  vomiting  and  bloody  stools.  Given 
the  other  usual  symptoms,  the  presence  of  the  characteristic  tumour  is 
conclusive  evidence  of  intussusception.  Unless  the  patient  is  very  much 
relaxed,  a  satisfactory  examination  is  possible  only  under  full  antesthesia. 
In  any  case  of  acute  obstruction  in  infants,  intussusception  should  first  be 
considered.  Chronic  cases  present  no  diagnostic  symptoms  except  the 
tumour.  In  both  acute  and  chronic  cases  the  rectal  examination  is  most 
important  for  diagnosis,  and  often  settles  the  question  at  once. 

Prognosis. — The  prognosis  of  intussusception  depends  upon  the  age  of 
the  patient,  upon  the  variety  of  the  disease — whether  acute,  subacute,  or 
chronic — and  upon  the  time  when  proper  treatment  is  begun. 

There  were  collected  by  Pilz  *  in  1870,  94  cases  under  one  year,  the 
mortality  being  84  per  cent.  Of  135  cases  of  the  same  age  reported  be- 
tween 1870  and  1891  the  mortality  was  59  per  cent.  In  Pilz's  table,  of  51 
cases  between  one  and  ten  years  of  age,  the  mortality  was  G8  per  cent ; 
while  of  82  cases  between  one  and  ten  years  of  age,  from  1873  to  1891, 
the  mortality  was  but  40  per  cent.  Formerly  recovery  was  rare,  except 
in  cases  of  sloughing;  but  with  earlier  diagnosis  and  a  better  under- 
standing of  the  proper  methods  of  treatment,  tlie  mortality  has  been  very 

*  Jahrbuch  fiir  Kinderh.,  Bd.  iii,  p.  6. 


432 


DISEASES  OF   THE  DIGESTIVE  SYSTEM. 


mucli  reduced.     Combining  the  figures  of  Pilz  with  my  own,  there  are 
362  cases  with  231  deaths,  or  63  -5  per  cent. 

Gibson  (Xew  York)  in  1900  collected  187  operations  for  intussus- 
ception, with  a  general  mortalit}"  of  51  per  cent;  in  126  cases^  in  which 
the  tumour  was  reducible,  it  was  but  36  per  cent;  in  61,  in  which  it 
was  irreducible  or  gangrenous,  it  was  80  per  cent.  The  table  gives  the 
mortality  in  relation  to  time  of  operation: 


Time  of  Operation. 

Number  of 
operations. 

Xumber 
reducible. 

Mortality. 
Per  cent. 

First;      day 

35 
36 
33 

15 

33 

30 

20 

6 

37 

Second    " 

39 

Third       "     

61 

Fourth    "           

67 

Fifth       "    

73 

Sixth       "      

75 

After  the  second  day  the  chances  of  success  are  greatly  reduced. 

Treatment. — One  should  first  attempt  reduction  by  inflation  or  injec- 
tions with  the  assistance  of  taxis,  and,  this  failing,  resort  early  to 
laparotomy. 

In-fiation  should  always  be  done  under  an  anaesthetic,  unless  there  is 
extreme  relaxation.  Occasional  inversion  of  the  child  may  be  practised, 
to  get  the  assistance  of  traction  of  the  intestine  above  upon  the  seat  of 
invagination.  An  ordinary  hand  bellows  with  a  catheter  attached  is  the 
best  apparatus;  air  should  be  injected  very  slowly,  and  prevented  from 
escaping  by  pressing  the  buttocks  tightly  together.  The  best  guide  to  the 
amount  introduced  is  the  tension  of  the  abdominal  walls.  A  thorough 
trial  of  this  method  should  not  occupy  more  than  fifteen  or  twenty 
minutes. 

Eeduction  is  sometimes  indicated  by  rumbling  sounds,  and  by  the 
abdomen  resuming  its  normal  contour  because  the  whole  of  the  colon  is 
filled,  in  place  of  the  unequal  distention  before  present.  In  some  cases 
a  gush  of  fluid  faeces  has  followed  disinvagination.  Xot  infrequently  all 
such  decisive  symptoms  are  absent,  and  the  physician  may  be  in  doubt 
whether  or  not  reduction  has  taken  place.  The  air  is  allowed  to  escape 
and  the  abdomen  examined  while  the  patient  is  still  under  chloroform. 
The  right  iliac  fossa  should  be  examined  with  the  greatest  care,  as  it 
often  happens  that  all  the  tumour  except  the  last  few  inches  has  been 
reduced.  The  question  of  reduction  must  be  frec[uently  decided  by  the 
general  symptoms.  If  vomiting  continues,  if  no  gas  or  fgeces  pass  the 
bowels,  if  there  is  no  improvement  in  the  pulse  or  the  general  condition, 
and,  besides,  if  the  temperature  rises,  it  is  almost  certain  that  reduction 
has  not  been  effected.  In  a  very  acute  case  two  or  three  hours'  delay  is 
all  that  should  be  permitted.    The  abdomen  should  then  be  opened  if  the 


INTUSSUSCEPTION.  433 

child  is  strong  enough  to  hear  tlie  operation.  In  cases  not  so  acu-t-e, 
where  three  or  four  days  have  passed  without  symptoms  indicating  stran- 
gulation, it  is  admissible  to  make  another  attempt  at  reduction  before 
resorting  to  laparotomy. 

Injections  of  fluids. — A  saline  solution  may  be  used,  milk  and  water, 
or  thin  gruel.  The  temperature  should  be  from  100°  to  105°  F.  for  the 
relaxing  effect.  The  fluid  is  placed  in  a  fountain  syringe  suspended  four 
or  five  feet  above  the  patient's  bed.  The  injections  should  be  made 
through  a  catheter,  the  escape  of  the  fluid  being  prevented  as  in  inflation. 
From  time  to  time  the  patient  should  be  inverted.  It  may  be  desirable 
to  increase  the  pressure  by  raising  the  syringe  to  the  height  of  five  or  six 
feet,  but  more  is  rarely  advisable.  After  from  ten  to  twenty  minutes 
the  water  is  allowed  to  escape  and  the  abdomen  examined. 

The  choice  between  inflation  and  injection  depends  somewhat  upon 
individual  experience.  The  danger  of  rupturing  the  intestine  belongs 
alike  to  both ;  but  that  it  is  not  likely  to  occur  with  either  is  conclusively 
shown  by  the  fact  that  in  a  series  of  225  collected  cases,  all  in  children,  and 
including  nearly  all  those  reported  between  1870  and  1891,  this  accident 
has  been  recorded  only  once.  In  rare  cases  the  symptoms  may  continue 
after  reduction.  Pick  records  such  a  case  in  which  laparotomy  was  done 
with  the  belief  that  reduction  had  not  been  effected.  ISTo  intussusception 
was  found,  and  the  continuance  of  the  symptoms  was  attributed  to  intes- 
tinal paralysis. 

After  reduction  the  patient  should  be  kept  absolutely  quiet  and  mod- 
erately under  the  influence  of  opium  for  two  or  three  days.  The  diet 
should  be  very  light.  Cathartics  especially  should  be  avoided  for  several 
days. 

Eecurrence  of  the  invagination  is  not  uncommon.  It  was  noted  in 
13,  or  about  six  per  cent,  of  my  collected  cases  under  ten  years ;  of  this 
number  nine  recovered  and  four  died.  Eecurrence  is  more  likely  to 
happen  in  the  flrst  twenty-four  hours  after  reduction ;  this  was  the  time 
in  nine  of  the  thirteen  cases.  It  may,  however,  be  as  late  as  a  month, 
rarely  later.  In  one  half  the  cases  there  was  but  a  single  recurrence,  but 
three,  four,  and  even  six  recurrences  in  the  course  of  a  few  weeks  have 
been  seen.  Ludwig  reports  a  case  in  an  infant  eight  months  old  in  whom 
twenty-two  recurrences  were  seen  in  one  month.  This  was  of  the  colic 
variety;  it  could  hardly  happen  in  any  other  form. 

Laparotomy  is  indicated  as  soon  as  a  thorough  trial  of  reduction  by 
inflation  or  injection  has  been  made  without  success.  In  the  very  acute 
cases  the  operation  should  not  be  delayed  an  hour  after  such  failure  is 
evident.  ISTeedless  delays  have  caused  death  in  many  instances.  The 
operation  should  not  be  looked  upon  as  a  last  resort  in  hopeless  cases,  but 
as  a  measure  which,  if  emploj-ed  reasonably  early,  offers  a  fair  prospect 
of  success  where  disinvagination  can  not  be  accomplished  by  any  other 


434:  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

means.  All  statistics  show  that  the  result  depends  more  upon  the  time 
when  the  operation  is  done  than  upon  any  other  single  factor.  With 
earlier  diagnosis  and  more  prompt  resort  to  operation  in  case  of  failure 
of  reduction  by  mechanical  means  the  mortality  from  intussusception 
has  during  the  past  ten  years  been  steadily  falling.  The  great  majority 
of  the  infants  who  suffer  from  this  accident  can  be  saved  if  they  receive 
proper  treatment  in  season. 


CHAPTEK    X. 

DISEASES  OF  TEE  INTESTINES.— {Continued.) 
APPENDICITIS. 

The  terms  typhlitis,  perityphlitis,  and  perityphlitic  abscess  were  for- 
merly much  used  to  denote  certain  forms  of  inflammation  occurring  in 
the  right  iliac  fossa.  Of  late  these  terms  are  but  little  employed,  as  it 
has  been  shown  that  these  conditions  are  almost  invariably  due  to  disease 
of  the  vermiform  appendix.  The  existence  of  typhlitis  as  a  separate  and 
independent  disease  is  exceedingly  rare,  if  indeed  it  ever  occurs  except  as 
a  result  of  faecal  impaction. 

Etiology. — The  predominance  of  the  male  sex  holds  even  in  child- 
hood. Of  101  cases  under  fifteen  years,  73  were  males  and  29  were 
females.  Appendicitis  is  exceedingly  rare  in  infancy,  the  condition  hav- 
ing never  once  been  found  in  about  2,000  autopsies,  nearly  all  upon  chil- 
dren under  two  years  old,  in  three  institutions  with  which  I  have  been 
connected.  It  does,  however,  occasionally  occur  even  in  very  young  in- 
fants. The  youngest  cases  that  have  come  under  my  observation  were 
infants  of  nine*  and  fourteen  months  respectively.  Goyen's  case  was  in 
an  infant  only  six  weeks  old;  Shaw's,  seven  weeks;  Demme's,  seven 
weeks ;  and  Savage's,  nine  weeks  old. 

Appendicitis  is  rather  more  frequent  in  children  Avho  have  suffered 
from  digestive  disturbances,  particularly  chronic  constipation,  than  in 
others.  Eegarding  the  exciting  cause  of  an  attack  but  little  is  yet  defi- 
nitely known.  In  only  a  very  small  proportion  of  the  cases  is  a  foreign 
body  discovered  in  the  appendix.  In  one  of  my  own  a  pin  was  found,  and 
a  number  of  similar  cases  are  on  record.  There  is,  however,  almost  in- 
variably a  fffical  concretion  which  is  moulded  into  the  shape  of  a  foreign 
body,  and  formerly  often  regarded  as  such.  This  probably  has  some  rela- 
tion to  the  attack  by  causing  disturbances  of  circulation  and  increasing 
the  chances  of  infection.  The  bacteria  most  frequently  found  in  abscesses 
from  appendicitis  are  streptococci  usually  associated  with  colon  bacilli. 

Lesions. — Tlie  position  of  the  appendix  is  extremely  variable.  It 
may  be  found  low  in  the  pelvis,  as  high  as  the  liver,  in  front  of  the 


APPENDICITIS.  435 

kidney,  and  sometimes  near  the  umbilicus.  Tliis  anatomical  peculiarity 
accounts  for  the  variation  seen  in  the  situation  of  the  abscesses  due  to 
ajjpendicitis.  Inflammation  of  the  appendix  may  be  acute  catarrhal, 
suppurative,  or  gangrenous,  and  it  may  be  recurrent  or  chronic. 

Catarrhal  appendicitis. — In  this  form  there  is  an  inflammation  of  the 
mucous  membrane  with  swelling  of  the  follicles  and  infiltration  of  the 
mucosa  with  round  cells ;  the  process  may  extend  to  the  muscular 
and  possibly  also  to  the  serous  coat.  As  a  result,  the  appendix  is  thick- 
ened and  stiffer  than  normal.  It  may  become  distended  with  mucus  or 
muco-pus  to  the  size  of  the  thumb  or  even  larger.  The  inflammation 
sometimes  results  in  the  formation  of  superficial  ulcers  involying  the 
mucous  membrane.  Catarrhal  appendicitis  may  subside  without  any 
serious  consequences,  and  complete  recovery  follow.  In  most  cases, 
however,  some  changes  remain;  there  may  be  adhesions;  the  lumen 
may  be  constricted  at  any  point;  and  sometimes  communication 
with  the  ea?cum  may  be  shut  off  entirely.  Catarrhal  appendicitis  may 
be  followed  by  a  chronic  form  of  inflammation  or  b}'  the  suppurative 
form. 

Suppurative  appendicitis. — This  may  follow  one  or  more  attacks  of 
the  catarrhal  form,  or  the  inflammation  may  be  of  the  suppurative  type 
from  the  beginning.  In  this  variety  the  inflammation  of  the  mucosa  is 
much  more  extensive;  the  infiltration  of  the  muscular  layer  is  more 
marked,  and  the  serous  coat  is  usually  involved.  As  a  result,  the  appen- 
dix usually  becomes  distended  with  a  foul,  purulent  fluid.  This  process 
may  terminate  in  several  ways.  Drainage  into  the  intestine  may  be  re- 
established and  the  pus  escape  in  this  way,  the  inflammation  of  the  coats 
of  the  appendix  undergoing  resolution,  but  leaving  some  thickening  and 
adhesions.  This  termination  is  not  common.  A  more  frequent  course  is 
for  perforation  to  take  place  either  by  ulceration  or  localized  gangrene. 
Perforation  may  be  followed  by  a  general  septic  peritonitis,  or  the  in- 
flammation ma}^  be  circumscribed  by  adhesions  and  result  in  a  localized 
peritoneal  abscess.  Such  an  abscess  may  subsequently  burst  into  the  gen- 
eral peritoneal  cavity,  or  spontaneous  opening  may  occur  into  the  intes- 
tine, the  bladder,  or  the  vagina ;  or  the  abscess  may  burrow  for  a  long 
distance.  Secondary  lesions  are  occasionally  seen  in  children ;  there  may 
be  suppurative  pylephlebitis,  abscess  of  the  liver,  empyema,  pneumonia, 
or  general  pyaemia. 

Gangrenous  appendicitis. — Gangrene  of  the  appendix  may  be  local- 
ized, in  which  case  it  is  usually  one  of  the  forms  of  termination  of  the 
suppurative  inflammation ;  or  it  may  be  general,  in  some  cases  involv- 
ing the  entire  appendix,  in  others  only  the  distal  portion.  Such  a  pro- 
cess is  the  result  of  some  cause  which  completely  arrests  the  circulation. 
The  rupture  of  a  gangrenous  appendix  is  usually  followed  by  a  general 
septic  peritonitis  which  develops  with  great  rapidity ;  less  frequently  the 


436  DISEASES   OF   THE  DIGESTIVE  SYSTEM. 

peritoneal  inflammation  is  localized  and  there  develops  a  peritoneal 
abscess. 

Chronic  appendicitis. — This  nsualh"  follows  one  or  more  attacks  of 
the  catarrhal  form.  It  results  in  thickening,  adhesions,  constrictions, 
and  more  or  less  interference  with  the  communication  with  the  caecum, 
the  appendix  being  sometimes  distended  with  mucus  or  muco-pus. 

Symptoms. — Catarrhal  appendicitis  is  often  not  recognised,  and  in 
many  cases  a  diagnosis  is  impossible.  The  milder  attacks  are  usually 
passed  over  as  acute  indigestion.  The  only  suspicious  symptoms  are 
acute  abdominal  pain  and  tenderness.  In  a  very  large  proportion  of  the 
cases  the  pain  is  not  in  the  region  of  the  appendix.  It  may  be  referred 
to  almost  any  part  of  the  abdomen,  and  is  frequently  about  the  umbili- 
cus. When  the  abdomen  is  carefully  examined,  by  making  pressure  with 
the  finger  point,  there  is  generally  found  well-defined  localized  tender- 
ness, in  the  right  iliac  fossa,  one  or  two  inches  from  the  spine  of  the 
ileum  on  an  arc  described  with  the  spine  as  a  centre.  The  onset  is  often 
with  vomiting,  and  there  is  some  fever,  though  rarely  over  101:5°  F. 
The  bowels  are  usually  constipated,  although  occasionally  diarrhrea  is 
present.  The  disease  gradually  subsides  in  the  course  of  four  or  five 
days,  the  local  symptoms  being  the  last  to  disappear. 

In  the  more  severe  attacks  the  pain  and  tenderness  are  much  more 
marked.  There  is  never  any  area  of  induration,  but  the  swollen  appen- 
dix may  sometimes  be  felt  if  the  abdominal  walls  are  thin  and  relaxed. 
The  onset  is  usually  more  severe  than  in  the  cases  first  described;  the 
vomiting  may  be  repeated  several  times,  and  constipation  is  often 
marked.  The  early  temperature  frequently  reaches  102°  or  102  -5°  F. ; 
but  it  soon  falls  to  100°  or  101°,  and  in  two  or  three  days  may  be  nor- 
mal, and  the  symptoms  gradually  subside,  the  whole  duration  being  usu- 
alh'  less  than  a  weak.  Subsequent  attacks,  however,  occur  in  the  great 
majority  of  cases. 

Suppurative  appendicitis. — The  onset  resembles  the  more  severe  at- 
tacks of  catarrhal  appendicitis,  but  both  the  local  and  the  general  symp- 
toms are  apt  to  be  more  acute.  The  disease  may  follow  one  of  three 
courses,  according  as  the  termination  is  a  localized  plastic  peritonitis, 
a  peritoneal  abscess,  or  general  peritonitis. 

1.  With  localized  plastic  peritonitis. — The  symptoms  in  this  variety 
usually  last  about  ten  days.  They  are  severe  only  for  the  first  two  or 
three  days,  and  then  gradually  subside.  There  is  present,  in  addition  to 
the  symptoms  described  in  the  catarrhal  variety,  a  distinct  inflammatory 
induration  in  the  region  of  the  appendix.  At  first  this  is  somewhat  dif- 
fuse, but  later  it  becomes  more  and  more  circumscribed,  until  after  three 
or  four  days  a  small  mass  not  much  larger  than  an  egg  remains,  which 
after  another  week  can  scarcely  be  felt.  In  such  cases  there  is  a  suppu- 
rative inflammation  of  the  wall  of  the  appendix  with  localized  plastic 


APPENDICITIS.  437 

peritonitis,  or  a  slow  perforation  occurs  which  is  immediately  surrounded 
by  an  exudate  of  lymph  protecting  the  general  peritoneal  cavity. 

2.  With  peritoneal  abscess. — In  some  of  the  cases  with  an  acute  onset 
there  is  a  continuance  of  the  high  fever,  pain,  and  tenderness,  with  the 
rapid  formation  of  an  abscess.  A  distinct  tumour  may  be  noticed  at  the 
end  of  two  or  three  days,  and  pus  may  be  found  at  operation  as  early  as 
the  third  day  from  the  onset.  At  other  times  tkecourse  in  the  early 
stage  resembles  that  of  the  cases  which  terminate  nfffesolution.  Marked 
improvement  takes  place  after  four  or  five  days  of  rather  severe  symp- 
toms. The  temperature  does  not,  however,  quite  reach  normal.  After 
a  variable  period  of  quiescence,  lasting  from  two  or  three  days  to  as 
many  weeks,  the  temperature  gradually  rises;  the  pain  and  tenderness 
become  more  severe  and  are  felt  over  a  larger  area ;  the  induration,  which 
has  been  stationary,  enlarges  and  becomes  more  prominent,  and  the 
existence  of  abscess  is  unmistakable.  In  a  small  number  of  the  cases 
terminating  in  abscess  the  onset  is  very  gradual,  without  any  of  the  acute 
symptoms  mentioned.  It  may  be  accompanied  by  slight  pain  only,  re- 
traction of  the  right  thigh,  and  moderate  fever.  Wliether  the  formation 
of  the  abscess  is  rapid  or  slow,  the  subsequent  course  may  be  the  same. 
The  sac  is  gradually  distended  with  pus,  which  may  accumulate  in  im- 
mense quantities ;  as  much  as  five  pints  have  been  evacuated.  At  the 
present  time  but  few  abscesses  are  allowed  to  open  externally,  incision 
being  commonly  made  before  that  time.  The  situation  of  the  abscess 
depends  upon  the  position  of  the  appendix.  It  may  be  in  the  pelvis,  in 
the  lumbar  region,  and  occasionally  just  below  the  liver.  Pelvic  abscess 
may  be  recognised  by  rectal  examination.  The  termination  in  a  single 
abscess  is  a  favourable  one,  for  with  proper  surgical  treatment  these 
cases  almost  invariably  recover. 

3.  With  general  peritonitis. — This  may  occur  early  in  the  disease 
with  a  rapidly  spreading  inflammation  of  the  suppurative  variety  termi- 
nating in  perforation ;  or  it  may  develop  late,  being  caused  by  the  rup- 
ture of  an  abscess  into  the  general  peritoneal  cavity.  It  is  seen  more 
frequently  with  gangrenous  appendicitis,  with  which  its  symptoms  are 
described  below. 

Gangrenous  appendicitis. — At  the  outset  this  form  of  appendicitis  is 
not  characterized  by  any  distinctive  symptoms.  For  two,  three,  or  even 
four  days,  things  may  go  so  smoothly  as  to  excite  no  apprehension,  nei- 
ther the  general  nor  local  symptoms  indicating  anything  more  serious 
than  an  ordinary  attack  of  catarrhal  appendicitis  of  moderate  severity; 
when  suddenly  witliout  warning  a  marked  change  for  the  worse  occurs, 
as  perforation  into  the  general  peritoneal  cavity  takes  place.  Sometimes 
there  are  no  early  symptoms  which  are  recognised,  the  signs  of  perfora- 
tion being  the  first  to  attract  attention  to  the  abdomen. 

In  the  most  severe  cases  the  symptoms  immerliatcly  become  alarm- 


438  DISEASES  OP  THE  DIGESTIVE   SYSTEM. 

ingly  worse,  and  death  may  occur  within  twenty-four  hours.  Eupture 
of  a  gangrenous  appendix  is  usually  indicated  by  a  sudden  attack  of 
vomiting,  very  severe  abdominal  pain,  followed  by  great  prostration  or 
even  collapse.  The  temperature  varies  greatly  in  the  different  cases, 
and  is  no  guide  to  the  gravity  of  the  condition.  It  may  rise  rapidly  to 
105°  or  106°  F.,  or  it  may  be  subnormal.  The  pulse  is  uniformly  rapid, 
small,  and  compressible.  The  expression  of  the  face  is  anxious  and 
the  features  are  drawn,  and  usually  the  forehead  is  covered  with  a 
cold  perspiration.  The  abdomen  soon  becomes  tense  and  t3^mpanitic. 
In  the  most  severe  cases  there  is  no  reaction,  and  prostration  deepens 
with  the  occurrence  of  stercoraceous  vomiting,  hiccough,  clammy  skin, 
collapse,  and  death. 

In  other  cases,  after  the  first  shock  of  perforation,  there  is  some 
reaction,  and  the  usual  symptoms  of  general  septic  peritonitis  develop, 
with  which  the  child  may  live  for  from  two  to  five  days.  The  tempera- 
ture is  not  usually  very  high,  generally  averaging  from  102°  to  104°  F. ; 
vomiting  is  almost  invariably  present,  and  is  of  greenish  material,  indi- 
cating regurgitation  from  the  small  intestine  into  the  stomach ;  pain  and 
tenderness  are  acute  and  rapidly  extend  over  all  or  the  greater  part  of 
the  abdomen.  The  other  important  symptoms  are,  absolute  constipation, 
tympanites,  a  rapid,  feeble  pulse,  and  general  jDrostration.  There  is 
mental  dulness  or  apathy,  and  occasionally  convulsions.  The  case  usu- 
ally goes  on  steadily  from  bad  to  worse;  sometimes,  after  the  first  in- 
tense onset,  there  may  be  a  lull  in  the  symptoms  for  a  day  or  two,  to  be 
followed  by  a  recurrence  of  the  severe  pain,  vomiting,  and  collapse.  Such 
a  course  indicates  that  the  first  perforation  has  been  followed  by  some 
limiting  adhesions,  which  subsequent^  give  wa}^  causing  all  the  symp- 
toms of  a  new  perforation. 

When  general  peritonitis  occurs  from  perforation  due  to  ulceration  its 
symptoms  are  rather  less  violent  in  their  onset,  less  intense  in  their  de- 
velopment, and  slower  in '  their  progress,  the  usual  duration  being 
from  five  to  fourteen  days.  liMien  the  peritonitis  is  the  result  of  an 
abscess  which  has  ruptured  into  the  general  peritoneal  cavity  the  symp- 
toms are  like  those  of  a  sudden  perforation.  This  accident  may  come  as 
late  in  the  disease  as  the  second  or  third  week. 

Course  and  Termination. — Few  diseases  differ  more  widely  in  their 
course  than  does  appendicitis.  So  often  do  cases  apparently  mild  sud- 
denly develop  most  severe  symptoms  that  all  such  patients  should  be 
very  carefully  watched  from  the  outset  in  order  to  determine  what  the 
course  of  the  disease  is  likely  to  be. 

It  is  hard  to  state  in  figures  the  relative  frequency  of  the  dif- 
ferent terminations.  Of  102  cases  in  children  under  fourteen  yesLTS  old, 
in  which  this  was  definitely  known,  11  ended  in  resolution,  52  in  ab- 
scess, and  40  in  general  peritonitis.     These  figures  probably  do  not 


APPENDICITIS.  439 

represent  correctly  the  proportion  of  those  terminating  in  resolution, 
for  many  such  are  doubtless  overlooked  or  wrongly  diagnosticated.  Of 
the  53  cases  which  terminated  in  abscess,  all  but  6  were  operated  upon ; 
4  of  the  latter  opened  into  the  rectum  with  a  favourable  result;  1 
opened  externally,  and  1  ruptured  into  the  general  peritouEeum,  caus- 
ing death.  From  these  statistics  it  would  appear  that  general  perito- 
nitis is  a  more  frequent  termination  in  children  than  in  adults,  and  this 
is,  I  think,  borne  out  by  general  surgical  experience. 

Prognosis. — The  prognosis  in  young  children  is  not  good;  but  in 
those  over  seven  years  old  it  is  rather  better  than  in  adults.  The  results 
depend  much  upon  early  diagnosis  and  proper  treatment.  General  peri- 
tonitis is  the  cause  of  death  in  about  80  per  cent  of  the  cases,  pyemia 
being  next  in  frequency.  Of  43  fatal  cases,  nearly  all  of  them  from 
general  peritonitis,  only  6  died  during  the  first  three  days,  19  from  the 
fourth  to  the  seventh  day,  13  in  the  second  week,  and  5  in  the  third  week. 
Cases  terminating  in  the  formation  of  a  single  abscess  usually  recover 
when  properly  treated.  If  general  peritonitis  occurs,  whether  early  or 
late,  the  chances  of  recovery  are  small ;  but  it  has  occasionally  followed 
when  general  peritonitis  existed  at  the  time  of  operation. 

Diagnosis. — The  diagnostic  symptoms  of  appendicitis  are  a  sudden 
onset  with  vomiting,  sharp  pain  in  the  abdomen,  and  persistent  acute 
localized  tenderness  in  the  right  iliac  fossa.  Eigidity  of  any  or  all  of 
the  abdominal  muscles  is  also  significant.  Constipation  is  much  more 
frequent  than  diarrhoea.  There  is  almost  invariably  some  elevation  of 
temperature,  but  not  usually  high  fever.  The  different  forms  can  seldom 
be  distinguished  from  each  other  at  the  outset.  In  some  of  the  catarrhal 
cases  the  onset  may  be  acute  and  severe;  while,  on  the  other  hand,  per- 
foration or  rupture  may  take  place  without  any  preceding  characteristic 
symptoms.  Abscesses  out  of  the  usual  situation,  due  to  an  abnormal 
position  of  the  appendix,  often  lead  to  mistakes  in  diagnosis. 

Appendicitis  may  be  confounded  with  colic,  indigestion,  and  in  in- 
fants with  intussusception ;  in  older  children  with  abscesses  due  to  pso- 
itis. Colic  is  distinguished  by  the  absence  of  localized  tenderness  and 
fever,  by  its  short  duration,  and  by  the  fact  that  the  pain  is  generally 
less  intense.  Severe  colic  with  fever  in  children  over  three  years  old 
should,  however,  always  be  regarded  with  suspicion.  From  acute  indi- 
gestion the  diagnosis  of  appendicitis  is  difficult  at  the  onset,  and  it  may 
be  impossible  for  twenty-four  hours.  However,  the  pain  of  indigestion 
is  rarely  so  severe  while  the  fever  is  usually  higher.  It  should  be  remem- 
bered that  the  pain  in  appendicitis  is  not  always  localized,  nor  is  the 
tumour  always  in  the  right  iliac  fossa.  The  presence  of  pain,  vomiting, 
and  localized  tenderness,  and  the  greater  severity  of  the  constitutional 
symptoms,  indicate  appendicitis.  I  have  twice  known  pneumonia  at  the 
right  base  to  be  mistaken  for  appendicitis.    There  was  severe  localized 


440  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

pain  in  the  iliac  fossa,  which  was  evidently  to  be  explained  by  pleurisy 
involving  the  lower  intercostal  nerves.  Intussusception,  from  its  intense 
pain,  colic,  and  vomiting,  may  suggest  appendicitis,  but  is  very  rare  ex- 
cept in  infants.  Between  the  various  forms  of  local  suppuration  in  the 
right  iliac  fossa  and  appendicitis  the  diagnosis  is  rarely  difficult.  Acute 
or  subacute  suppuration  in  this  region  is  almost  invariabW  due  to  appen- 
dicitis. 

The  leucocyte  count  may  be  of  considerable  assistance  in  differentiat- 
ing appendicitis  from  :!olic,  ileo-colitis,  intussusception,  and  other  intes- 
tinal conditions  with  which  it  might  be  confounded;  also  in  distin- 
guishing the  catarrhal  from  the  suppurative  form.  As  between  the  two 
conditions  last  mentioned,  it  is  not  only  the  actual  number  of  leucocytes 
present,  but  their  rapid  increase,  which  indicates  the  presence  of  sup- 
puration. It  should,  however,  be  remembered  that  in  some  of  the  gravest 
cases  the  leucocytosis  may  be  slight  or  there  may  be  none  at  all.  On  the 
whole,  while  the  presence  of  marked  leucocytosis — i.  e.,  above  20,000 — 
may  be  of  considerable  assistance  in  the  diagnosis,  no  inference  can  be 
drawn  from  a  normal  count  or  a  slight  leucocytosis. 

Whenever,  in  children  over  two  years  old,  there  are  symptoms  point- 
ing to  acute  peritonitis,  no  matter  what  their  combination  or  variety, 
appendicitis  should  always  be  suspected,  since  it  is  by  far  the  most  fre- 
quent cause  of  this  condition. 

Treatment. — Absolute  rest  in  bed  can  not  be  too  strongly  insisted 
upon  in  every  case,  no  matter  how  mild  it  may  appear.  With  nervous, 
intractable  children  the  most  effective  means  of  securing  complete  rest 
to  the  parts  is  by  the  application  of  a  long  side  splint,  reaching  from 
the  axilla  to  the  foot,  or  by  a  plaster-of-Paris  spica.  Every  child  in 
whom  appendicitis  has  been  diagnosticated  or  is  suspected  should  be 
closely  watched,  as  very  alarming  symptoms  often  develop  suddenly  in 
the  course  of  attacks  which  appear  mild.  As  a  local  application  the  ice- 
bag  is  to  be  preferred.  Morphine  may  be  given  in  sufficient  quantities  to 
relieve  excessive  pain,  but  the  effect  should  not  be  carried  further,  for  it 
often  does  harm  by  obscuring  important  symptoms  and  increasing  con- 
stipation. The  colon  should  be  kept  empty  by  the  daily  use  of  enemata. 
After  a  thorough  clearing  of  the  bowels  in  the  beginning,  preferably 
by  a  saline,  cathartics  are  to  be  avoided. 

Appendicitis  is  a  surgical  disease,  and  surgical  advice  should  be 
sought  early.  It  is  undoubtedly  true  that  many  lives  have  been  need- 
lessly sacrificed  because  operation  was  delayed  too  long.  It  is  clearly 
indicated  in  two  conditions :  First,  as  soon  as  there  is  positive  evidence 
of  the  existence  of  abscess ;  secondly,  when  the  symptoms  point  to  per- 
foration into  the  general  peritoneal  cavity.  In  the  latter  immediate 
operation  should  be  done,  as  it  offers  the  only  chance  of  recovery.  Re- 
garding other  cases,  the  question  of  operation  is  modified  by  the  condi- 


INTESTINAL  WORMS.  441 

tions  under  which,  the  case  is  seen.  If  circumstances  make  the  closest 
observation  (i.  e.,  several  visits  a  day)  impossible,  operation  is  advisable; 
otherwise  delay  is  admissible  if  the  disease  is  progressing  favourably 
at  the  end  of  forty-eight  hours.  Many  of  the  best  surgeons  advise  opera- 
tion in  every  case  as  soon  as  the  symptoms  are  definite  enough  to  indi- 
cate the  existence  of  appendicitis  of  any  variety,  with  the  hope  of  fore- 
stalling sudden  perforation  with  its  resulting  dangers.  Doubtless  some 
cases  are  operated  upon  which  might  terminate  in  resolution.  But  the 
dangers  from  the  operation  per  se  are  at  the  present  time  slight,  while 
even  in  cases  which  resolve,  the  danger  of  subsequent  attacks  is  always 
present ;  and  we  have  no  means  of  knowing  in  what  cases  symptoms  of 
perforative  peritonitis  may  suddenly  develop.  The  tendency  at  the  pres- 
ent time  is  certainly  toward  more  frequent  operative  interference,  and  in 
all  cases  of  doubt  it  is  safer  to  operate.  Eegarding  the  treatment  of 
recurrent  appendicitis,  surgeons  are  also  divided;  but  the  drift  of  opin- 
ion is  toward  operation  between  attacks.  For  the  details  of  the  surgical 
management  the  reader  is  referred  to  surgical  works. 

INTESTINAL  WORMS. 

Judging  by  published  reports,  intestinal  worms  are  much  more  com- 
mon in  Europe  than  in  this  country.  In  10,000  patients  treated  for  med- 
ical diseases  in  my  dispensary  service,  there  was  positive  evidence  of 
worms  in  but  79  cases.  Of  these,  9  had  tapeworms,  40  roundworms,  27 
threadworms,  and  3  both  round  and  threadworms.  In  private  practice 
among  the  better  classes,  worms  are  certainly  rare. 

Cestodes — Tapeworms. — Cestodes  are  usually  introduced  into  the 
body  by  the  ingestion  of  some  form  of  food  containing  larvae  (cysticcrci). 
The  larva  of  the  tania  solium  is  most  frequently  found  in  pork;  that  of 
the  tcenia  medio  can  ellata  in  beef;  that  of  the  hothriocephalus  latus  in 
fish;  that  of  the  tcenia  cucumerina  inhabits  dog  or  cat  lice,  being  intro- 
duced into  the  intestinal  tract  accidentally  by  the  hands. 

In  the  intestine  the  larvae  develop  into  the  mature  tapeworms,  usually 
in  from  three  to  three  and  a  half  months ;  after  which  the  terminal  seg- 
ments becoming  mature,  separate,  and  are  discharged  in  the  faeces,  some- 
times singly,  sometimes  connected.  New  segments  continually  form 
next  to  the  head  as  the  terminal  ones  are  cast  off,  so  that  the  length  of 
the  worm  is  not  diminished.  The  duration  of  life  of  tbo  worm  is  estimated 
to  be  from  ten  to  thirty  years.  Each  mature  segment  is  provided  with 
both  male  and  female  sexual  organs,  and  contains  ova  in  great  numbers. 
The  ova  escape  after  the  rupture  of  the  segment  outside  the  body.  Tliey 
find  their  way  into  the  stomach  usually  of  herbivorous  animals  with  their 
food.  Here  the  thick  shells  of  the  ova  are  dissolved  by  the  gastric  juice 
and  the  embryo  set  free.    By  means  of  the  booklets  with  which  it  is  pro- 


442 


DISEASES   OF   THE  DIGESTIVE   SYSTEM. 


vided,  it  migrates  from  the  stomach  or  intestine  and  may  be  found  in  the 
muscles  or  in  any  organ  of  the  body,  even  the  brain  and  eye.  When  it 
reaches  its  final  resting  place  it  loses  its  hooks  and  gradually  becomes 
transformed  into  a  vesicle,  from  the  inner  surface  of  which  there  projects 
something  resembling  the  head  of  the  future  tapeworm.  In  this  stage  it 
is  known  as  the  bladderworm  or  cysticercus.  The  cysticerci  of  the  tcBnia 
solium  are  sometimes  found  in  man,  but  the  other  varieties  very  rarely. 
For  the  further  development  of  the  larval  form  it  must  be  taken  into  the 
stomach  of  man  or  some  carnivorous  animal.  This  occurs  when  pork, 
beef,  or  fish  containing  cysticerci  is  eaten.  The  vesicle  wall  is  now  dis- 
solved, and  the  head  passing  into  the  intestine  develops  into  the  mature 
tapeworm.     Several  varieties  of  tsenia  are  found  in  the  human  intestine  : 

Taenia  Saginata  or  Mediocanellata — Beef  Tapeworm  (Fig.  78).  This 
is  the  most  frequent  form  found  in  children,  all  others  being  rare.  In- 
fection results  from  eating  raw  or  partially  cooked  beef  containing  cys- 
ticerci. The  worm  is  from  twelve  to  twenty  feet  in  length,  and  has  a 
square  pigmented  head  without  hooks  but  provided  with  four  suckers. 
The  full-sized  segments  are  from  one  half  to  three  fourths  of  an  inch 
long  and  about  half  as  wide. 

Taenia  Solium — Pork  Tapeworm  (Fig.  79).  This  is  a  rare  form  in 
children,  and  comes  from  eating  raw  or  partially  cooked  pork  or  sausage. 
It  is  from  six  to  ten  feet  in  length,  the  segments  being  nearly  square. 


Ill  I  s  ymata;  head,  segment, 
aud  egg.     (Jakbch.) 


Fig.  79. — Taenia  solium  ;  head,  segment, 
and  egg;.     (Jaksch.) 


The  head  is  about  the  size  of  a  mustard  seed  and  is  pigmented.  It  also  is 
provided  with  four  suckers  and  a  proboscis,  surrounding  which  is  a  circle 
of  about  twenty-six  hooks. 

Taenia  Cucumerina  or  EUiptica  (Fig.  80).  The  larvae  of  this  form 
develop  in  a  louse  found  on  the  skin  of  dogs  and  cats.  Children  who 
play  with  infected  animals  are  the  ones  affected,  the  parasite  being  con- 
veyed to  the  mouth  usually  by  means  of  the  hands ;  it  may  thus  be 
found  even  in  young  infants.  Most  of  the  tapeworms  in  infants  are  of 
this  variety.  This  form  of  taenia  is  much  smaller  than  either  of  the  pre- 
ceding varieties,  the  full  length  being  only  from  six  to  twelve  inches. 


INTESTINAL   WORMS. 


Ul 


Bothriocephalus  Latus  (Fig.  81).    This  is  a  rare  form  except  in  the 
sea  conntries  of  northern  Europe  and  Switzerland,  where  it  is  said  to  be 


Fig.  80. — Head  and  segment  of  taenia 
cucumerina.     (Jaksch.) 


Fig.  81. — Bothriocephalus  latus;  a,  J,  front 
and  side  views  of  head ;  c,  segments ; 

d,  eggs.     (Jaksch.) 


very  common.  The  larvae  are  harboured  by  certain  fish,  through  which 
they  are  introduced  into  the  body.  The  full-grown  worm  is  from  twenty- 
five  to  thirty  feet  in  length. 

Taenia  Nana  and  Taenia  Flava  Punctata.  These  are  two  rare  varieties 
that  have  been  found  in  children  in  a  few  instances. 

Usually  but  a  single  worm  is  present,  although  as  many  as  five  or  six 
'have  been  found.    Earely  tffinia?  have  been  associated  with  roundworms 
and  also  with  threadworms. 

Symptoms, — -The  only  positive  evidence  of  tapeworm  is  the  discharge 
of  the  separated  segments,  either  singly  or  in  groups.  Occasionally  worms 
pass  into  the  stomach  and  are  vomited.  Various  abdominal  symptoms 
may  be  associated  with  worms,  but  most  of  these  are  very  indefinite  in 
character  and  are  more  often  due  to  other  causes.  The  most  frequent 
symptoms  are  bad  breath,  various  annoying  sensations,  colicky  attacks,  in- 
ordinate or  capricious  appetite,  and  diarrhoea.  Usually,  if  the  patient  is 
in  good  health,  no  constitutional  symptoms  are  seen.  Sometimes,  particu- 
larly with  the  bothriocephalus  latus,  there  is  a  very  grave  degree  of  anremia. 
Many  cases  are  now  on  record,  some  of  them  in  children,  in  which  the 
symptoms  of  pernicious  anaemia  have  been  present  and  have  disappeared 
after  the  expulsion  of  the  tapeworm.  Nervous  symptoms  are  not  so  often 
seen  as  with  roundworms,  and  will  be  discussed  in  connection  with  them. 

Treatment. — Prophylaxis  requires  the  cooking  of  meat  to  a  sufficient 
degree  to  destroy  the  cysticerci.  There  is  especial  danger  in  eating  raw 
pork  or  sausage;  that  from  rare  beef  is  much  less.  The  list  of  drugs 
used  for  the  expulsion  of  the  worm  is  a  long  one;  probably  the  most  sat- 
isfactory is  the  olcoresin  of  male  fern,  whicli  should  bo  given  in  capsule, 
in  TTl.xv  doses  to  a  child  of  ten  years,  four  capsules  usually  being  adminis- 
tered at  hourly  intervals.  The  vermifuge  should  be  preceded  by  several 
hours'  fasting,  and  the  bowels  should  be  previously  opened  by  a  laxative. 


444 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


The  following  plan  of  administration  has  been  found  satisfactory :  A  light 
supper  of  milk,  and  in  the  morning  a  saline  laxative  on  rising,  but  no 
breakfast ;  after  the  saline  has  acted  freely  the  capsules  are  to  be  given, 
one  every  hour,  and  following  the  last  one,  half  an  ounce  of  castor  oil  or 
some  other  active  purge.  The  effect  of  the  cathartic  is  aided  by  an  injec- 
tion. Only  milk  should  be  given  that  day.  The  fragments  passed  should 
be  carefully  examined  to  see  if  the  head  has  been  expelled,  as  the  worm  is 
very  likely  to  be  broken  at  the  neck.  If  this  occurs  it  will  grow  again,  and 
in  about  three  months  segments  will  appear  in  the  stools.  Other  drugs 
useful  for  taenia  are  infusion  of  pomegranate  root,  turpentine,  and  chlo- 
roform. 

Nematodes. — Two  varieties  are  found  in  the  intestinal  canal,  the  as- 
caris  lumbricoides  and  the  oxyuris  vermicularis. 

Ascaris  Lumbricoides — Roundworm. — This  worm  occupies  the  small 
intestine.    It  is  much  more  frequently  met  with  in  children  than  is  the 

tapeworm.  It  is  exceedingly  rare  in  infancy, 
but  is  usually  seen  between  the  third  and 
tenth  years.  In  over  one  thousand  autopsies 
upon  infants  I  have  only  once  found  a  round- 
worm in  the  intestine. 

The  roundworm  is  from  five  to  ten  inches 
long,  the  female  being  longer  than  the  male. 
It  is  of  a  light  gray  colour  with  a  slightly 
pinkish  tint,  cylindrical,  and  tapering  toward 
the  extremities  (Fig.  82).  The  eggs  are  oval 
in  form,  about  -^^  inch  in  diameter,  and  are 
numbered  by  millions.  These  worms  rarely 
exist  singly ;  usually  from  two  to  ten  are  pres- 
ent, but  there  may  be  hundreds.  When 
very  numerous  they  coil  up  and  form  large 
masses,  which  may  cause  intestinal  obstruc- 
tion. 

The  life  history  of  the  roundworm  is  not 
yet  perfectly  understood.  Epstein  cultivated 
outside  of  the  body  eggs  taken  from  the  stools,  and  found  that  under 
favourable  conditions  of  sun  and  air  five  weeks  were  required  for  the 
development  of  the  embryo.  These  were  then  fed  to  children.  In  three 
months  the  ova  appeared  in  the  stools,  and  after  the  administration  of 
santonin  many  worms  were  discharged.  From  these  experiments  it  would 
appear  that  no  intermediate  host  is  required,  although  this  was  pre- 
viously supposed  to  be  the  case.  It  was  believed  that  the  ova  were  swal- 
lowed by  some  worm  or  insect,  and  in  this  form  were  taken  into  the  intes- 
tinal canal  with  green  vegetables,  fruit,  or  drinking  water. 

The  migration  of  these  worms  is  curious,  and  in  some  instances  truly 
remarkable.    They  frequently  enter  the  stomach  and  are  vomited.    Occa- 


YiG.  82. — Ascaris  lumbricoides ; 
a,  entire  worm  ;  J,  head  ;  c, 
eggs.    (Jaksch.) 


INTESTINAL   WORMS.  445 

sionally  one  may  appear  in  the  nose.  They  have  been  known  to  pass 
through  the  Eustachian  tube  into  the  middle  ear  and  to  appear  in  the  ex- 
ternal meatus.  Entering  the  larynx  they  have  produced  fatal  asphyxia. 
It  is  not  very  rare  for  them  to  enter  the  common  bile  duct  and  pro- 
duce jaundice.  They  may  even  enter  in  great  numbers  the  smaller  bile 
ducts  and  produce  hepatic  abscesses.  They  have  been  found  in  the  pan- 
creatic duct,  in  the  vermiform  appendix,  and  in  the  splenic  vein.  It 
has  long  been  known  that  they  would  perforate  an  intestine  which  was  the 
seat  of  ulceration,  but  well  authenticated  cases  have  been  reported  in  which 
they  have  perforated  an  intestine  previously  healthy,  setting  up  a  fatal 
peritonitis.  In  Archambault's  case  they  perforated  the  stomach.  In  cases 
of  a  persistent  Meckel's  diverticulum,  worms  have  been  discharged  from  an 
umbilical  fistula.  They  have  been  found  in  umbilical  abscesses.  Consid- 
ering, however,  the  frequency  of  roundworms,  migrations  are  rare. 

Symptoms. — The  symptoms  of  roundworms  are  of  the  most  indefinite 
kind;  often  there  are  none  until  the  worm  is  discovered  in  the  stools. 
It, is  then  fair  to  assume  that  other  worms  are  also  present.  The  most 
frequent  abdominal  symptoms  are  colic,  tympanites,  and  other  symptoms 
of  indigestion,  loss  of  appetite,  restless,  disturbed  sleep,  grinding  of  the 
teeth  at  night,  and  picking  the  nose.  These  symptoms  are  much  more 
frequently  due  to  other  causes  than  to  worms,  but  when  all  are  present 
the  existence  of  worms  should  be  suspected. 

A  great  variety  of  nervous  symptoms  may  be  associated  with  intestinal 
worms.  They  are  more  often  seen  with  lumbricoids  than  with  either  of 
the  other  varieties.  The  symptoms  may  be  of  the  most  puzzling  character, 
and  may  simulate  very  closely  those  of  serious  organic  disease.  There 
may  be  chills,  headache,  vertigo,  hallucinations,  hysterical  seizures,  epi- 
leptiform attacks,  convulsions,  tetany,  transient  paralyses  such  as  strabis- 
mus, and  even  hemiplegia  and  aphasia.  All  these  have  been  observed 
in  connection  with  intestinal  worms,  and  from  the  fact  that  the  symptoms 
disappeared  completely  after  the  worms  were  expelled  there  seems  to  be 
but  little  doubt  that  they  were  the  cause  of  the  symptoms.  As  in  the  case 
of  the  abdominal  symptoms,  however,  intestinal  worms  are  only  one  of  the 
causes  of  such  nervous  disturbances,  and  certainly  not  the  most  frequent; 
but  the  possibility  that  they  may  depend  upon  worms  should  not  be 
overlooked. 

The  only  positive  evidence  of  the  existence  of  roundworms  is  the  dis- 
charge of  a  worm  from  the  body,  or  the  discovery  of  the  ova  in  the  stools. 
A  microscopic  examination  of  the  stools  is  a  valuable  means  of  diagnosis, 
and  one  that  is  too  infrequently  employed.  When  worms  are  present  the 
ova  may  be  found  in  great  numbers.  Their  continued  presence  after  the 
discharge  of  one  worm,  indicates  that  other  worms  remain. 

Treatment. — Altogether  the  most  efficient  agent  for  the  removal  of 
the  worms  is  santonin.  The  same  plan  of  administration  may  be  fol- 
30 


446 


DISEASES  OF   THE  DIGESTIVE   SYSTEM. 


lowed  as  in  the  case  of  the  tapeworm — viz.,  to  give  the  drug  on  an  empty 
stomach,  preceded  by  a  laxative.  Santonin  is  best  given  in  powdered 
form  mixed  with  sugar.  For  a  child  of  five  years  three  grains  are  usually 
required.  This  amount  should  be  given  in  three  doses  at  intervals  of  four 
hours,  soon  followed  by  a  purge  of  calomel  or  castor  oil. 

Oxyuris  Vermicularis — Pinworm — Threadworm. — The  oxyuris  (Fig. 
83)  resembles  a  short  piece  of  white  thread.  The  female  is  about  one- 
third  of  an  inch  long,  the  male  about  one-half  that  length,  but  is  less  fre- 
quently seen.  The  worm  tapers  toward  the  tail.  The  ova  are  of  slightly 
irregular  size,  and  are  considerably  smaller  than  those  of  the  round- 
worm. 

The  oxyuris  inhabits  chiefly  the  rectum  and  lower  colon;  less  fre- 
quently it  may  be  found  as  high  as  the  caecum.  These  worms  have  been 
seen  in  the  stomach,  and  even  in  the  mouth.  If  j^resent  in  the  rectum  they 
are  usually  discovered  by  separating  the  folds  of  the  anus.    The  number 

of  wor^is  is  usually  large.  The 
irritation  to  which  they  gjve 
rise,  causes  a  great  production 
of  mucus,  and  frequently  leads 
to  a  chronic  catarrh  of  the 
colon  of  considerable  severity. 
The  worms  are  imbedded  in  the 
mucus ;  often  they  form  with 
it  small  balls.  According  to 
Leuckart,  the}'  are  incapable  of 
multiplying  in  situ.  For  devel- 
opment, the  ova  must  be  swal- 
lowed. The  ova  as  well  as  the 
worms  are  passed  in  enor- 
mous numbers  with  the  stools. 
They  attach  themselves  to  the 
folds  of  the  skin,  the  hairs 
about  the  anus,  and  even  to  the 
genitals.  The  patient  may, 
through  lack  of  cleanliness  of  the  parts,  continually  re-infect  himself. 
After  discharge  from  the  body,  the  ova  may  be  carried  by  flies  and  de- 
posited upon  fruits,  vegetables,  or  in  drinking  water. 

Symptoms. — The  principal  symptom  caused  by  the  oxyuris  is  itching 
of  the  anus  or  the  genitals.  This  is  caused  by  the  migration  of  the  worms 
from  the  bowel,  and  usually  comes  on  at  about  the  same  hour  at  night, 
generally  soon  after  the  patient  has  retired.  It  is  sometimes  so  intense 
as  to  be  almost  intolerable.  It  leads  to  frequent  micturition,  to  incon- 
tinence of  urine,  in  the  male  to  balanitis,  and  in  the  female  to  vaginitis 
or  vulvitis,  and  in  both,  but  especially  in  the  latter,  it  may  be  the  cause 


Fig.  83. — Pinworms.  a, head;  i,  female :  c, male; 
e,  female  and  male,  natural  size ;  d,  ova. 
(Jakselj.) 


INTESTINAL  WORMS.  447 

of  masturbation.  Owing  to  the  catarrhal  colitis  which  is  excited,  there  is 
discharged  a  large  quantity  of  mucus.  The  irritation  may  lead  to  pro- 
lapsus ani.  Nervous  symptoms  are  not  so  frequently  associated  as  with 
the  other  varieties  of  worms,  although  I  have  seen  at  least  one  case  of 
chorea  in  which  they  were  almost  certainly  the  cause.  They  have  been 
known  to  excite  convulsions. 

Treatment. — This  is  usually  spoken  of  as  a  very  simple  matter,  and  no 
doubt  in  recent  cases,  or  where  the  number  of  worms  is  small,  this  is  true ; 
but  where  the  number  is  large,  and  considerable  catarrhal  inflammation  of 
the  colon  is  present,  it  is  often  a  matter  of  the  greatest  difficulty  to  rid  the 
bowel  of  these  parasites.  Cases  often  resist  the  most  approved  methods 
of  treatment  for  months,  even  though  carefully  and  thoroughly  applied. 
The  reason  for  this  difficulty  is,  that  the  whole  colon  is  doubtless  infected, 
and  that  the  upper  part  is  very  imperfectly  reached  by  injections.  While, 
therefore,  injections  are  important  and  indeed  invaluable,  they  can  not 
be  relied  upon  exclusively.  The  most  scrupulous  attention  to  cleanliness 
is  an  absolute  necessity  as  the  first  step  in  the  treatment  of  all  cases.  It 
is  well  to  bathe  the  parts  about  the  anus  after  each  stool,  and  even  two 
or  three  times  a  day,  with  a  bichloride  solution,  1  to  10,000.  Itching  is 
best  controlled  by  the  application  of  mercurial  ointment  to  the  folds  of 
the  anus  at  bedtime,  this  effectually  preventing  the  escape  of  the  worms 
from  the  bowel.  The  local  application  of  cold  will  sometimes  have  the 
same  effect.  The  most  efficient  of  the  injections  is  probably  the  bichlo- 
ride. The  colon  should  first  be  thoroughly  cleansed  by  an  injection  of 
lukewarm  water  containing  one  teaspoonful  of  borax  to  the  pint,  in  order 
to  remove  the  mucus.  When  this  has  been  discharged,  half  a  pint  of  the 
bichloride  solution  mentioned  should  be  injected  high  into  the  bowel 
through  a  catheter,  and  retained  as  long  as  possible.  This  should  be  re- 
peated every  second  or  third  night.  On  other  nights  a  simple  saline 
injection  may  be  employed.  The  infusion  of  quassia,  asafoetida,  aloes, 
and  garlic  are  also  useful. 

When  the  -worms  are  high  in  the  colon,  drugs  by  the  mouth  must 
be  combined  with  injections.  The  worms  must  be  dislodged  by  the  use  of 
saline  cathartics,  and  simple  bitters,  especially  quassia  and  gentian, 
should  be  given  by  the  mouth.  I  have  known  one  case,  which  resisted  for 
over  two  years  everything  which  had  been  tried,  to  be  cured  in  two  or  three 
weeks  by  injections  of  a  decoction  of  garlic,  in  connection  witli  which 
garlic  was  given  in  large  quantities  by  the  mouth. 


448  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


CHAPTER  XI. 

DISEASES  OF  THE  RECTUM. 

PROLAPSUS  ANI. 

Under  this  term  are  included  two  conditions.  In  the  first,  or  partial 
prolapse,  there  is  simply  an  eversion  of  the  mucous  membrane  which  pro- 
trudes beyond  the  sphincter.  In  the  second,  or  complete  prolapse,  there 
is  invagination  of  the  rectal  wall  for  a  variable  distance,  usually  two  or 
three  inches. 

Etiology. — Prolapse  is  most  common  in  children  during  the  second 
and  third  years.  Its  frequency  in  early  life  is  partly  due  to  the  lack  of 
support  furnished  by  the  levator-ani  muscles.  It  also  occurs  very  readily 
when  the  ischio-rectal  fat  is  scanty ;  it  is  therefore  often  seen  in  children 
suffering  from  marasmus.  The  exciting  cause  may  be  anything  which  pro- 
vokes severe  and  prolonged  straining.  This  may  be  either  the  tenesmus 
accompanying  inflammation  of  the  rectal  mucous  membrane  or  chronic 
constipation.  It  may  come  from  phimosis  or  stricture  of  the  urethra,  and 
it  is  a  very  frequent  symptom  of  stone  in  the  bladder. 

Symptoms. — Prolapse  usually  occurs  during  the  act  of  defecation.  It 
is  generally  easily  reduced,  but  shows  a  great  disposition  to  return  with 
every  stool.  In  obstinate  cases  the  bowel  comes  down  at  other  times. 
The  appearance  of  the  tumour  varies  with  its  size.  In  the  slighter  form 
there  is  simply  a  ring  composed  of  a  fold  of  mucous  membrane  surround- 
ing the  anus.  In  the  more  severe  form  there  is  a  flattened,  corrugated 
tumour,  usually  about  the  size  of  a  small  tomato  (Fig.  8-1).  The  mucous 
membrane  covering  the  tumour  is  of  a  deep  purplish-red  colour,  and 
bleeds  readily.  It  may  be  the  seat  of  catarrhal  or  membranous  inflamma- 
tion. The  diagnosis  in  most  cases  is  easy,  although  the  tumour  has  been 
confounded  with  polypus  and  intussusception. 

Treatment. — In  most  cases  reduction  is  easily  accomplished  by  laying 
the  child  upon  its  face  across  the  lap,  and  making  gentle  pressure  upon  the 
tumour  with  oiled  fingers.  The  application  of  cold,  either  by  means 
of  ice  or  cold  cloths,  is  of  assistance  in  cases  which  are  not  at  once  reduced 
by  pressure.  After  reduction,  in  the  milder  cases  the  child  should  be  kept 
upon  its  back  for  at  least  an  hour.  Where  the  tumour  tends  to  come 
down  with  every  stool,  special  attention  should  be  given  at  this  time.  If 
an  infant,  the  bowels  should  always  move  wliile  the  child  lies  upon  its 
back,  and  during  defecation  the  buttocks  should  be  pressed  together  by  a 
nurse.  Older  children  should  use  an  inclined  seat  placed  at  an  angle  of 
about  forty-five  degrees,  but  should  never  sit  upon  a  low  chair  or  assume 


PROLAPSUS  ANI.  449 

any  position  in  which  straining  is  easy.  After  defecation  the  patient 
should  lie  down  for  at  least  half  an  hour.  AVhere  there  is  constipation,  the 
bowels  should  be  kept  free  by  means  of  laxatives.     If  there  is  a  diarrhoea, 


Fig.  84.— l'rolup«us  aiii. 

tenesmus  may  be  overcome  by  frequent  sponging  with  ice  water,  or  by 
the  use  of  small  injections  of  ice  water  and  tannic  acid,  in  the  proportion 
of  twenty  grains  to  the  ounce.  In  more  severe  cases  it  may  be  controlled 
by  the  use  of  suppositories  of  opium  or  cocaine.  Where  the  bowel  tends 
to  come  down  frequently,  this  may  be  prevented  by  the  use  of  an  adhesive 
strap  two  or  three  inches  wide,  placed  tightly  across  the  buttocks.  This 
is  better  in  the  milder  cases  than  a  T-bandage.  The  great  majority  of  the 
cases  are  cured  by  these  means  in  the  course  of  a  few  weeks. 

In  the  most  severe  cases  the  bowel  not  only  protrudes  during  defeca- 
tion, but  also  in  the  interval,  and  it  may  be  down  for  weeks  at  a  time. 
Such  cases  are  rarely  seen  except  in  infants  who  have  very  flabby  muscles, 
and  but  little  adipose  tissue  at  the  floor  of  the  pelvis.  Reduction  is  some- 
times difificult  in  cases  where  the  prolapse  has  lasted  a  long  time.  .  It 
is  often  facilitated  by  painting  the  protruding  part  with  a  4-per-cent  solu- 
tion of  cocaine,  and  then  dilating  the  sphincter  by  passing  the  finger  into 
the  central  opening  of  the  tumour.  After  reduction,  suppositories  con- 
taining from  one  fourth  to  one  grain  of  cocaine  may  be  inserted.  They 
are  more  efficient  than  those  containing  opium  or  belladonna.  A  firm  pad 
should  be  applied  over  the  anus,  held  in  position  by  a  T-bandage.  The 
tone  of  the  levator  and  sphincter-ani  muscles  is  often  greatly  improved  by 
local  injections  of  strychnia.  For  a  child  two  years  old  j^^  grain  may  be 
used  twice  a  day.  Where  these  measures  fail,  the  protruding  part  may 
be  touched  with  the  Paquelin  cautery,  linear  markings  being  made  at  in- 
tervals of  an  inch.     Amputation  or  excision  is  not  required  in  children. 


450  DISEASES  OF  THE  DIGESTIVE   SYSTEM. 

FISSURE   OF   THE  ANUS. 

This  is  not  a  very  uncommon  condition  in  children.  The  most  fre- 
quent cause  is  the  passage  of  a  large,  hard,  fgecal  mass.  Sometimes  it  re- 
sults from  traumatism  inflicted  with  the  nozzle  of  a  syringe  while  giving 
an  enema.  It  may  be  produced  by  the  scratching  excited  by  pinworms.  In 
the  beginning  there  is  a  simple  tear  at  the  margin  of  the  anus.  The 
laceration  which  is  produced  usually  heals  promptly  ;  but  if  the  cause  is 
repeated,  healing  is  prevented,  and  there  is  finally  produced  a  linear  ulcer, 
or  a  true  fissure,  which  may  last  for  some  time  and  be  a  source  of  great 
annoyance. 

A  fresh  fissure  has  the  appearance  of  any  other  tear  at  a  muco-cuta- 
neous  orifice.  One  of  longer  standing  has  a  gray  base,  slightly  indurated 
edges,  often  discharges  a  small  amount  of  pus,  and  bleeds  a  drop  or  two 
with  nearly  every  movement  of  the  bowels.  The  most  constant  symptom 
is  pain,  which  usually  occurs  with  the  act  of  defecation,  and  continues  for 
some  time  afterward.  It  is  most  severe  when  the  fissure  is  just  at  the 
margin  of  the  sphincter,  and  leads  the  child  to  resist  every  inclination  to 
have  the  bowels  move,  so  that  it  becomes  a  cause  of  chronic  constipation, 
which  condition  again  greatly  aggravates  the  fissure.  The  pain  is  often 
referred  to  other  parts  in  the  neighbourhood. 

The  treatment  is  simple  and  usually  efficient.  It  consists  in  clean- 
liness, overcoming  the  constipation,  and  touching  the  fissure  with  nitrate 
of  silver,  preferably  with  the  solid  stick.  If  the  case  is  not  speedily  re- 
lieved by  such  measures,  the  sphincter  should  be  stretched  as  in  adult 
patients. 

PROCTITIS. 

Proctitis,  or  inflammation  of  the  rectum,  usually  occurs  with  inflam- 
mation of  the  rest  of  the  large  intestine,  but  it  may  occur  alone.  It  is 
to  the  cases  in  which  only  the  rectum  is  involved  that  the  term  is  gen- 
erally applied. 

The  causes  are  for  the  most  part  local.  A  frequent  one  in  infants 
is  the  use  of  irritating  injections  or  suppositories,  either  for  the  relief  of 
constipation  or  as  a  means  of  administering  certain  drugs.  I  have  seen 
one  obstinate  case  in  an  infant  a  year  old,  following  the  prolonged  use  of 
glycerin  suppositories.  It  is  sometimes  caused  by  traumatism,  especially 
by  the  careless  giving  of  an  enema.  It  accompanies  pinworms.  In 
certain  cases  it  may  result  from  direct  infection  through  the  anus.  This 
may  be  from  a  gonorrhoeal  iuflammation  extending  from  the  vagina  or 
urethra,  or  from  an  infection  due  to  other  bacteria,  particularly  in  cases 
of  measles,  scarlet  fever,  and  diphtheria;  or  finally,  it  may  be  due  to  syph- 
ilis. The  varieties  of  inflammation  are  the  same  as  in  the  rest  of  the  in- 
testine.    Proctitis  may  thus  be  catarrhal,  membranous,  or  ulcerative. 


PROCTITIS.  451 

Catarrhal  Proctitis. — The  pathological  conditions  are  the  same  as  in 
ordinary  catarrhal  inflammation  of  the  intestinal  mucous  membrane.  By 
the  introduction  of  a  speculum,  or  by  simply  everting  the  mucous  mem- 
brane, it  is  seen  to  be  reddened,  swollen,  and  bleeds  easily.  There  is  a  co- 
pious secretion  of  mucus.  In  cases  of  long  standing  there  may  be  super- 
ficial ulceration  appearing  as  a  white  or  yellowish-white  surface,  usually 
just  inside  the  sphincter. 

Tlie  symptoms  are  chiefly  local,  although  a  condition  of  general  irrita- 
bility may  result  from  the  local  condition.  There  is  heightened  reflex 
action,  so  that  the  stool  often  comes  with  a  squirt.  There  is  pain  with 
defecation,  and  mucus  is  discharged,  usually  as  a  clear,  jelly-like  mass, 
and  sometimes  in  the  form  of  a  cast,  but  not  generally  mixed  with  the 
stool.  There  are  usually  traces  of  blood,  but  rarely  large  haemorrhages. 
In  the  most  acute  cases,  tenesmus  is  always  present  both  during  and  after 
the  stool.  There  may  be  prolapsus  ani.  The  skin  in  the  vicinity  is  irri- 
tated by  the  discharges,  most  frequently  so  in  infants.  If  the  cause  is  pin- 
worms,  there  may  be  intense  itching.  The  duration  of  the  disease  is 
indefinite,  depending  upon  the  cause.  It  may  be  a  few  days  or  many 
months.  The  inflammation  may  extend  from  the  rectum  to  neighbouring 
parts,  leading  to  ischio-rectal  abscess. 

Membranous  Proctitis. — It  has  been  customary  to  describe  this  as  a 
complication  of  diphtheria,  usually  occurring  with  diphtheria  of  the  exter- 
nal genitals.  As  very  few  of  these  cases  have  been  studied  bacteriolog- 
ically,  it  is  impossible  to  say  what  proportion  of  them,  if  any,  are  to  be 
regarded  as  true  diphtheria.  It  is  probable  that  the  great  majority  are 
due  to  infection  by  streptococci.  When  the  infection  is  from  the  intestine 
above,  the  rectum  is  never  affected  alone.  When  it  is  from  below,  this 
may  be  the  case.  The  lesions  are  the  same  as  in  membranous  inflamma- 
tion occurring  higher  in  the  colon.  The  symptoms  resemble  those  of  the 
catarrhal  variety,  with  the  addition  that  the  stools  contain  pieces  of 
pseudo-membrane.  This  can  be  made  out  only  by  repeatedly  washing 
the  discharges  with  water.  If  accompanied  by  prola])se,  the  pseudo- 
membrane  may  be  seen.  Membranous  proctitis  may  be  complicated  by  a 
membranous  inflammation  of  the  genitals  or  the  perinseum.  Although 
it  is  usually  acute,  it  may  last  for  weeks. 

Ulcerative  Proctitis. — Ulcers  of  the  rectum  may  be  the  result  of  a  ca- 
tarrhal inflammation  ;  these,  however,  are  usually  superficial,  affecting  the 
mucous  membrane  only,  and  in  most  cases  heal  rapidly.  Sometimes  they 
extend  more  deeply  into  the  submucous  or  even  the  muscular  coat.  They 
are  then  chronic,  often  very  obstinate,  and  may  last  indefinitely.  Follicu- 
lar ulcers  of  the  rectum  are  nearly  always  associated  with  the  same  con- 
dition in  the  sigmoid  flexure.  These  are  always  multiple  and  usually 
small,  rarely  being  more  than  a  quarter  of  an  inch  in  diameter.  Some- 
times the  small  ones  coalesce,  producing  much  larger  ulcers.    Membranous 


452  DISEAS-ES  OP  THE  DIGESTIVE  SYSTEM. 

proctitis  is  rarely  followed  by  ulceration,  although  this  is  a  possible  result 
where  sloughing  has  occurred.  Single  ulcers  may  be  of  tuberculous  ori- 
gin. Steffen  reports  two  cases  of  tuberculous  ulcer  of  the  rectum  in 
children  of  seven  months  and  three  years  respectively.  I  have  seen  one 
such  ulcer  in  a  young  infant,  which  was  fully  three-fourths  of  an  inch  in 
diameter,  and  was  not  associated  with  other  tuberculous  disease  of  the  • 
large  intestine.    Syphilitic  ulcers  are  extremely  rare  in  children. 

The  symptoms  of  ulcer  of  the  rectum  are  mainly  two — pain  and  haem- 
orrhage. The  pain  is  of  variable  intensity,  and  may  be  referred  to  the 
coccyx,  or  to  any  of  the  neighbouring  parts.  The  amount  of  bleeding 
may  be  small,  the  blood  coming  in  clots,  or  it  may  be  fluid  and  in  so  large 
a  quantity  as  to  produce  general  symptoms.  It  usually  accompanies  every 
stool.  In  addition  the  stool  contains  more  or  less  pus,  particularly  in 
chronic  cases.  When  the  ulcer  is  low  down,  tenesmus  is  present  and  may 
be  a  prominent  symptom.  A  positive  diagnosis  of  ulcer  can  be  made  only 
by  examination  with  a  speculum. 

Treatment. — In  cases  of  acute  catarrhal  proctitis  injections  of  some 
bland  fluid  should  be  employed,  such  as  a  starch- water,  limewater,  a  mixture 
of  oil  and  limewater,  or  a  warm  one-per-cent  saline  solution.  The  local 
cause,  if  one  is  present,  should  be  removed.  Where  the  stools  are  excess- 
ively acid,  alkalies  may  be  given  by  the  mouth.  The  disordered  digestion, 
when  present,  is  to  be  treated  according  to  its  special  symptoms.  In  the 
most  acute  cases  the  patient  should  be  kept  in  bed.  Where  the  tenesmus 
is  severe,  suppositories  of  opium  or  cocaine  may  be  used.  In  the  more 
chronic  cases  saline  injections  should  be  given,  and  followed  by  a  mild 
astringent  like  tannic  acid,  ten  grains  to  the  ounce,  or  a  one-per-cent  solu- 
tion of  hamamelis.  Cases  associated  with  pin  worms  are  especially  obsti- 
nate. Here  the  treatment  is  first  to  be  directed  to  the  worms,  and  after- 
ward to  the  proctitis. 

In  the  membranous  cases  the  same  measures  are  to  be  employed,  and 
in  addition  the  injection  of  a  warm  boric-acid  solution  two  or  three- 
times  a  day. 

Cases  of  ulcer  require  the  most  careful  treatment.  In  many  there  i& 
but  little  tendency  to  spontaneous  recovery.  An  examination  with  the 
speculum  should  be  insisted  upon  in  all  cases  of  chronic  proctitis,  to 
make  sure  of  the  diagnosis.  Kest  in  bed  is  essential  to  a  rapid  improve- 
ment. The  patient  should  be  put  upon  a  bland  diet,  especially  of  milk, 
and  the  bowels  kept  freely  open  by  the  use  of  laxatives,  and  injections 
twice  a  day  of  a  saturated  boric-acid  solution.  Locally  there  should  be 
applied  a  solution  of  nitrate  of  silver,  one  grain  to  the  ounce,  the  bowel 
having  previously  been  washed  with  tepid  water.  If  a  stronger  solution 
than  this  is  used,  it  should  be  neutralized  after  half  a  minute  by  the: 
injection  of  a  salt  solution. 


HiExMORRIIOIDS.  453 


ISCHIO-RECTAL  ABSCESS. 

This  is  not  a  very  rare  condition  even  in  infancy.  Infection  from  the 
rectum,  usually  through  the  lymph  channels,  seems  to  be  the  most  com- 
mon cause,  although  sometimes  the  abscess  maybe  traced  directly  to  trau- 
matism. In  a  single  year  I  have  seen  six  cases.  All  but  two  were  small, 
circumscribed  abscesses  and  quite  superficial,  apparently  starting  as  an 
acute  inflammation  of  the  lymph  glands  of  the  region.  They  are  analo- 
gous to  a  similar  process  in  the  lymph  glands  of  the  neck,  seen  in  in- 
fancy. These  cases  healed  promptly  after  incision.  In  other  instances 
there  is  seen  a  disposition  to  burrow,  as  in  adults.  Only  once  have  I  met 
with  diffuse  suppuration  in  the  ischio-rectal  region,  terminating  in  slough- 
ing and  death,  and  this  was  in  an  infant  only  three  months  old. 

Essentially  the  same  varieties  of  inflammation  are  seen  in  early  life  as 
in  adults.  Most  of  these  cases  recover  promptly  after  simple  incision  and 
cleanliness,  fistula  being  a  rare  sequel. 

HEMORRHOIDS. 

These,  fortunately,  are  not  often  seen  in  children,  although  they  occur 
in  those  as  young  as  three  or  four  years,  and  in  some  cases  may  even  be 
,  congenital.  The  principal  cause  is  chronic  constipation,  rarely  diarrhoea. 
The  tumours  are  generally  small  and  external,  the  chief  symptom  com- 
plained of  being  pain  on  defecation.  Bleeding  sometimes  accompanies 
the  pain,  but  the  haemorrhages  are  usually  small.  The  treatment  is  to  be 
directed  toward  the  underlying  cause.  In  most  of  the  cases  this  suffices 
to  cure  the  condition.  I  have  rarely  seen  in  a  young  child  a  case  requir- 
ing operation,  although  neglect  may  make  this  procedure  necessary. 

INCONTINENCE   OF  FECES. 

Inability  to  control  the  fsecal  evacuations  is  seen  in  certain  cases  of 
paraplegia  due  to  myelitis,  in  injury  of  the  lumbar  portion  of  the  spinal 
cord,  and  in  spina  bifida.  It  is  also  seen  in  the  coma  of  meningitis,  and 
occasionally  in  the  typhoid  condition  and  in  extreme  adynamia,  no  matter 
in  the  course  of  what  diseases  they  develop.  In  all  these  conditions  in- 
continence of  faeces  is  a  symptom  giving  rise  to  much  annoyance  and 
needing  careful  attention.  Uncleanliness  with  reference  to  excreta,  seen 
in  idiocy,  can  hardly  be  classed  as  incontinence. 

Besides  these  familiar  forms,  the  condition  is  sometimes  seen  from 
causes  somewhat  resembling  those  of  incontinence  of  urine.  The  tone 
of  the  sphincter  becomes  so  feeble  that  it  does  not  resist  even  the  slightest 
impulse  to  evacuate  the  rectum.  The  discharge  may  take  place  with  but 
little  warning,  and  may  occur  either  by  day  or  night.  In  some  cases  a 
local  cause  exists,  such  as  stretching  of  the  sphincter  by  a  rectal  prolapse 


454 


DISEASES  OP   THE  DIGESTIVE  SYSTEM. 


or  by  impaction  of  faeces ;  more  frequently,  however,  the  causes  relate  to 
the  general  nervous  condition  of  the  patient.  Fowler  *  (New  York)  has 
reported  two  very  typical  cases  of  this  variety,  and  I  have  seen  one.  They 
are,  however,  very  rarely  met  with  in  practice.  Of  the  cases  reported  in 
literature,  the  majority  have  occurred  in  highly  nervous,  ansemic  children. 
Fowler's  cases  were  cured  by  the  use  of  ergot  given  by  the  mouth  and  by 
suppository.  In  cases  not  relieved  by  this  treatment,  strychnia  should  be 
injected  locally  as  described  under  Prolapsus  Ani.  In  all  cases  the  gen- 
eral condition  should  receive  careful  attention. 


CHAPTEE    XII. 
DISEASES  OF  TEE  LIVER. 

Aside  from  the  different  forms  of  degeneration  which  are  seen  in  the 
various  infectious  diseases,  the  liver  is  not  often  the  seat  of  serious  dis- 
ease in  infancy  and  early  childhood.  In  later  childhood  nearly  all  the 
forms  seen  in  adult  life  are  occasionally  met  with,  although  even  then 
they  are  quite  rare. 

Size  and  Position. — The  weight  of  the  liver  in  the  newly-born  child, 
from  one  hundred  and  seven  observations  of  Birch-Hirschfeld,  is  4*5  ounces 
(127  grammes),  or  about  4*2  per  cent  of  the  body  weight.  The  following 
table  gives  the  results  of  one  hundred  and  seventy-four  observations  upon 
the  liver  in  infancy  in  the  autopsy  room  of  the  New  York  Infant  Asylum  : 


Weight  of  the  Liver  in  Infancy. 


AVEKAGK. 

Age. 

Ounces. 

Grammes. 

body  weight. 

3  months 

6-3 

7-5 
11-0 
14-0 
16-0 

180 
212 
311 
397 
453 

31 

6       "       

3-0 

12       "           

3-40 

2  years     

3-37 

3     "     

3-26 

In  adults,  according  to  Frerichs,  the  weight  of  the  liver  is  about  2'5 
per  cent  of  the  weight  of  the  body. 

The  upper  border  of  the  liver  is  best  made  out  by  percussion.  In  the 
child,  the  upper  limit  of  the  liver  dulness  in  the  mammary  line  is  found 
in  the  fifth  intercostal  space  ;  in  the  axillary  line,  in  the  seventh  space  ; 
posteriorly,  in  the  ninth  space.  The  lower  border  is  best  determined  by 
palpation.  This,  as  a  rule,  in  the  mammary  line  is  found  about  one  half 
an  inch  below  the  free  border  of  the  ribs.  According  to  Steffen,  the  left 
lobe  is  relatively  larger  in  the  child  than  in  the  adult.     The  liver  may  be 


♦American  Journal  of  Obstetrics  and  Diseases  of  Children,  October,  1882. 


FUNCTIONAL   DISORDERS   OF   THE   LIVER.  455 

displaced  downward  by  contraction  of  the  chest,  as  in  rickets,  or  by  an 
accumulation  of  fluid  in  the  pleural  cavity.  It  is  frequently  found  lower 
than  normal  in  conditions  of  great  emaciation,  owing  to  relaxation  of  the 
abdominal  walls  and  its  ligamentous  supports.  Upward  displacement  is 
much  less  frequent,  and  depends  usually  upon  ascites  or  abdominal  tumours. 

Malformations  and  Malpositions. — Congenital  malformations  relate 
chiefly  to  the  bile  ducts.  These  have  been  considered  in  the  chapter  de- 
voted to  Icterus  in  the  Newly  Born  (page  76). 

The  liver  may  be  found  upon  the  left  side  in  cases  of  general  transpo- 
sition of  the  viscera.  In  fissure  of  the  diaphragm  it  has  been  found  in  the 
thoracic  cavity. 

ICTERUS. 

Icterus,  or  jaundice,  occurs  in  children,  as  in  adults,  from  two  general 
classes  of  causes.  The  first  includes  those  cases  in  which  there  is  some 
obstruction  to  the  flow  of  bile  from  the  liver  into  the  intestine,  or  obstruc- 
tive jaundice.  In  the  second  group,  in  which  the  jaundice  is  classed  as 
non-obstructive,  it  depends  upon  certain  changes  in  the  blood  itself.  This 
is  seen  in  the  physiological  jaundice  of  the  newly  born,  in  that  associated 
with  septic  conditions  and  as  the  result  of  certain  poisons. 

Obstructive  jaundice  from  pressure  upon  the  bile  ducts  is  extremely 
rare  in  children.  Obstruction  by  a  roundworm  entering  the  common 
duct  has  been  recorded,  but  is  also  very  rare.  The  principal  form  of  ob- 
structive jaundice  seen  in  early  life,  is  catarrhal.  This  has  already  been 
considered  in  connection  with  Oastro-duodenitis. 

FUNCTIONAL   DISORDERS. 

Functional  derangements  of  the  liver  are  undoubtedly  exceedingly  com- 
mon in  childhood.  They  are  as  yet  but  little  understood,  and  it  is  almost 
impossible  to  separate  them  from  the  other  symptoms  of  intestinal  indiges- 
tion with  which  they  are  associated.  These  are  described  in  the  chapter 
upon  Chronic  Intestinal  Indigestion.  Some  of  these  symptoms  depend 
upon  a  diminution  in  the  quantity,  or  the  impoverished  quality  of  the 
biliary  secretion.  There  are  gray  or  white  stools,  flatulence,  and  other  evi- 
dences of  increased  intestinal  putrefaction.  These  in  all  probability  depend 
upon  imperfect  absorption  in  consequence  of  the  absence  of  bile,  rather 
than  upon  the  absence  of  some  antiseptic  property,  as  recent  experiments 
seem  to  show  that  the  bile  is  not  an  intestinal  antiseptic.  The  other 
functional  disturbances  of  the  liver  relate  to  its  effect  upon  the  jiroteid 
substances  which  undergo  destructive  metamorphosis  in  this  organ.  The 
nature  of  this  change,  and  the  symptoms  whicli  result  from  this  disturbance 
are  as  yet  but  imperfectly  understood.  It  is  quite  probable  that  many  of 
the  nervous  functional  disorders  of  children — for  example,  attacks  of 
migraine  or  of  cyclic  vomiting — may  depend  upon  such  a  cause. 


456  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


ACUTE  YELLOW  ATROPHY. 

This  form  of  hepatic  disease,  although  rare  in  adults,  is  still  more 
rare  in  children.  Greves  *  has  reported  a  well-marked  case  in  an  infant 
of  twenty  months,  and  has  collected  seventeen  other  cases  under  ten  years 
of  age ;  the  youngest  was  in  an  infant  three  months  old.  The  causes  are 
obscure.  The  symptoms  and  course  of  the  disease  are  essentially  the 
same  as  in  adults. 

CONaESTION  OF   THE  LIVER. 

Congestion  of  the  liver  occurs  from  the  same  causes  in  children  as  in 
adults.  Acute  congestion  is  not  often  seen.  It  may  result  from  ma- 
larial fever  and  from  certain  poisons,  particularly  phosphorus.  Chronic 
congestion  is  more  common,  and  is  usually  secondary  to  general  venous, 
obstruction  dependent  upon  congenital  or  acquired  heart  disease,  atelec- 
tasis, or  other  pulmonary  conditions,  particularly  chronic  pleurisy, 
chronic  interstitial  pneumonia,  and  emphysema.  Chronic  congestion  of 
the  liver  causes  no  characteristic  symptoms  except  a  moderate  enlarge^ 
ment  of  the  organ.  The  disturbance  of  its  functions  is  not  of  such  a 
nature  as  to  be  diagnostic.  In  acute  congestion,  there  may  be  in  addi- 
tion to  the  swelling  of  the  liver,  some  localized  pain  or  tenderness.  The 
treatment  is  that  of  the  original  disease  upon  which  the  congestion  de- 
pends. 

ABSCESS  OF  THE  LIVER— SUPPURATIVE  HEPATITIS. 

In  1890  Musser  f  found  but  thirty-four  recorded  cases  of  abscess  in 
children  under  thirteen  years.  Since  that  time  a  few  additional  cases 
have  been  reported.  This  suffices  to  show  how  rare  the  disease  is  in  early 
life.  In  the  above  collection,  there  have  not  been  included  cases  of  sup- 
purative hepatitis  occurring  in  the  newly  born. 

As  in  adults,  abscess  of  the  liver  may  result  from  traumatism,  or  it 
may  be  secondary  to  suppurative  pylephlebitis,  which  depends  upon  a 
focus  of  infection  in  the  umbilical  vein,  or  in  some  part  of  the  abdomen 
from  which  the  branches  of  the  portal  vein  arise.  Pylephlebitis  may  fol- 
low appendicitis  (Bernard's  case),  it  may  follow  typhoid  fever  directly 
(Aseh's  case),  or  be  due  to  suppuration  of  the  mesenteric  glands  or  peri- 
tonitis following  typhoid.  In  seven  of  the  cases  collected  by  Musser 
the  disease  was  due  to  migration  of  roundworms  from  the  intestine  into 
the  hepatic  ducts.  Menger  (Texas)  has  reported  one  case  following  dysen- 
tery, the  only  one,  I  think,  on  record  in  this  country.  In  quite  a  number 
of  cases  no  adequate  cause  can  be  found.    A  striking  example  of  this  was 


■*  Liverpool  Medico-Chirurgical  Journal,  July,  1884. 
■{•  Keating's  Cyclopaedia,  vol.  iii,  p.  466. 


ABSCESS  OF   THE   LIVER.  457 

reported  to  the  New  York  Pathological  Society  by  Swift,  in  1882,  where 
an  abscess  occupying  nearly  the  whole  right  lobe  occurred  in  a  child 
three  years  old. 

In  the  cases  occurring  in  pyaemia  and  in  those  associated  with  pyle- 
phlebitis there  are  usually  several  abscesses ;  in  traumatic  cases  generally  but 
one.  The  abscesses  of  early  life  do  not  differ  very  much  from  those  of 
adults.  If  untreated,  the  majority  of  cases  prove  fatal  either  from  exhaus- 
tion or  from  rupture  into  the  pleura  or  peritonaeum.  In  Asch's  case  spon- 
taneous cure  took  place  by  rupture  into  the  intestine. 

Symptoms. — Occasionally  abscess  in  the  liver  is  latent,  but  in  most  of 
the  cases  the  symptoms  are  marked  and  sufficiently  characteristic  to  make 
the  diagnosis  a  matter  of  no  great  difficulty.  The  most  constant  general 
symptoms  are  chills,  which  may  be  single,  but  are  usually  repeated  ;  fever, 
which  is  commonly  of  the  hectic  variety  and  followed  by  sweating ;  pros- 
tration, vomiting,  diarrhoea,  and  cachexia.  Jaundice  is  present  in  less  than 
half  the  cases,  and  is  rarely  intense.  The  liver  is  almost  invariably  suffi- 
ciently enlarged  to  be  easily  made  out  by  palpation  or  by  percussion  ;  the 
enlargement  in  most  cases  is  chiefly  downward.  Tumours  on  the  surface 
of  the  liver  are  often  present ;  these  may  be  recognised  us  abscesses  by  the 
presence  of  fluctuation.  Pain  is  quite  constant,  and  frequently  intense, 
but  not  always  in  the  i*egion  of  the  liver.  It  may  be  in  the  epigastrium, 
at  the  umbilicus,  in  the  lower  part  of  the  abdomen,  and  occasionally 
in  the  right  shoulder.  Tenderness  over  the  liver  is  usually  present.  A 
positive  diagnosis  of  hepatic  abscess  is  to  be  made  only  by  aspiration  and 
the  withdrawal  of  a  fluid  having  the  characteristics  of  "  liver  pus."  Pul- 
monary symptoms  usually  exist  with  an  abscess  occupying  the  convexity 
of  the  right  lobe.  There  may  be  cough  and  dyspnoea  from  pressure,  or 
pleurisy  from  extension  of  the  inflammation  through  the  diaphragm,  or 
from  rupture  into  the  pleural  cavity.  The  usual  duration  of  abscess  of 
the  liver  after  the  beginning  of  the  symptoms  is  from  one  to  two  months. 
The  prognosis  will  depend  upon  the  cause  of  the  disease.  The  pyaemic 
cases  are  usually  fatal.  In  Musser's  collection,  the  proportion  of  recov- 
eries was  about  thirty  per  cent.  At  the  present  time,  with  improved 
methods  of  treatment  and  earlier  diagnosis,  the  outlook  is  somewhat 
better  than  this. 

Treatment. — This  is  purely  surgical.  Without  operation  the  chances 
of  recovery  are  very  slight.  A  small  number  of  cases  have  been  cured 
by  aspiration,  but  in  the  vast  majority  only  incision  and  drainage  are  to 
be  depended  upon,  and,  if  the  abscess  is  accessible,  should  be  resorted  to 
as  soon  as  the  diagnosis  is  established. 

CIRRHOSIS. 

Cirrhosis  of  the  liver  is  exceedingly  rare  in  early  life,  although  quite 
:a  number  of  cases  are  now  on  record  between  the  ages  of  seven  and  four- 


458  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

teen  years.  Sixty-five  have  been  collected  by  Howard  *  and  fifty-three  by 
Laure  and  Honorat.f  Nearly  all  the  cases  in  these  collections  were  be- 
tween nine  and  fifteen  years  old.  Cirrhosis  in  infancy  is  usually  of  syphi- 
litic origin.  Two-thirds  of  those  in  Howard's  collection  were  males. 
The  etiology  in  most  of  the  cases  is  obscure;  in  over  half  of  t^iose  re- 
ported no  cause  could  be  discovered.  Fifteen  per  cent  of  Howard's  cases 
were  traced  to  alcoholism,  eleven  per  cent  to  syphilis,  and  eleven  per  cent 
to  tuberculosis.  Laure  and  Honorat  believe  that  the  eruptive  fevers 
sometimes  play  an  important  part  as  an  etiological  factor,  and  that  at 
other  times  the  cause  is  possibly  malaria. 

The  anatomical  features  of  cirrhosis  in  early  life  are  essentially  the 
same  as  in  adults.  The  liver  is  sometimes  enlarged,  but  usually  it  is 
smaller  than  normal.  The  connective  tissue  may  be  distributed  around 
the  lobules,  along  the  bile  ducts,  in  irregular  patches,  or  in  striations- 
through  the  organ.  Associated  with  this  there  is  atrophy  and  fatty 
degeneration  of  the  liver  cells.  In  some  of  the  cases  reported  there  has 
been  also  a  similar  increase  in  the  connective  tissue  of  the  spleen  and 
kidneys. 

Symptoms. — These  are  very  much  the  same  as  in  adult  life.  In  the 
beginning  there  are  the  indefinite  disturbances  referable  to  the  digestive 
organs,  and  the  liver  may  be  found  to  be  slightly  enlarged;  later  there  is 
ascites,  enlargement  of  the  spleen,  and  dilatation  of  the  abdominal  veins. 
Ascites  is  a  pretty  constant  symptom,  and  is  generally  marked.  Slight 
icterus  is  often  present,  but  a  marked  amount  is  rare.  There  may  be 
haemorrhages  from  the  stomach,  from  the  nose,  or  from  other  organs ;  in 
a  few  cases  there  is  slight  fever.  The  late  symptoms  are  a  small  liver,, 
marked  ascites  with  the  consequent  embarrassment  of  respiration,  ca- 
chexia, and  sometimes  general  dropsy.  Diarrhoea  is  a  much  more  con- 
stant symptom  than  in  adults.  Death  usually  takes  place  from  exhaus- 
tion. The  course  of  cirrhosis  in  children  is  commonly  more  rapid  than 
in  adults,  and  the  progress  is  steadily  downward. 

Treatment. — Medicinal  treatment  is  of  avail  only  in  cases  which  are 
syphilitic.  These  should  be  put  upon  mercury  and  large  doses  of  the 
iodides.  The  treatment  in  other  respects  is  symptomatic  and  palliative. 
As  largely  as  possible  patients  should  be  kept  upon  a  milk  diet.  The 
ascites  may  require  aspiration  or  puncture,  as  in  adults. 

AMYLOID  DEGENERATION  (WAXY,  LARDACEOUS  LIVER). 

From  the  experiments  of  Krawkow,  Davidsohn,  and  others  there 
seems  now  little  doubt  that  amyloid  degeneration  is  produced  by  the 
prolonged  action  of  the  toxins  of  the  staphylococcus  pyogenes  aureus. 

*  American  Journal  of  the  Medical  Sciences,  1887,  p.  350. 

f  Revue  Mensuelle  des  Maladies  de  I'Enfance,  1887,  pp.  97,  159. 


FATTY   LIVER.  459 

Amyloid  degeneration  of  the  liver  is  associated  with  similar  changes  in 
the  spleen  and  kidneys,  and  sometimes  in  the  villi  of  the  small  intestine, 
and  is  usually  seen  in  children  after  long-continued  suppuration  in 
chronic  bone  or  joint  disease,  empyema,  tuberculosis,  or  syphilis. 

The  liver  is  generally  very  much  enlarged ;  in  extreme  cases  a  weight 
of  six  or  seven  pounds  may  be  reached.  It  is  of  a  glistening,  waxy  ap- 
pearance, very  firm  and  hard.  With  a  solution  of  iodine,  a  mahogany- 
brown  reaction  is  obtained.  The  amyloid  degeneration  affects  first  the 
arterioles,  and  finally  the  hepatic  cells. 

Amyloid  liver  per  se  produces  few  symptoms.  Ascites  is  rarely  pres- 
ent except  in  cases  in  which  the  liver  is  verj  large,  and  jaundice  does  not 
occur.  In  addition  to  the  symptoms  of  the  original  disease  in  the  course 
of  which  the  amyloid  degeneration  occurs,  there  is  the  peculiar  waxy 
cachexia  which  is  seen  in  no  other  condition,  but  resembles  somewhat 
that  belonging  to  malignant  disease.  The  face  has  the  appearance  of  ala- 
baster, and  the  skin  has  a  singular  translucency.  The  liver  may  be  so 
large  as  to  form  a  tumour,  sometimes  nearly  filling  the  abdominal  cavity. 
Not  infrequently  it  extends  to  the  umbilicus,  and  even  to  the  crest  of  the 
ilium.  The  surface  is  smooth  and  hard,  and  the  edges  usually  rounded. 
There  is  no  localized  pain  or  tenderness.  The  spleen  is  invariably  en- 
larged. As  a  result  of  the  associated  amyloid  degeneration  of  the  kidney,. 
there  may  be  dropsy  and  albuminuria.  Dropsy  may  occur  from  pressure 
of  the  large  liver  upon  the  vena  cava,  apart  from  the  condition  of  the 
kidney. 

Amyloid  changes  usually  take  place  slowly,  the  whole  course  of  the 
disease  being  marked  by  years,  the  patient  dying  from  slow  asthenia, 
from  nephritis,  or  from  some  acute  intercurrent  disease.  As  a  rule,  cases 
go  on  steadily  from  bad  to  worse ;  but  sometimes,  after  the  disease  has- 
reached  a  certain  point,  the  condition  is  stationary  for  a  long  time. 

The  prognosis  is  always  bad,  although  in  a  few  cases  improvement, 
and  even  cure,  are  stated  to  have  occurred  after  the  excision  of  the  dis- 
eased joints  upon  which  the  amyloid  degeneration  depended.  When  due 
to  syphilis,  the  usual  anti-syphilitic  remedies  should  be  given. 


FATTY  LIVER. 

Fatty  infiltration  of  tlic  liver  is  generally  a  secondary  condition  in 
early  life,  and  causes  no  symptoms  by  which  it  can  be  positively  recog- 
nised. Considerable  discussion  has  of  late  arisen  regarding  its  frequency 
in  infants.  From  our  records  at  the  Babies'  Hospital,  Dr.  Martha  Woll- 
stein  has  tabulated  345  consecutive  autopsies  in  which  the  condition  of 
the  liver  was  carefully  noted.  The  liver  was  fatty  in  201,  or  58  per  cent. 
Of  these  autopsies,  63  were  cases  of  tul)erculosis,  in  43  of  wliicli,  or  68 
per  cent,  the  liver  was  fatty. 


460  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

The  general  nutrition  of  the  345  infants  was  as  follows : 


Wasted 188 

Fairly  nourished 80 

Well  nourished 77 


liver  fatty,  104,  or  55  per  cent — very  fatty  in  17. 

52,  "  65    "      '^  "        "      "     9. 

"         45,  "  59    "      "  "        "      "  20. 


These  figures  coincide  very  closely  with  the  observations  of  Freeman 
at  the  jSTew  York  Foundling  Hospital,  and  indicate  that  fatty  liver  is  not, 
as  has  been  so  often  asserted,  much  more  frequent  in  wasted  infants  than 
in  others.  The  cause  of  this  change  in  the  liver  is  as  yet  but  little  under- 
stood. 

The  liver  is  moderately  enlarged,  smooth,  with  rounded  edges,  of  a 
yellowish-red  or  a  lemon-yellow  colour,  and  can  be  indented  with  the 
finger.  A  warm  knife  becomes  coated  with  oil  after  cutting.  Microscop- 
ically there  is  seen  an  accumulation  of  fat  in  the  liver  cells,  usually  irreg- 
ularly distributed.  Jaundice,  ascites,  and  the  other  peculiar  symj^toms  of 
hepatic  disease,  are  absent.  The  liver  is  moderately  increased  in  size  and 
its  functions  are  interfered  with,  but  not  in  such  a  way  as  to  be  recog- 
nised by  the  symptoms.    The  treatment  is  that  of  the  original  disease. 

HYDATIDS. 

Echinococcus  disease  of  the  liver,  while  rare  among  adults  in  this 
■country,  is  almost  unknown  in  children.  I  have  been  able  to  find  but  two 
recorded  cases  in  America.  From  twenty-two  European  cases  collected 
loy  Pontou  (Paris,  1867),  it  appears  that  unilocular  cysts  are  especially 
frequent  in  young  subjects.  If  the  upper  surface  is  affected,  pulmonary 
symptoms,  cough  and  dyspnoea,  are  usually  present;  if  the  under  surface 
of  the  organ,  there  is  pressure  upon  the  portal  vein,  the  vena  cava,  bile 
ducts,  stomach,  and  intestines.  This  preSvSure  may  cause  icterus,  dilata- 
tion of  the  superficial  abdominal  veins,  and  sometimes  ascites.  The  local 
signs  are  enlargement  of  the  liver  with  a  tumour,  which  is  easily  recog- 
nised in  children  because  of  the  thin  abdominal  walls.  The  hydatid 
fremitus  is  usually  obtained.  By  aspiration  a  clear  fluid  is  withdrawn, 
showing  under  the  microscope  the  presence  of  the  hooklets,  which  es- 
tablishes the  diagnosis.  Occasionally  cure  may  take  place  by  spon- 
taneous rupture  or  suppuration  of  the  cyst,  but  in  most  cases,  when  left 
to  itself,  the  disease  proves  fatal.  The  treatment  is  surgical,  and  con- 
sists in  aspiration  or  in  incision,  and  the  evacuation  of  the  cyst. 

BILIARY  CALCULI. 

Up  to  the  age  of  jDuberty  calculi  are  extremely  rare.  Still  (Transac- 
tions London  Pathological  Society,  1899)  was  able  to  collect  but  twenty 
eases  from  medical  literature,  eleven  of  which  occurred  in  newly  born 
infants  or  else  gave  symptoms  during  the  first  month  of  life.  The 
prominent  symptom  was  intense  and  persistent  jaundice.  Kearly  all 
■died  within  the  first  month,  the  autopsy  usually  showing  multiple  calculi 
in  the  common  duct. 

The  cases  in  older  children  do  not  differ  from  those  in  adults. 


ACUTE   PERITONITIS. 


461 


CHAPTER    XIII. 
DISEASES  OF  THE  PERITOXuSUM. 

Ixflam:matiox  of  the  peritoneum  is  not  very  frequent  in  childhood, 
because  at  this  time  most  of  the  causes  which  are  operative  in  later  life 
either  do  not  exist  at  all  or  are  infrequent.  An  analj-sis  of  187  collected 
eases  of  peritonitis — not  including -those  associated  with  appendicitis — 
gave  the  following  results,  which  are  of  some  interest  as  showing  the 
relative  frequency  of  the  different  forms  in  early  life : 


Acute. 

Chronic. 

Total. 

Fibrinous 

22 

22 
46 

18 

10 
15 
16 

38 

32 

Serous 

37 

Purulent 

Tuberculous 

62 
56 

Total 

108 

79 

187 

We  shall  consider  separately  acute,  chronic,  and  tuberculous  perito- 


nitis. 


ACUTE  PERITONITIS. 


Acute  peritonitis  may  occur  at  any  period  of  infancy  or  childhood. 
It  may  even  exist  in  intra-uterine  life.  In  the  newly  born,  peritonitis  is 
quite  frequent.  After  this  time  it  is  exceedingly  rare  during  infancy, 
only  four  cases,  including  all  varieties,  being  met  with  in  726  consecutive 
autopsies  in  the  Xew  York  Infant  Asylum.  After  the  fifth  year  the  dis- 
ease is  relatively  much  more  common.  Of  the  187  cases  above  referred 
to,  25  per  cent  occurred  in  the  newly  born,  21  per  cent  between  one  and 
five  years,  and  54  per  cent  between  the  fifth  and  the  sixteenth  years. 

Etiology. — In  the  newly  born,  peritonitis  is  seen  as  one  of  the  most 
frequent  lesions  of  acute  pyogenic  infection  (page  81).  It  is  usually  due 
to  direct  infection  through  the  umbilical  vessels.  In  infancy  and  child- 
hood, peritonitis  occurs  both  as  a  primary  and  secondary  inflanmiation. 
The  primary  form  is  rare.  It  may  be  due  to  traumatism,  such  as  falls  or 
blows,  or  to  surgical  operations  upon  the  abdomen ;  it  has  occurred  after 
an  injection  for  the  cure  of  a  congenital  hydrocele.  In  a  very  small 
number  of  cases  the  inflammation  seems  to  have  been  excited  by  cold 
or  exposure,  and  it  may  follow  severe  burns. 

The  secondary  form  is  more  common.  The  most  frequent  of  all 
causes  is  appendicitis,  which  should  always  be  suspected  in  acute  perito- 
nitis occurring  without  definite  cause.  Extension  of  inflammation  from 
the  viscera  to  the  peritonaeum  is  very  much  less  frequent  in  children  than 
in  adults.  I  have  seen  it  but  once  in  autopsies  in  acute  intestinal  dis- 
eases. It  is  also  rare  in  typhoid  fever,  being  noted  but  twice  among  my 
31 


462  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

collected  cases.  It  is  occasionally  due  to  abscess  of  the  liver,  ulcer  of 
the  stomach,  acute  intestinal  obstruction  from  internal  strangulation,, 
intussusception,  volvulus,  or  congenital  atresia.  It  may  extend  from  in- 
flammation of  the  pleura.  This  may  be  in  the  form  of  empyema  which 
burrows  through  the  diaphragm,  or,  without  burrowing,  the  infection 
may  take  place  through  the  lymph  channels.  It  is  not  very  infre- 
quently due  to  infection  through  the  female  genital  tract,  especially  in 
gonorrhceal  vulvo-vaginitis  in  young-  girls.  Extension  of  inflammation 
from  the  male  genital  organs  is  not  common.  In  one  case  at  the  New 
York  Infant  Asylum,  fatal  peritonitis  in  an  infant  started  from  a  sup- 
purative inflammation  of  the  tunica  vaginalis  of  unknown  origin,,  the 
infection  extending  into  the  peritonaeum  through  the  inguinal  canal. 
Any  abscess  in  the  neighborhood  may  rupture  into  the  peritonaeum  and 
excite  peritonitis.  The  most  frequent  in  children  are  those  connected 
with  Pott's  disease,  perinephritis,  and  cellulitis  of  the  abdominal  wall. 

Of  the  acute  infectious  diseases,  peritonitis  is  most  frequently  seen 
with  pneumonia  and  scarlet  fever,  occasionally  with  influenza.  In  iowr 
cases  occurring  in  the  New  York  Infant  Asylum,  the  disease  was  twice 
secondary  to  pneumonia,  in  both  complicated  by  extensive  pleurisy.  It 
may  be  accompanied  by  pericarditis,  and  even  by  m-eningitis. 

The  bacteria  most  frequently  associated  with  acute  peritonitis  in  chil- 
dren are :  the  streptococcus,  especially  in  the  newly  born ;  the  micrococcus 
lanceolatus  (pneumococcus),  in  cases  complicating  pneumonia  or  empy- 
ema ;  and  the  bacterium  coli  commune  in  those  following  intestinal  per- 
foration. Those  mentioned  may  be  associated  with  other  pyogenic  bac- 
teria, or  less  frequently  the  laltter  may  occur  alone. 

Lesions. — In  the  fibrinous  form  we  have  changes  similar  to  those  oc- 
curring in  inflammation  of  the  pleura  and  the  other  serous  membranes. 
The  peritoneum  is  injected  and  lymph  is  thrown  out  in  considerable 
quantity,  usually  accompanied  by  a  small  amount  of  serum.  The  process 
may  be-  localized  or  general.  It  is  more  frequently  general  in  the  child 
than  in  the  adult.  The  peritonaeum  lining  the  abdominal  wall,  as  well  as 
that  covering  the  coils  of  intestine  and  the  solid  viscera,  is  covered  by 
patches  of  yellowish-gray  lymph,  causing  adhesions  between  the  various 
viscera  and  often  matting  the  intestines  together.  In  recent  cases  these 
adhesions  are  soft,  and  easily  broken  down;  in  old  cases  they  are  quite 
firm,  and  they  may  result  in  the  formation  of  connective-tissue  bands 
which  are  the  source  of  subsequent  trouble. 

In  the  serous  form  there  is  a  moderate  amount  of  lymph,  generally 
less  than  in  the  plastic  variety,  and,  in  addition,  an  outpouring  of  serum 
in  considerable  quantity.  This  is  usually  clear,  but  may  be  turbid  from 
flakes  of  lymph,  or  it  may  even  be  bloody.  In  most  cases  the  amount  is 
not  very  large,  usually  varying  from  half  a  pint  to  two  pints.  In  cases 
going  on  to  recovery  the  serum  is  absorbed,  but  there  may  result  adhe- 
sions as  in  the  preceding  variety. 


ACUTE   PERITONITIS.  403 

In  the  purulent  form  the  products  are  serum,  lymph,  and  pus.  When 
peritonitis  results  from  perforation  it  is,  as  a  rule,  purulent  from  the  out- 
set, and  the  pus  is  foul  and  stinking.  The  amount  of  pus  is  generally- 
larger  than  in  adult  cases.  When  the  disease  proves  fatal  in  a  few  days 
there  is  found  an  extensive  exudation  of  plastic  lymph,  with  the  forma- 
tion of  small  pockets  containing  pus,  among  the  coils  of  intestine.  Occa- 
sionally there  may  be  larger  collections  of  pus  in  the  peritoneal  cavity. 
In  eases  which  have  lasted  a  longer  time — generally  those  of  localized 
inflammation — the  process  results  in  the  formation  of  a  peritoneal  ab- 
scess. This  consists  in  a  collection  of  pus  in  some  part  of  the  peritoneal 
cavity,  the  situation  depending  upon  the  cause,  but  it  is  usually  in  one 
iliac  fossa  or  in  the  pelvis.  The  abscess  is  shut  off  from  the  rest  of  the 
peritoneal  cavity  by  a  thick  wall  of  fibrin.  If  left  alone,  such  abscesses 
may  open  into  the  rectum,  vagina,  bladder,  pelvis  of  the  kidney,  or  exter- 
nally, usually  at  the  umbilicus.  After  the  discharge  of  pus  the  cavity 
may  contract  and  fill  up  by  granulations,  and  the  patient  recover. 

Inflammations  of  the  other  serous  membranes,  especially  the  pleura, 
are  often  associated  with  peritonitis. 

Symptoms. — The  symptoms  of  acute  peritonitis  in  older  children,  as 
in  adults,  are  usually  well  marked  and  sufficiently  characteristic  to  enable 
one  to  recognise  the  disease  easily ;  but  not  so  in  the  case  of  infants.  In 
them  the  symptoms  are  often  obscure,  and  the  disease  may  be  found  at 
autopsy  when  not  suspected  during  life.  The  onset  is  nearly  always 
abrupt,  with  fever  and  vomiting.  As  a  rule,  the  temperature  is  high — 
from  103°  to  105°  F.  Vomiting  may  be  only  at  the  onset,  but  it  often 
continues;  vomited  matters  are  usually  green.  Older  children  complain 
of  pain,  which  may  be  localized  or  general ;  and  in  younger  ones  this  is 
indicated  by  crying  and  fretfulness.  The  abdomen  very  soon  becomes 
swollen  and  tympanitic,  this  being  one  of  the  most  constant  features 
of  the  disease.  The  distention  is  generally  uniform,  but  it  may  be  irreg-' 
ular.  It  is  very  rare  in  acute  cases  that  there  is  a  sufficient  amount  of 
fluid  present  to  give  the  sensation  of  fluctuation.  There  is  tenderness 
on  pressure,  and  usually  marked  rigidity  of  the  abdominal  walls.  The 
position  assumed  by  the  patient  is'  generally  dorsal,  with  the  thighs 
flexed.  The  bowels  are  in  most  cases  constipated,  but  diarrhoea  is  by  no 
means  rare.  The  abdominal  distention  causes  dyspnoea  and  thoracic 
breathing.    There  may  be  retention  of  urine  or  frequent  micturition. 

The  general  symptoms,  almost  from  the  beginning,  are  those  of  a  seri- 
ous disease.  The  pulse  is  small,  rapid,  and  compressible.  The  prostra- 
tion is  great,  from  the  very  outset.  The  face  is  pinched,  the  mouth  is 
drawn,  and  the  features  indicate  pain.  In  severe  cases  there  may  be  hic- 
cough, cold  extremities,  clammy  perspiration,  and  collapse.  The  mind  is 
usually  clear.     In  infants  there  may  be  convulsions. 

In  the  most  severe  forms  of  general  peritonitis  the  course  is  short  and 


464:  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

intense,  and  the  disease  goes  on  rapidly  from  bad  to  worse  until  death 
occurs.  In  infants  this  is  often  on  the  third  or  fourth  day.  The  most 
severe  forms  of  general  peritonitis  in  older  children  run  the  same  rapid 
course.  In  other  cases  the  course  is  slower,  lasting  a  week  or  ten  days. 
If  the  patient  lives  longer  than  this  the  case  is  more  hopeful,  because  the 
process  is  more  apt  to  be  localized.  The  development  of  peritoneal  ab- 
scess is  indicated  by  the  continuance  of  the  temperature,  which  may 
assume  a  hectic  type,  and  be  accompanied  by  chills  and  sweating.  There 
are  the  local  signs  of  an  abdominal  tumour. 

Prognosis. — Acute  general  peritonitis,  whatever  its  cause,  is  a  very 
serious  disease  in  childhood.  Of  eighty  cases  of  all  varieties  under  six- 
teen years  of  age,  sixty-nine  per  cent  died.  In  the  newly  born  and  in 
infancy  the  disease  is  almost  invariably  fatal.  In  older  children  the  out- 
look is  not  quite  so  hopeless,  and  depends  upon  the  exciting  cause.  It  is 
better  in  localized  than  in  general  inflammation;  also  in  the  fibrinous 
than  in  the  purulent  form ;  but  the  most  favourable  cases  are  those  with 
a  sero-fibrinous  exudation. 

Treatment. — The  medical  treatment  of  acute  general  peritonitis  in 
children  is  extremely  unsatisfactor}^,  as  the  disease  is  usually  fatal  unless 
it  can  be  relieved  surgically.  Opium  is  indicated  only  for  the  relief  of 
the  single  symptom,  pain ;  according  to  its  severity,  the  size  of  the  dose 
and  the  frequency  of  its  repetition  should  be  determined.  On  account 
of  vomiting  it  is  well  to  administer  it  hypodermieally.  The  only  other 
medical  measures  deserving  much  consideration  are  catharsis  by  salines, 
and  saline  injections.  Used  early,  and  in  sufficient  amount,  free  purga- 
tion by  salines  seems  to  produce  a  derivative  effect  upon  the  peritoneal 
inflammation,  which  is  sometimes  very  marked.  Either  the  sulphate 
or  the  citrate  of  magnesia  may  be  used,  often  advantageously  preceded 
by  calomel.  Much  larger  doses  than  in  most  conditions  are  necessary  on 
account  of  the  constipation  which  belongs  to  the  disease,  this  being  one 
reason  why  so  little  effect  is  sometimes  seen.  High  saline  injections  are 
useful  in  aiding  the  elimination  of  poisonous  products  from  the  intes- 
tinal tract.  A  normal  salt  solution  should  be  given  at  a  little  above  the 
body  temperature,  at  least  one  quart  being  employed  for  a  single  injec- 
tion, to  be  repeated  two  or  three  times  a  day  if  the  effect  upon  the  gen- 
eral condition  is  favourable. 

As  a  local  application  cold  is  usually  to  be  preferred.  It  may  be 
applied  either  by  an  ice-bag  or  by  a  Leiter's  coil.  If  children  rebel 
against  the  use  of  cold,  heat  must  be  substituted.  Turpentine  stupes 
may  aid  in  relieving  tympanites. 

Feeding  is  always  a  difficult  matter  on  account  of  the  strong  tendency 
to  vomiting ;  this  is  due  to  the  regurgitation  from  the  intestine  into  the 
stomach,  which  in  some  cases  is  almost  continuous.  In  such  conditions 
I  have  found  great  benefit  from  washing  the  stomach  shortly  before 


CHRONIC  PERITONITIS.  465 

feeding,  repeiiting  this  several  times  each  clay.  In  this  way  vomiting 
may  often  be  controlled  and  the  stomach  made  ready  for  food.  The 
diet  should  be  peptonized  milk,  broth,  or  kumyss.  As  stimulants,  brandy 
with  ice,  or  if  this  is  vomited,  champagne  may  be  given. 

Surgical  treatment. — In  every  clear  case  of  acute  peritonitis  of  doubt- 
ful origin,  an  early  exploratory  operation  should  be  done  if  the  child's 
•general  condition  will  permit.  Appendicitis  is  often  found  to  be  the 
cause  when  least  expected;  besides,  in  most  other  conditions  this  gives 
the  only  chance  for  recovery.  Acute  perforative  peritonitis  in  a  child 
is  usually  fatal  under  any  treatment;  but  immediate  laparotomy  should 
be  tried.     Operation  is  also  indicated  in  peritoneal  abscesses. 

CHRONIC   (NON-TUBERCULOUS)   PERITONITIS. 

Peritonitis  may  occur  in  foetal  life  with  the  production  of  extensive 
adhesions,  which  may  interfere  with  the  development  of  the  intestine  and 
result  in  various  malformations.  These  cases  have  been  ascribed  by  Sil- 
bermann  *  to  syphilis. 

Chronic  peritonitis  may  follow  the  acute  form,  in  which  there  are  left 
adhesions  which  slowly  increase  owing  to  the  production  of  new  connect- 
ive tissue.    Such  cases  are  sometimes  chronic  from  the  beginning. 

The  peritoneal  abscesses  which  follow  the  suppurative  form  may  run 
a  chronic  course.  Chronic  localized  peritonitis  may  occur  in  connection 
with  disease  of  any  of  the  organs  covered  by  the  peritoneum. 

Chronic  Peritonitis  with  Ascites. — In  most  cases  this  is  chronic  from 
the  outset  and  independent  of  the  causes  above  mentioned.  By  far  the 
most  frec[uent  form  of  inflammation  is  that  due  to  tuberculosis,  and  by 
some  writers  the  opinion  is  still  held  that  this  form  is  always  tuberculous. 
After  the  observations  reported  by  Henoch,  Yierordt,  Fiedler,  and  others, 
.there  seems  to  be  no  longer  any  room  for  doubt  regarding  the  existence 
of  a  chronic  non-tuberculous  form  of  peritonitis  with  ascites,  although 
it  must  be  considered  a  rare  disease.  In  its  pathological  and  clinical 
aspects  it  is  to  be  compared  to  subacute  or  chronic  pleurisy  with  effusion. 

Etiology. — Xearly  all  the  cases  thus  far  reported  have  occurred  in 
children  over  six  years  old.  The  causes  are  for  the  most  part  obscure. 
The  disease  has  been  attributed  to  exposure,  rheumatism,  and  injury. 
In  a  few  instances  it  has  followed  measles.  It  may  be  associated  with 
disease  of  the  intestines  or  the  solid  viscera  of  the  abdomen,  especially 
with  new  growths  of  the  kidney,  liver,  etc. 

Lesions. — The  post-mortem  observations  thus  far  have  been  few.  In 
the  rei)orted  cases  there  has  been  found  a  large  anu^unt  of  greenish 
serum  in  the  general  peritoneal  cavity,  with  a  very  moderate  amount  of 
fibrin  and  adhesions,  which  are  sometimes  few  and  sometimes  very 
numerous.     Clironic  pleurisy  may  be  associated. 

*  Jahrbuch  fiir  Kindcrh..  Bel.  xviii.  420. 


4:QQ  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Symjjtoms. — The  early  symptoms  are  of  a  very  indefinite  character, 
such  as  a  decline  in  the  general  health,  or  dyspeptic  symptoms ;  but  often 
nothing  whatever  is  noticed  until  the  swelling  of  the  abdomen  begins. 
The  enlargement  comes  on  rather  gradually  in  the  course  of  a  few  weeks. 
Pain  is  slight,  or  wanting  altogether.  There  may  be  some  abdominal  ten- 
derness, but  this  is  rarely  marked.  The  bowels  are  irregular ;  sometimes 
there  is  diarrhoea  and  sometimes  constipation.  The  abdomen  is  usually 
distended  with  fluid,  the  umbilicus  protruding,  and  the  superficial  veins 
prominent.  The  enlargement  is  generally  regular  and  symmetrical,  and 
the  wave  of  fluctuation  is  readily  obtained.  The  general  symptoms  are 
very  few.  In  some  cases  there  is  a  slight  evening  rise  of  temperature  of 
one  or  two  degrees.  There  may  be  general  weakness,  loss  of  appetite, 
and  moderate  anaemia. 

The  usual  course  of  the  disease  is  for  the  fluid  to  remain  for  a  time 
and  then  undergo  slow  absorption,  the  case  going  on  to  complete  recov- 
ery. Occasionally  relapses  are  seen.  The  results  are  not  always  so  favour- 
able, for  in  some  instances  there  is  no  tendency  to  absorption  of  the  fluid, 
the  general  health  is  gradually  undermined,  and  the  patients  die  from 
exhaustion  or  from  some  intercurrent  disease.  The  diagnosis  rests  upon 
the  presence  of  ascites,  develojaing  gradually  without  any  signs  or  symj)- 
toms  of  disease  in  the  heart,  liver,  or  other  organs.  The  points  which 
distinguish  it  from  tuberculous  peritonitis  are  considered  under  that  dis- 
ease. In  the  cases  which  recover,  the  fact  that  no  other  signs  of  tubercu- 
losis subsequently  develop  is  an  important  point  in  diagnosis.  The  prog- 
nosis is  in  most  cases  favourable,  but  must  be  guarded  on  account  of  the 
difficulty  in  making  a  positive  diagnosis  from  the  tuberculous  form.  Ee- 
covery  is  usually  complete  and  permanent. 

Treatment. — It  is  important  that  the  patient  should  be  kept  at  rest, 
preferably  confined  to  bed.  The  best  results  are  usually  obtained  by  the 
adoption  of  a  general  tonic  plan  of  treatment.  If  absorption  of  the 
fluid  does  not  begin  with  such  means,  saline  diuretics  should  be  given  and 
the  amount  of  fluid  allowed  the  patient  limited.  When  there  is  no  tend- 
ency to  absorption  after  a  thorough  trial  of  the  above  measures,  and 
especially  when  the  patient's  general  health  begins  to  suffer,  the  fluid 
should  be  removed  by  aspiration.  If  it  continues  to  accumulate  after 
repeated  aspirations,  laparotomy  may  be  performed,  for  in  some  cases 
this  has  the  same  beneficial  effect  as  in  tuberculous  peritonitis. 

TUBERCULOUS  PERITONITIS. 

The  peritonaeum  is  quite  frequently  the  seat  of  tuberculous  inflamma- 
tion in  early  life ;  but  not  so  often  in  infants  as  in  older  children.  Of 
56  collected  cases,  7  were  under  three  years  of  age,  36  from  three  to  eight 
years,  and  23  from  eight  to  sixteen  years.  In  119  autopsies  upon  tubercu- 
lous patients,  most  of  them  under  three  years  old,  of  which  I  have  records, 


TUBERCULOUS  PERITONITIS.  407 

the  peritonaeum  was  involved  in  8  -5  per  cent.  In  105  autopsies,  for  the 
most  part  upon  older  tuberculous  children,  Ashby  found  the  peritonaeum 
involved  in  36  per  cent.  In  883  collected  autopsies  upon  tuberculous  chil- 
dren of  all  ages,  Biedert  *  found  the  peritonaeum  involved  in  18  -3  per 
cent.  These  figures  do  not  represent  the  number  of  cases  of  tuberculous 
peritonitis,  as  in  manj^  of  them  only  a  few  miliary  tubercles  were  present. 

It  is  no  doubt  possible  for  peritonitis  to  occur  as  the  primary  lesion 
■of  tuberculosis,  but  in  the  great  majority  of  cases  it  is  secondary.  It 
may,  however,  appear  as  the  most  important  tuberculous  lesion  in  the 
body.  The  peritonaeum  may  be  infected  directly  from  the  intestine,  the 
mesenteric  glands,  or  the  pleura,  or  from  more  distant  parts,  such  as  the 
lungs,  the  bronchial  glands,  the  cervical,  or  other  external  glands.  In  a 
small  number  of  eases  there  is  a  history  of  some  local  exciting  cause, 
such  as  a  fall  or  blow  upon  the  abdomen.  Tha  disease  may  follow  expo- 
sure, or  occur  as  a  sequel  to  one  of  the  exanthemata. 

Tuberculous  peritonitis  may  be  acute  or  chronic.  It  presents  several 
varieties,  c^uite  distinct  from  one  another,  both  in  their  pathological  and 
clinical  features. 

1.  Miliary  Tuberculosis  of  the  Peritonaeum  accompanying  General 
Tuberculosis.- — The  peritonseum  may  be  involved  as  one  of  the  lesions  in 
acute  or  subacute  general  miliary  tuberculosis.  This  is  the  most  common 
form  seen  in  infants.  The  lesions  consist  in  a  deposit  of  miliary  tuber- 
cles, which  are  generally  rather  sparsely  scattered  over  the  peritonaeum. 
•The  evidences  of  inflammation  are  very  slight,  or  they  may  be  absent 
altogether.  These  cases  do  not  come  under  observation  as  cases  of  peri- 
tonitis, as  there  are  no  abdominal  symptoms. 

2.  Miliary  Tuberculosis  of  the  Peritonaeum  with  Ascites. — Although 
not  the  most  common  variety  in  children,  these  cases  form  an  important 
group.  The  peritonseum  is  thickly  sown  with  miliary  tubercles,  both  dis- 
crete and  in  conglomerate  masses.  They  are  found  in  the  omentum  and 
the  mesentery,  upon  the  surface  of  the  intestines  and  the  solid  viscera. 
The  peritomieum  shows  in  varying  degrees  the  changes  of  acute  or  sub- 
acute inflammation.  There  is  congestion,  with  the  production  of  a  mod- 
erate amount  of  fibrin  and  a  large  amount  of  serum.  In  the  most  acute 
cases  the  fluid  is  in  the  general  peritoneal  cavity.  In  those  of  longer  du- 
ration it  may  be  sacculated.  The  fluid  is  usually  abundant.  l)nt  not  excess- 
ive. It  is  most  commonly  an  olive-coloured  serum,  l)ut  it  may  be  sero- 
purulent,  and  even  bloody.  There  are  commonly  other  lesions  of  tul)ercu- 
losis  in  the  body,  but  they  are  less  marked  than  tliose  of  the  peritonanim. 

These  ascitic  cases  generally  I'un  an  acute  or  subacute  course,  the  usual 
duration  being  from  one  to  four  months.     Clinically  they  present  the 

*  Jahrbuch  fiir  Kinderh.,  xxi,  178 ;  see  also  Osier,  Johns  Hopkins  Hospital  Reports, 
vol.  ii. 


468  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

symptoms  of  a  moderate  grade  of  peritoneal  inflammation  with  ascites. 
The  onset  is  rather  gradual,  with  indefinite  general  symptoms.  There  is 
usually  some  fever — 100°  to  101-5°  F.  There  are  general  weakness,  pros- 
tration, and  loss  of  flesh,  but  not  rapid  emaciation.  Vomiting  is  not 
prominent,  and  pain  and  tenderness  are  rarely  very  marked.  There  may 
be  nothing  distinctive  until  distention  of  the  abdomen  is  seen.  This  at 
first  is  due  to  gas,  but  later  to  fluid,  which  may  accumulate  in  sufficient 
quantity  to  fill  the  general  peritoneal  cavity.  The  bowels  are  constipated,, 
or  there  may  be  diarrhoea. 

The  usual  course,  when  untreated,  is  for  the  disease  to  go  on  to  a  fatal 
termination  from  exhaustion.  Less  frequently  the  fluid  is  absorbed,  and 
the  case  becomes  one  of  the  fibrous  type,  with  a  tendency  to  relapses  y 
rarely  it  is  followed  by  the  ulcerative  form. 

3.  The  Fibrous  Form.^This,  in  its  general  characters,  may  be  com- 
pared to  the  fibroid  form  of  pulmonary  tuberculosis.  There  is  a  tuber- 
culous inflammation,  the  products  of  which  have  undergone  transfor- 
mation into  fibrous  tissue.  This  may  in  a  certain  sense  be  regarded  as 
a  method  of  cure.  The  essential  feature  of  the  lesion  in  these  cases  is  the 
production  of  extensive  organized  adhesions  between  the  intestinal  coils^ 
and  between  the  intestines  and  the  abdominal  walls.  The  intestines  may 
be  compressed  against  the  spine  by  bands.  Ascites  may  be  present,  but  it 
is  frequently  absent  altogether.  If  there  is  fluid,  it  may  be  in  the  gen- 
eral peritoneal  cavity,  or  it  may  be  sacculated.  The  fluid  may"  consist 
either  of  serum  or  of  sero-j)us.  There  is  no  tendency  to  caseation  or 
breaking  down. 

Clinically  these  cases  are  distinguished  by  their  slow,  irregular  course. 
They  are  the  most  chronic  of  all  the  forms.  The  disease  may  be  chronic 
from  the  outset,  or  it  may  follow  the  variety  previously  mentioned.  The 
onset  is  generally  insidious;  fever  is  slight,  or  entirely  absent.  There 
is  rarely  vomiting.  The  bowels  may  be  constipated  or  loose.  For  a 
long  time  the  general  health  may  remain  good.  The  only  characteristic 
symptom  is  the  enlargement  of  the  abdomen.  In  the  early  part  of  the 
disease  this  is  chiefly  from  the  tympanites,  but  later  it  may  depend  wholly 
or  in  part  upon  an  accumulation  of  fluid.  Ascites  usually  develops  very 
slowly,  but  may  be  abundant.  The  adhesions  of  the  intestines  may  give 
rise  to  irregularities  in  the  outline  of  the  abdomen.  Ascites  may  be  pres- 
ent for  a  time  and  then  disappear  spontaneously,  and  the  general  health 
may  so  improve  that  the  patient  is  considered  quite  well.  There  may 
even  be  a  permanent  cure.  In  other  cases,  after  symptoms  hare  been 
absent  for  some  time,  relapses  occur,  and  more  fluid  is  poured  out.  In 
addition  to  these  symptoms,  others  are  present  depending  upon  the  me- 
chanical effects  of  pressure  from  the  contracting  adhesions.  There  may 
be  more  or  less  constriction  of  the  intestine,  pressure  upon  the  vena  cava, 
the  renal  or  portal  veins,  the  thoracic  duct  or  its  branches,  or  upon  the 


TUBERCULOUS  PERITONITIS.  469 

stomach.  These  may  give  rise  to  dyspeptic  symptoms,  emaciation, 
oedema  of  the  lower  extremities,  and  albuminuria. 

In  some  cases  the  disease  is  entirely  latent,  and  it  is  discovered  at 
autopsy  when  there  have  been  either  no  abdominal  symptoms  during  life, 
or  only  colicky  pains  of  an  indefinite  character.  The  course  of  this  form 
of  peritonitis  is  slow  and  irregular;  it  generally  lasts  for  from  three  to 
twelve  months,  although  with  intermissions  and  exacerbations  it  may  ex- 
tend over  several  years.  The  fatal  .result  may  be  due  to  an  acute  exacer- 
bation, to  exhaustion,  or  to  the  development  of  tuberculosis  elsewhere. 

■i.  The  Ulcerative  Form. — This  is  an  inflammation  associated  with 
large  tuberculous  deposits  which  go  on  to  caseation  and  softening.  It 
may  be  compared  to  ulcerative  phthisis.  In  point  of  chronicity  it  stands 
midway  between  the  two  preceding  varieties.  It  is  one  of  the  most  fre- 
quent forms  seen  in  children,  and,  while  it  may  be  localized,  it  is  usually 
general. 

There  is  commonly  a  very  abundant  fibrinous  exudate,  matting  the 
coils  of  intestine  together  and  causing  them  to  adhere  to  the  solid  viscera 
and  to  the  abdominal  walls.  In  this  exudate  there  are  seen  tuberculous 
deposits  consisting  of  small,  yellow  nodules  and  larger  caseous  masses, 
often  broken  down  at  the  centre.  These  caseous  deposits  are  also  found 
in  the  mesentery  and  in  the  omentum,  which  may  be  very  greatly  thick- 
ened. Pockets  are  formed  by  the  adhesions  which  sometimes  contain 
clear  serum,  but  more  frequently  pus  or  a  brownish  fluid.  The  tuber- 
culous deposits  are  found  upon  the  peritoneal  surface  of  the  intestine, 
and  infiltrate  the  intestinal  walls,  often  leading  to  perforation,  and  some- 
times to  fistulous  communications  between  adherent  intestinal  coils. 
There  ma}^  also  be  tuberculous  infiltration  of  the  abdominal  walls,  ac- 
companied by  cellulitis,  resulting  in  abscesses,  which  may  open  exter- 
nally, usually  in  the  neighbourhood  of  the  umbilicus. 

The  ulcerative  form  may  succeed  either  the  miliary  or  fibrous  form, 
or  the  inflammation  may  be  of  this  type  from  the  outset.  Tuberculous 
lesions  are  always  found  in  the  other  organs,  especially  in  the  lungs, 
where  they  are  usually  advanced. 

Clinically  the  ulcerative  cases  are  characterized  by  well-marked  con- 
stitutional symptoms,  which  are  due  partly  to  the  peritonitis  and  partly 
to  the  general  tuberculosis.  Fever  is  regularly  present,  the  temperature 
usually  ranging  from  99°  to  103°  F.  Sometimes  it  assumes  a  distinctly 
hectic  type.  There  is  progressive  emaciation,  ana?mia,  prostration,  and 
sweating.  Diarrhcea  is  frequent  and  the  intestinal  discharges  may  at 
times  be  bloody.  The  abdomen  is  large,  hut  not  so  niucli  distended  as  in 
some  of  the  other  forms;  the  superficial  veins  arc  often  prominent.  It 
is  rare  that  ascites  can  be  made  out  by  percussion,  although  fluid  can 
often  be  found  by  puncture.  Areas  of  dulness  and  tympanitic  resonance 
are  irregularly  distributed.    Xodular  masses  from  one  to  two  inches  in 


4Y0  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

diameter  may  be  felt  anywhere  in  the  abdomen.  The  epigastric  and  um- 
bilical regionsma}'  be  occupied  by  a  smooth,  hard  tumour — the  thickened 
omentum — ^ndiich  may  resemble  the  liver.  There  may  be  the  signs  of 
i^hlegmonous  inflammation  of  the  abdominal  wall  in  the  neighbourhood 
cf  the  umbilicus,  and  even  an  abscess,  which,  after  opening,  may  leave  a 
fistulous  communication  with  the  peritonaeum.  There  are  usuallj'  some 
signs  of  disease  in  the  lungs,  and  the  pulmonary  symptoms  may  mask 
those  of  the  abdomen.  The  course  of  the  disease  is  steadily  progressive, 
the  usual  duration  being  two  to  six  months.  Death  results  from  the 
pulmonary  disease,  from  tuberculous  meningitis,  from  exhaustion,  and 
occasionally  it  is  due  to  accidents  associated  with  perforation. 

5.  Peritonitis  associated  with  Tuberculosis  of  the  Mesenteric  Lymph 
Nodes. — These  nodes  may  be  tuberculous  in  any  of  the  preceding  varie- 
ties. In  certain  cases  this  is  the  principal  lesion,  and  it  is  accompanied 
by  localized  peritonitis,  which  results  in  the  formation  of  a  large,  irregu- 
lar, nodular  mass  tying  close  against  the  spine.  It  is  usually  associated 
with  tuberculous  ulcers  of  the  intestine.  There  may  be  no  symptoms 
except  those  depending  upon  the  pressure  of  the  glandular  masses  upon 
the  great  vessels.  This  may  lead  to  oedema  of  the  lower  extremities  or  to 
thrombosis  of  the  vena  cava,  and  may  give  rise  to  an  abdominal  tumour. 
There  may  be  diarrhoea  due  to  the  intestinal  lesions. 

Diagnosis  of  Tuberculous  Peritonitis. — In  children,  chronic  ascites 
with  fever  usually  means  tuberculous  peritonitis.  If  the  abdominal  effu- 
sion is  sacculated  instead  of  diffuse,  the  probabilities  of  peritonitis  are 
much  increased.  If  there  are  added  the  physical  signs  and  symptoms  of 
disease  of  the  lungs,  the  diagnosis  is  almost  certain.  Cirrhosis  of  the 
liver  is  much  more  chronic  in  its  course,  and  is-  very  rare  previous  to  the 
ninth  year,  being  almost  unknown  in  inf  anc}^  and  early  childhood.  In  it 
there  is  often  a  history  of  syphilis,  and  jaundice  may  be  present.  If 
ascites  is  absent,  tuberculosis  of  the  peritonaeum  may  be  suspected  if 
there  are  irregular  nodules  or  tumours  in  various  parts  of  the  abdo- 
men, with  tenderness,  emaciation,  moderate  pain,  and  persistent  fever. 
Chronic  abscess  in  the  neighbourhood  of  the  umbilicus  is  always  suspi- 
cious. The  idcerative  form  is  generally  accompanied  by  evidences  of  tu- 
berculous disease  in  the  lungs  and  other  organs,  and  is  easily  recognised. 
The  fibroid  form  may  be  suspected  if,  with  tuberculosis  of  other  organs, 
there  are  irregular  colicky  pains  and  abdominal  tenderness.  From  the 
-abdominal  symptoms  alone  it  can  not  he  recognised  unless  there  is  as- 
cites.   In  all  doubtful  cases  an  exploratory  incision  should  be  made. 

Between  tuberculous  and  non-tuberculous  chronic  peritonitis  a  diag- 
nosis is  at  times  impossible.  If  there  is  a  good  family  history ;  if  there 
are  no  signs  of  tuberculosis  in  the  lungs  or  elsewhere  :  if  abdominal  ten- 
derness is  slight  or  absent ;  if  there  are  no  nodular  tumours  :  if  fever  and 
marked  emaciation  are  wantins:;  and  if  the  amount  of  fluid  is  excessive, 


TUBERCULOUS  PERITONITIS.  471 

"the  probabilities  are  in  favour  of  a  simple  iufiamnaation.  There  are,  how- 
ever, some  cases  in  which  the  diagnosis  can-  be  made  only  by  an  explora- 
tory incision,  and  sometimes  not  even  then  without  an  examination  of 
the  fibrous  nodules  by  the  microscope  or  by  inoculation  experiments.  In 
doubtful  cases  the  chances  are  alwa3's  in  favour  of  tuberculous  inflam- 
mation on  account  of  its  greater  frequency. 

Prognosis. — This  depends  most  of  all  upon  the  form  of  the  disease. 
Cases  of  the  ulcerative  type  are  absolutely  hopeless.  In  the  ascitic  and 
fibrous  forms  the  prognosis  is  better,  especially  since  the  general  adop- 
tion of  laparotomy  as  a  means  of  treatment.  Life  is  prolonged  in  nearly 
all  cases  by  the  operation,  and  a  considerable  number  are  permanently 
cured.  Exactly  in  what  proportion  a  permanent  cure  results,  it  is  at 
present  impossible  to  say,  for  most  of  the  reported  cases  were  not  under 
■observation  long  enough  to  make  it  certain  that  relapses  did  not  occur. 

Treatment. — The  general  treatment  of  tuberculous  peritonitis  is  the 
same  as  that  of  tuberculosis  in  other  parts  of  the  body.  In  the  acute 
cases  the  local  symptoms  are  to  be  relieved  by  the  same  means  as  in  other 
forms  of  acute  peritonitis.  The  only  local  treatment  which  can  be.  con- 
sidered in  any  way  curative  is  surgical.  Nothing  can  be  said  in  favour  of 
aspiration  except  for  purposes  of  diagnosis.  The  results  of  laparotomy 
-are  so  satisfactory  that  the  question  of  operation  should  be  considered  in 
every  case.  The  most  favourable  cases  for  operation  are  those  of  the 
ascitic  variety.  Aldibert,*  in  his  monograph,  gives  the  indications  and 
contra-indications  for  operation  as  follows :  Laparotomy  is  indicated  in 
all  forms  accompanied  b}^  ascites,  although  in  acute  cases  it  may  be  only 
palliative;  in  suppurative  forms  which  are  difEuse,  or  with  a  unilocular 
cyst;  in  all  cases  of  intestinal  obstruction  in  the  course  of  tuberculous 
peritonitis;  and  in  all  cases  of  doubtful  diagnosis.  Operation  is  contra- 
indicated  in  the  fibrous  form  not  attended  by  pain,  this  usually  tending 
to  spontaneous  recovery;  in  the  dry  ulcerative  form,  except  at  the  out- 
set ;  in  the  suppurative  form  with  multilocular  cysts.  The  existence  of 
other  foci  of  tuberculosis  does  not  contra-indicate  operation  except  when 
these  are  chiefly  intestinal,  or  when  there  is  general  tuberculosis  with 
extensive  and  rapidly  progressing  lesions. 

Aldibert  has  collected  statistics  of  fifty-two  o])erations  for  tuber- 
culous peritonitis  in  children,  with  seven  deaths  and  forty-five  recoveries. 
Nine  patients  were  reported  well  one  year  after  o]ieration.  It  is  possible 
that  among  these  cases  some  of  simple  inflammation  were  included; 
of  eighteen  cases,  however,  in  which  the  diagnosis  of  tuberculosis  was 
established  by  the  microscope  or  inoculation  experiments,  all  recovered, 
and  six  were  well  one  year  after  operation.  Why  it  is  that  the  operation 
of  opening  the  abdomen  and  draining  or  washing  out  the  peritoneal  cav- 

*  De  la  Laparotoinie  dans  la  Poritonite  Tuberculeuse  chez  rEnfant.  Paris,  1892. 


4Y2  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

ity  should  have  such  an  influence  in  arresting  the  disease,  has  not  yet 
been  satisfactorily  explained.  For  the  surgical  aspect  of  the  treatment 
the  reader  should  consult  works  upon  surgery. 

ASCITES. 

Ascites  consists  in  an  accumulation  of  fluid,  usually  clear  serum,  in 
the  general  peritoneal  cavity.  It  is  a  symptom  of  the  various  forms  of 
peritonitis,  especially  the  chronic  varieties  described  in  the  preceding 
pages.  It  may  be  due  also  to  portal  obstruction  from  cirrhosis  of  the 
liver,  or  pressure  upon  the  portal  vein  by  peritoneal  adhesions  or  large 
lymphatic  glands.  It  is  occasionally  seen  in  all  forms  of  abdominal 
tumours.  Ascites  may  occur  in  general  dropsy  from  cardiac  disease, 
chronic  pleurisy,  or  interstitial  pneumonia,  or  from  any  condition  caus- 
ing pressure  lipon  the  vena  cava.  It  is  also  seen  in  the  general  dropsy  of 
renal  disease.  A  moderate  amount  of  ascites  is  often  met  with  in  es- 
treme  angemia  or  leukaemia. 

Small  accumulations  of  fluid  in  the  peritoneal  cavity  are  difficult  of 
detection.  Large  amounts  are  generally  easily  made  out.  There  is  a  uni- 
form smooth  distention  of  the  abdomen  and  dilatation  of  the  superficial 
veins,  especially  •  about  the  umbilicus.  On  palpation,  the  wave  of  fluctu- 
ation can  be  obtained  by  placing  one  hand  against  the  abdomen  upon  one 
side  and  giving  the  opposite  side  a  sharp  tap.  A  similar  wave  may  be  felt 
when  there  is  tympanitic  distention.  The  two  are,  however,  readily  dis- 
tinguished by  having  an  assistant  make  pressure  with  the  edge  of  the  hand 
along  the  linea  alba  while  the  test  is  being  made  ;  this  obstructs  the  wave 
transmitted  through  the  abdominal  wall,  but  does  not  affect  that  through 
the  fluid.  On  percussion  in  the  sitting  posture,  there  are  dulness  below 
and  resonance  above.  When  the  patient  is  recumbent,  there  are  resonance 
in  the  median  line  and  dulness  or  flatness  in  the  lateral  portion  of  the 
abdomen. 

The  prognosis  and  treatment  of  ascites  will  depend  upon  its  cause. 
Chylous  Ascites. — This  term  is  applied  to  certain  cases  in  which  the 
abdominal  fluid  contains  fat.  The  colour  may  be  milky-wbite  or  light 
brown,  and  the  fluid,  after  standing,  may  have  at  its  surface  a  thick,, 
creamy  layer.  The  amount  of  fat  present  has  been  as  high  as  five  per  cent. 
This  condition  is  rare  in  childhood.  In  1884,  Letulle  *  could  find  but 
seven  cases  on  record.  The  exact  pathology  is  as  yet  not  well  understood. 
In  the  cases  which  have  thus  far  come  to  autopsy  there  has  usually 
been  found  chronic  peritonitis,  sometimes  simple,  sometimes  tuberculous. 
The  lymph  vessels  in  some  of  the  cases  have  been  empty,  and  often  no 
obstruction  of  the  lymph  circulation  could  be  discovered.  The  fat  is 
believed  by  some  to  be  derived  from  fatty  degeneration  of  the  prod-ucts  of 
chronic  inflammation,  but  this  seems  hardly  sufficient  to  explain  the  large 


Revue  de  Medecine,  1884,  No.  9. 


SUBPHRENIC   ABSCESS. 


473 


amount  of  fat  sometimes  found.  In  some  of  the  cases  it  has  been  due 
to  a  wound  of  the  thoracic  duct.  The  amount  of  fluid  is  frequently  very- 
large.  The  prognosis  is  usually  bad,  although  Pounds  has  reported  (Brit- 
ish Medical  Journal,  1893)  a  case  in  a  girl  of  ten  years,  where  recovery 
followed  laparotomy.     Tuberculous  peritonitis  was  present. 

SUBPHRENIC  ABSCESS. 

In  the  group  of  cases  of  localized  peritonitis  or  peritoneal  abscess  must 
be  included  subphrenic  abscess.  This  is  a  rare  condition  in  childhood, 
and  consists  in  an  accumulation  of  pus  just  beneath  the  diaphragm  and 
above  the  liver.  Its  cause  may  be  either  in  the  thorax  or  in  the  abdomen. 
It  may  complicate  acute  pneumonia,  usually  of  the  right  lower  lobe,  by  a 
direct  extension  of  infection  through  the  lymph  channels.  Sometimes 
it  has  been  associated  with  phthisical  cavities.  In  the  abdomen  it  may  be 
associated  with  disease  of  the  liver.  The  accumulation  of  pus  is  some- 
times very  great,  so  that  the  diaphragm  is  crowded  high  into  the  thorax. 

The  symptoms  and  physical  signs  closely  resemble  those  of  empyema, 
and  most  of  the  cases  have  been  operated  upon  with  the  belief  that  the 
surgeon  was  dealing  with  empyema.  Meltzer*  has  reported  a  case  in  a 
child  of  two  years  which  followed  pneumonia  of  the  right  base.  At  the 
operation  only  a  few  drops  of  pus  were  found  in  the  pleural  cavity  ;  but 
there  was  discovered  a  pinhole  opening  in  the  diaphragm,  from  which  the 
pus  had  escaped  from  a  large  subphrenic  abscess.  This  was  evacuated, 
and  the  patient  recovered  perfectly.  Subphrenic  abscesses  may  contain 
air ;  they  are  then  likely  to  be  mistaken  for  pneumothorax.  These  ab- 
scesses require  incision  and  drainage  like  other  forms  of  peritoneal  abscess. 

*  New  York  Medical  Journal,  June  24,  1893.  In  this  article  will  be  found  refer- 
ences to  the  recent  literature. 


SECTIOI^  lY. 

DISEASES    OF    THE    RESPIRATOEY    SYSTEM. 

CHAPTER    I. 

NASAL  CAVITIES. 

ACUTE  NASAL  CATARRH— CORYZA. 

Although  the  symptoms  of  acute  nasal  catarrh  are  chiefly  nasal,  the 
principal  seat  of  the  pathological  process  is  the  rhino-pharynx. 

Etiology. — Certain  children  are  predisposed  to  attacks  of  acute  nasal 
catarrh.  This  predisposition,  as  it  sometimes  extends  to  entire  families,, 
may  be  inherited ;  but  more  frequently  it  is  acquired,  and  usually  by  the 
following  mode  of  life  :  It  is  seen  in  children  who  get  very  little  fresh  air, 
because  they  are  kept  indoors  unless  the  weather  is  perfect;  who  live  in 
houses  always  overheated ;  whose  sleeping  rooms  are  kept  carefully  closed 
at  night  for  fear  they  may  take  cold;  who  are  for  the  same  reason  so 
overloaded  with  clothing  that  they  can  not  engage  in. any  active  play 
without  being  thrown  into  a  profuse  perspiration.  These  conditions 
after  a  time  result  in  a  great  sensitiveness  of  all  the  mucous  membranes, 
but  especially  those  of  the  nose  and  pharynx,  which  is  much  increased 
by  residence  in  a  damp,  changeable  climate.  A  small  adenoid  growth  is 
very  often  present.  Young  infants  and  those  who  are  rachitic,  are 
frequent  sufferers  from  acute  nasal  catarrh.  Attacks  are  often  brought 
on  by  insufficient  covering  for  the  head,  by  wetting  the  feet,  by  cold  and 
exposure,  especially  to  the  raw  winds  of  spring,  accompanied  by  the 
dampness  which  occurs  with  melting  snow.  In  susceptible  children  the 
exciting  cause  is  often  a  very  trivial  one.  A  draught  of  cold  air  for  a 
few  minutes  may  be  sufficient  to  excite  sneezing  and  a  nasal  discharge. 
Atmospheric  conditions  are  probably  not  the  only  cause  of  acute  nasal 
catarrh.  Micro-organisms  certainly  play  an  important  part,  particularly 
in  the  purulent  variety.  Although  pyrogenic  germs  are  always  present 
in  the  nose,  they  do  not  excite  an  attack  of  acute  catarrh  without  the 
vascular  changes  which  are  produced  by  other  causes.  Acute  catarrh  may 
be  sporadic  or  epidemic;  it  is  probably  contagious,  being  communicated 
by  children  using  the  same  handkerchief  or  occupying  the  same  bed. 

Acute  nasal  catarrh  may  be  a  symptom  of  measles,  nasal  diphtheria, 
or  influenza,  and  it  may  accompany  erysipelas  of  the  face. 

474 


ACUTE  NASAL  CATARRH.   -  475 

Symptoms. — The  changes  in  the  mucous  membrane  of  the  nose  are  not 
great,  and  are  usually  secondary  to  those  of  the  rhino-pharynx,  being  in  a 
large  measure  due  to  the  discharge.  There  are  redness  and  slight  swell- 
ing. The  nasal  passages  may  be  for  the  time  quite  occluded  by  the  dis- 
charge, which  is  usually  profuse,  at  first  sero-mucous,  and  finally,  if  the 
attack  is  severe,  muco-purulent.  The  symptoms  may  be  very  transient, 
sometimes  passing  away  in  a  few  hours,  in  which  cases  there  is  only  a  vaso- 
motor disturbance ;  or  they  may  continue  and  develop  into  a  true  inflam- 
mation. The  discharge  excoriates  the  nostrils  and  the  upper  lip.  At  the 
onset  there  is  usually  sneezing,  and  in  infants  often  a  slight  fever.  In 
older  children  there  is  no  rise  of  temperature  except  in  the  most  severe 
cases.  The  obstruction  to  nasal  respiration  causes  mouth-breathing,  and  the 
dryness  and  discomfort  which  result  from  it  produce  disturbed  sleep,  snuf- 
fling and  diflBculty  in  nursing,  this  being  in  severe  cases  almost  impossible. 
The  inflammation  may  extend  to  the  lachrymal  duct,  involving  the  eyes  in 
a  mild  conjunctivitis.  There  may  be  closure  of  the  Eustachian  tubes^ 
causing  deafness  and  otalgia.  There  may  also  be  secondary  otitis.  The 
process  often  extends  to  the  larynx  and  bronchi,  with  hoarseness  and  cough. 

In  infants,  severe  cases  may  be  followed  by  inflammation  of  the  lymph 
glands  of  the  neck  or  of  the  retro-pharyngeal  region  ;  in  either  it  may  ter- 
minate in  abscess.  Less  frequently  these  catarrhal  colds  are  accompanied 
by  disturbances  of  the  digestive  tract,  and  there  is  vomiting,  or  diarrhoea 
with  large  mucous  stools. 

Attacks  of  acute  nasal  catarrh  are  stated  by  some  writers  to  cause 
death  in  young  infants  by  interfering  with  respiration.  I  have  never 
seen  dangerous  symptoms,  and  believe  them  to  be  exceedingly  rare,  if,  in- 
deed, they  ever  occur  as  a  result  of  a  simple  coryza.  In  the  mild  form 
the  attack  lasts  from  two  to  three  days ;  in  the  severe  form  from  one 
to  two  weeks.  Eepeated  attacks  are  frequently  followed  by  the  develop- 
ment of  the  chronic  form  of  the  disease. 

Diagnosis. — It  is  important  to  distinguish  between  a  simple  acute  ca- 
tarrh and  one  due  to  measles,  influenza,  nasal  diphtheria,  or  hereditary 
syphilis.  Measles  and  influenza  cause  more  fever  and  general  constitu- 
tional disturbance  than  does  simple  catarrh.  Nasal  diphtheria  is  usually 
characterized  by  the  appearance  of  membrane  in  the  anterior  nares  and 
by  patches  upon  the  tonsils.  These  may  be  wanting,  however,  and  there 
may  be  only  a  very  profuse  discharge  tinged  with  1)1  (K)d.  When  persisting 
for  two  or  three  weeks  this  is  always  to  be  regarded  with  susi)icion,  even 
though  the  constitutional  symptoms  ^nay  be  very  slight.  The  only  posi- 
tive means  of  excluding  diphtheria  is  by  cultures.  A  persistent  acute 
nasal  catarrh  in  a  young  infant  should  aways  suggest  syphilis,  and  the  pa- 
tient should  be  carefully  watched  for  th^^  development  of  other  symptoms. 

Treatment. — A  child  suffering  from  acute  coryza  should  always  be  kept 
indoors  in  a  room  with  an  even  temperature  of  about  70°  F.,  the  bowels 
freely  opened,  and  the  amount  of  food  somewhat  reduced.    The  only  drag 


476  DISEASES   OF   THE  RESPIRATORY  SYSTEM. 

which  seems  to  have  much  influence  upon  the  secretion  is  belladonna. 
This  may  be  given  in  the  form  of  atropine,  gr.  -gfg-  every  two  hours  to  a 
■child  of  six  months.  For  older  children  a  good  combination  is  that 
known  as  the  "  rhinitis  "  tablet  (camphor  gr.  I,  quinine  gr.  ^,  fluid  ex- 
tract of  belladonna  mi);  one  half  a  tablet  may  be  given  every  hour  to 
a  child  of  five  years. 

Useful  local  applications  are  albolene  oil,  oleo-stearate  of  zinc,  alka- 
line sprays,  such  as  Seller's  solution  (page  56),  to  clear  away  the  secre- 
tions, to  be  followed  by  a  spray  containing  adrenalin  or  some  other  prep- 
aration of  supra-renal  extract.  If  the  nasal  obstruction  causes  great 
interference  with  nursing,  a  two-per-cent  solution  of  cocaine  may  be 
applied  with  a  brush,  or  with  a  probe  and  cotton,  or  dropped  into  the 
nostril  just  before  each  nursing.  This  is  not  to  be  advised  unless  the 
symptoms  are  severe,  as  infants  are  quite  susceptible  to  cocaine.  In  all 
cases  the  upper  lip  and  nostrils  should  be  protected  by  vaseline  or  some 
simple  ointment.  Under  no  circumstances  should  irritating  or  astrin- 
gent injections  be  given.  In  older  children  inhalations  of  spirits  of 
camphor  or  fumes  of  carbolic  acid  may  be  used  with  advantage. 

Prophylaxis  consists  in  solving  the  perplexing  question,  so  often  put  to 
the  physician,  of  how  to  prevent  children  from  "  taking  cold."  This  is  a 
matter  of  the  utmost  importance,  and  follows  what  has  been  previously 
said  under  the  head  of  Etiology.  No  amount  of  cod -liver  oil  and  iron 
will  remove  this  tendency  to  catarrh  so  long  as  bad  hygienic  conditions 
continue.  Sleeping  rooms  should  be  large  and  well  ventilated,  and  a 
window  should  be  kept  open  at  night,  except  in  very  severe  weather  or 
during  acute  attacks.  The  temperature  of  the  house  during  the  day  should 
be  from  68°  to  70°  F.,  but  never  above  this.  Children  should  be  accus- 
tomed to  go  out  of  doors  unless  the  weather  is  especially  bad.  So  firmly 
rooted  in  the  minds  of  the  laity  is  the  idea  that  acute  catarrhs  come  from 
cold,  that  the  habit  of  coddling  delicate  children  is  always  likely  to  be 
carried  to  an  extreme. 

With  every  delicate  and  "  catarrhal "  child  one  should  begin  in  the 
summer  by  having  him  live  in  the  open  air  as  much  as  possible,  sleeping 
in  a  room  with  free  ventilation,  with  moderate  covering,  and  continuing 
the  same  practice  into  the  fall  and  early  winter.  If  begun  gradually  in 
this  way  there  is  little  difficulty  in  continuing  throughout  the  winter. 

The  next  point  to  be  insisted  on  is  cold  sponging  immediately  upon 
rising  in  the  morning,  especially  about  the  chest,  throat,  and  spine  (page 
55).  The  use  of  chest  protectors,  cotton  pads,  and  extremely  thick  cloth- 
ing should  be  prohibited.  Flannel  underclothing  should  be  worn  upon 
the  chest  throughout  the  year,  aAd  upon  the  legs  also  in  winter ;  the  very 
lightest  in  summer,  and  only  a  medium  weight  in  winter. 

Frequently  repeated  attacks  point  to  the  presence  of  adenoid  vegeta- 
tions in  the  pharynx,  and  no  measures  are  of  much  avail  until  these  are 
removed. 


CHRONIC   NASAL   CATARRH.  477 


CHRONIC   NASAL   CATARRH.       . 

This  term  is  rather  loosely  used  to  designate  a  chronic  nasal  discharge. 
■Such  a  discharge  is  frequent  both  in  infancy  and  childhood.  It  is  a  con- 
dition much  neglected  by  the  general  practitioner.  Patients  are  too  often 
subjected  to  routine  constitutional  treatment  by  cod-liver  oil  and  prep- 
arations of  iodine,  with  the  idea  that  such  cases  are  "  scrofulous,"  while 
local  treatment  is  either  neglected  altogether,  or  consists  only  of  the  use  of 
the  nasal  douche  or  syringing  with  a  saline  solution.  Sometimes,  when 
suggested  by  parents,  local  treatment  is  opposed  by  the  physician  in  the 
case  of  young  children,  and  a  great  amount  of  harm  follows.  Permanent 
damage  to  the  organs  of  hearing,  smell,  speech,  and  respiration  may  result 
from  neglecting  or  ignoring  chronic  nasal  catarrh  in  childhood. 

Chronic  nasal  catarrh  is  not  to  be  regarded  as  a  disease,  but  only  as 
a  symptom  which  may  be  due  to  any  one  of  a  variety  of  pathological  con- 
ditions, each  of  which  requires  very  different  treatment — viz.,  adenoid 
growths  of  the  pharynx,  foreign  bodies  in  the  nose,  polypi,  deviation 
of  the  septum  or  any  other  congenital  deformity  of  the  nasal  passages, 
the  various  forms  of  chronic  rhinitis,  and  syphilis,  which  causes  a  foi'm  of 
rhinitis  peculiar  to  itself. 

Adenoid  Growths  of  the  Pharynx. — These  are  more  fully  discussed 
elsewhere  (page  297).  They  are  by  far  the  most  frequent  cause  of  chronic 
nasal  discharge  in  infants  and  young  children,  and  should  be  the  first 
cause  suspected.  Every  general  practitioner  can  easily  familiarize  him- 
self with  the  method  of  digital  exploration  of  the  rhino-pharynx,  by 
which  means  these  growths  can  in  most  cases  be  easily  recognised.  The 
nasal  discharge  accompanying  adenoid  growths  is  due  to  a  chronic  rhino- 
pharyngitis. Treatment  is  without  avail  unless  the  growths  are  removed. 
After  this  is  done  the  nasal  discharge  usually  disappears  quite  promptly. 

Foreign  Bodies  in  the  Nose. — This  condition  should  be  suspected 
whenever  there  is  an  abundant  muco-purulent  discharge  limited  to  .one 
nostril.  Foreign  bodies  in  the  nose  are  quite  frequent  in  3'oung  children. 
Peas,  beans,  beads,  or  shoe  buttons  are  most  frequently  lodged  there. 
The  efforts  at  removal  on  the  part  of  the  child,  or  even  of  the  mother, 
generally  result  in  pushing  the  body  farther  into  the  nose.  It  first  sets 
up  a  mechanical  irritation,  accompanied  by  pain,  swelling,  sneezing,  and 
sometimes  hjemorrhage.  This  is  followed  by  a  catarrhal  inllammation, 
which  in  the  course  of  a  few  days  becomes  purulent,  and  may  last  in- 
definitely. The  discharge  is  generally  quite  abundant.  The  symptoms 
point  to  an  obstruction  of  one  nostril,  and  an  examination  with  the  probe 
readily  detects  the  presence  of  the  foreign  body. 

In  recent  cases  the  removal  of  the  foreign  body  may  sometimes  be  ac- 
complished by  compressing  the  empty  nostril  and  having  the  child  blow 
his  nose  strongly.  Often  the  sneezing  which  the  foreign  body  excite^  is 
33         " 


478  DISEASES  OP   THE   RESPIRATORY   SYSTEM. 

sufficdent  to  remove  it.  Before  any  attempt  is  made  to  seize  the  body 
with  forceps  cocaine  should  be  used^  not  only  for  the  purpose  of  prevent- 
ing pain,  but  in  order  to  shrink  the  mucous  membrane  so  as  to  allow 
better  manipulation.  In  many  cases  chloroform  is  necessary.  In  most 
circumstances  ordinary  foreign  bodies  can  with  proper  forceps  be  ex- 
tracted without  difficulty.  No  subsequent  treatment  is  required,  except 
the  use  of  some  mild  antiseptic  to  keep  the  nose  clean  for  a  few  days,  as 
the  inflammation  c[mckly  subsides  after  the  removal  of  the  cause. 

Nasal  Polypi. — These  are  among  the  infrequent  causes  of  chronic 
nasal  discharge  in  childhood.  They  are  especially  rare  before  the  seventh 
year,  but  both  mucous  and  fibrous  polypi  are  seen.  The  symptoms  are 
those  of  a  chronic  nasal  catarrh  with  partial  or  complete  obstruction  of 
one  or  both  sides.  Polypi  increase  in  size  with  the  occurrence  of  every 
acute  coryza,  and  are  always  especially  troublesome  in  damp  weather. 
They  may  be  accompanied  by  reflex  symptoms,  such  as  cough,  sneezing, 
and  even  by  attacks  of  asthma.  There  may  be  headache,  and  sometimes 
disturbances  of  smell,  taste,  and  hearing.  The  symptoms  are  of  much 
longer  duration  than  in  the  case  of  obstruction  from  a  foreign  body,  the 
discharge  is  not  so  abundant,  and  is  not  purulent.  The  diagnosis  is  made 
only  by  examining  the  nose  with  the  mirror  and  nasal  speculum. 

Polypi  may  be  removed  with  the  forceps,  but  this  is  best  accomplished 
by  the  use  of  the  wire  snare.  When  they  have  been  present  for  a  long 
time  the  accompanying  chronic  rhinitis  may  require  subsequent  treat- 
ment. 

Deviation  of  the  nasal  septum,  and  other  congenital  deformities 
which  cause  narrowing  of  the  nasal  respiratory  tract,  are  conditions  which 
belong  to  the  specialist. 

CHRONIC  RHINITIS. 

Three  forms  of  chronic  rhinitis  are  recognised — simple,  hypertrophic, 
and  atrophic. 

Simple  Chronic  Rhinitis. — Simple  chronic  rhinitis  existing  alone  is  of 
rare  occurrence  in  young  children.  In  the  cases  so  classed  the  symptoms 
are  usually  due  to  rhino-pharyngitis,  which  almost  invariably  depends 
upon  an  adenoid  growth.  The  growth  may  be  a  small  one,  so  that  the 
symptoms  of  obstruction  are  slight  or  absent.  A  frequent  compKcation 
is  chronic  enlargement  of  the  cervical  lymph  glands. 

The  only  constant  symptom  is  an  excessive  nasal  discharge,  which  is 
usually  mucous,  but  which  may  be  muco-purulent.  It  is  easily  removed 
by  blowing  the  nose,  if  the  child  is  old  enough  to  be  taught  to  do  this. 
Children  too  young  to  clear  the  nose  in  this  way,  suffer  from  almost  con- 
stant discomfort.  The  amount  of  discharge  depends  upon  the  severity  of 
the  case.  It  frequently  causes  irritation  of  the  upper  lip,  which  may  be 
the  seat  of  eczema  or  impetigo,  especially  in  infants.     The  lip  may  be 


CHRONIC   RHINITIS. 


479 


swollen  and  prominent.  The  condition  of  the  external  parts  is  aggra- 
vated by  the  constant  disposition  to  pick  the  nose,  which  may  be  over- 
come by  the  application  of  a  short  anterior  splint  to  each  elbow. 

Epistaxis  sometimes  occurs.  The  duration  of  the  disease  is  indefi- 
nite ;  it  may  last  for  months  or  even  for  years,  the  symptoms  in  summer 
being  insignificant,  but  returning  every  cold  season.  It  may  terminate 
in  recovery,  or,  in  children  with  flabby  tissues  and  delicate  constitution, 
it  may  be  followed  in  later  childhood  by  hypertrophic  rhinitis. 

Treatment. — Prophylaxis  is  very  important.  The  main  purpose 
should  be  to  prevent  attacks  of  acute  nasal  catarrh  by  the  measures  men- 
tioned in  the  discussion  of  that  disease.  The  general  treatment  should 
not  be  routine,  but  directed  according  to  the  indications  of  each  case. 
There  should  be  careful  attention  .to  diet  and  to  the  condition  of  the 
bowels.  Iron  and  arsenic  are  needed  when  there  is  anaemia.  A  general 
tonic  treatment  is  required  in  most  cases.  Cod-liver  oil  and  the  sja-up 
of  the  iodide  of  iron  are  both  useful,  but  are  not  specifics,  and  must  be 
intelligently  combined  with  other  measures. 

Local  treatment  consists  first  in  cleanliness,  and,  secondly,  in  the  use 
of  astringents  in  the  form  of  powder  or  solution.  For  cleansing,  a  solu- 
tion which  is  both  alkaline  and  antiseptic  is  desirable.  This  may  be  used 
in  the  form  of  a  spray,  after  which  the  nose  is  cleared  by  blowing;  or  in 
infants,  if  the  discharge  is  abundant,  the  only  efficient  method  of  getting 
rid  of  it  is  by  nasal  syringing.  This  is  attended  by  some  risk  of  forcing 
materials  into  the  middle  ear;  but  if  carefully  done,  the  danger  seems 
to  me  to  be  less  than  that  of  allowing  the  discharge  to  remain.  Syring- 
ing should  always  be  done  with  the  mouth  open  and  the  head  inclined 
forward.  All  solutions  are  to  be  made  with  sterilized  water  and  used 
warm.  But  little  force  should  be  employed,  and  it  may  be  well  to  have 
a  syringe  the  nozzle  of  which  does  not  completely  fill  the  nostril.  Either 
DobelFs  or  Seller's  solution  (page  o&)  may  be  employed,  diluted  with  an 
equal  amount  of  water.    As  a  spray  the  following  may  be  used  : 

5  Listerine  * ^  ss. 

Sodii  bicarb., 

Sodii  biborat aa  3  ss. 

Aqu« 3  iv. 

If  this  is  to  be  used  with  a  syringe,  twice  as  much  water  should  be  added. 
Ordinarily,  the  nose  should  be  cleansed  thoroughly  twice  a  day,  more  fre- 
quently in  very  severe  cases.  Once  a  day,  after  the  nose  has  been 
cleansed,  an  astringent  solution  or  powder  should  be  applied.  One  of  the 
best  solutions  i';  sulpho-carbolate  of  zinc  (gr.  v  to  water  ,^j).  This  may 
be  used  as  a  spray,  or,  better,  dropped  into  the  nostril  with  a  medicine 

*  Listerine  is  a  combination  containing  the  essential  oils  of  thyme,  eucalyptus,  bap- 
tisia,  gaulthcria,  and  mentha  arvensis. 


480  DISEASES   OF   THE  RESPIRATORY  SYSTEM. 

dropper,  the  head  being  held  far  back.  A  good  powder  is  a  combination 
of  salicylic  acid  gr.  iij,  tannic  acid  gr.  xxx,  and  stearate  of  zinc  §j,  which 
may  be  used  with  an  insufflator  once  daily. 

Hypertrophic  Rhinitis. — This  is  a  chronic  inflammation  of  the  nasal 
mucous  membrane,  accompanied  by  a  marked  hypertrophy  of  all  its  nor- 
mal structures,  particularly  its  blood-vessels.  The  parts  chiefly  affected 
are  those  covering  the  inferior  turbinated  bones.  The  mucous  mem- 
brane and  submucous  tissue  are  so  thickened  and  relaxed  that  they  may 
greatly  encroach  upon  the  nasal  respiratory  space,  and  when  these  venous 
sinuses  are  filled  with  blood,  they  may  entirely  occlude  the  passage. 
There  is  usually  associated  with  this  condition  some  degree  of  hyper- 
trophy of  the  adenoid  tissue  of  the  pharyngeal  vault. 

In  young  children  hypertrophic  rhinitis  is  a  very  infrequent  disease, 
if,  indeed,  it  ever  occurs.  It  is  fairly  common  in  moderate  degree  in 
older  children,  although  its  severe  forms  are  rare.  It  usually  follows  re- 
peated attacks  of  acute  nasal  catarrh  in  children  of  a  lymphatic  diath- 
esis.   A  frequent  local  cause  is  a  deflected  nasal  septum. 

The  symptoms  are  those  of  nasal  catarrh  with  bilateral  nasal  stenosis. 
The  discharge  is  usually  abundant,  thick,  and  tenacious,  being  increased 
by  dust  and  dampness.  All  the  symptoms  of  nasal  obstruction  are  pres- 
ent in  varying  intensity — the  "  wooden  "  voice,  mouth-breathing,  dis- 
turbed sleep,  etc.  There  may  be  reflex  cough,  catarrh  of  the  larynx  or 
bronchi,  accompanied  by  muscular  or  vaso-motor  spasm,  giving  rise  to 
spasmodic  croup  or  asthma.  Rhinoscopic  examination  shows  the  large 
pendulous  masses  of  mucous  membrane,  usually  red  and  irregular,  more 
or  less  completely  blocking  the  nasal  passage.  It  is  only  by  this  exami- 
nation that  the  disease  is  differentiated  from  adenoids  of  the  phar3rnx, 
with  which,  however,  it  is  frequently  associated.  In  infants  and  young 
children  the  adenoid  growth  is  much  the  more  frequent,  and  throughout 
childhood  generally  the  more  important  factor  in  producing  these  symp- 
toms. 

The  treatment  of  these  cases  falls  largely  to  the  specialist,  although 
very  much  can  be  done  by  the  general  practitioner  if  he  will  learn  to  use 
intelligently  a  few  remedial  agents.  Constitutional  treatment  is  indi- 
cated as  in  simple  rhinitis,  but  if  emplo3red  alone  it  accomplishes  little 
or  nothing.  The  purpose  of  local  treatment  is  the  reduction  of  the 
hypertrophied  tissue  by  cauterization  under  cocaine  anaesthesia,  by 
glacial-acetic  or  chromic  acid,  or  by  the  galvano-eautery.  Each  has  its 
advantages  and  its  advocates.  If  the  hypertrophied  tissue  forms  pendu- 
lous tumours,  it  may  be  removed  by  the  wire  snare.  Both  nostrils  should 
not  be  operated  upon  at  the  same  time.  In  most  cases  cauterization 
must  be  repeated  several  times  at  intervals  of  a  few  weeks.  In  the 
meantime  one  of  the  cleansing  solutions  mentioned  on  page  56  may  be 
employed. 


CHRONIC   RHINITIS.  481 

The  following  formula  of  Lefferts  is  an  excellent  one  for  a  spray  to 
be  nsed  in  this  condition : 

5  lodi gr.  iv 

Potass,  iodidi gi'-  s 

Zinci  iodidi, 

Zinei  sulpho-earbolat fui  gr.  xx 

Listerine §  j 

Aquas 3  iv 

To  be  used  as  a  spray  once  daily. 

Atrophic  Rhinitis  {Fetid  Catarrh). — This  is  rare  in  j^onng  children, 
and  only  occasionally  seen  in  those  over  twelve  years  old.  It  is  char- 
acterized by  the  formation  of  crusts  in  the  nose,  which  decompose  and 
produce  a  horribly  fetid  odour.  By  some  writers  the  term  ozcena  is  ap- 
plied to  this  disease,  but  usually  this  term  is  limited  to  rhinitis  associ- 
ated with  disease  of  the  bones.  Atrophic  rhinitis  has  been  regarded  by 
some  as  the  late  stage  of  the  hypertrophic  form.  This  view,  however,  is 
strongly  combatted  by  Bosworth,  who  considers  it  the  result  of  a  puru- 
lent form  of  acute  rhinitis.  The  changes  consist  in  an  atrophy  of  the 
mucous  membrane  and  the  destruction  of  many  of  the  secreting  glands. 
The  nasal  fossae  are  large  and  roomy.  The  voice  is  not  afEected,  but  the 
sense  of  smell  may  be  much  impaired.  There  are  no  symptoms  of  obstruc- 
tion. The  discharge  is  scanty,  and  tends  to  accumulate  between  the  bones, 
forming  large  crusts,  which  are  expelled  with  difficulty  by  blowing  the  nose. 

In  the  severe  cases  the  treatment  is  only  palliative,  yet  this  is  of  the 
utmost  importance  for  the  comfort  of  the  patient  and  those  about  him. 
The  object  of  treatment  is  to  prevent  as  much  as  possible  the  forma- 
tion of  crusts  by  the  frequent  use  of  an  oil  spray,  such  as  liquid  albolene, 
in  order  to  coat  the  dry  mucous  membrane.  For  the  removal  of  crusts 
they  must  first  be  macerated  by  a  prolonged  nasal  douche  as  hot  as  can  be 
borne.  This  should  be  thoroughly  used  morning  and  evening  as  a  part 
of  the  patient's  toilet.  In  employing  the  douche,  a  bag  containing  from 
one  to  two  pints  should  be  suspended  a  few  inches  above  the  patient's 
head.  One  of  the  alkaline  and  antiseptic  fluids  mentioned  on  page  56 
may  be  added  to  the  douche.  The  head  should  be  slightly  inclined  for- 
ward and  the  mouth  kept  open  during  the  douche.  The  mechanical 
removal  of  the  crusts  may  be  necessary  if  they  are  large,  hard,  and  im- 
pacted. Benefit  may  be  derived  in  some  cases  from  the  daily  use  of  a 
stimulating  spray  containing  ten  grains  of  menthol  to  one  ounce  of  liquid 
albolene.  One  of  the  very  best  deodorizers  for  general  use  is  listerine, 
which,  diluted  with  two  or  three  parts  of  water,  may  be  employed  as  a 
spray  several  times  a  day.  in  addition  to  the  other  measures  mentioned. 

Syphilitic  Rhinitis. — Kbinitis  is  seen  both  in  early  and  late  hereditary 
syphilis.  Coryza,  or  snuffles,  is  one  of  its  earliest  and  most  constant 
symptoms.    It  usually  begins  between  the  tbird  and  sixth  weeks  of  life, 


482  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

rarely  after  the  third  month.  The  pathological  condition  is  a  sub- 
acute catarrhal  rhinitis,  sometimes  with  the  formation  of  superficial 
ulcers  or  mucous  patches.  The  disease  is  attended  b}'  a  profuse  nasal 
discharge  of  sero-mucus  or  mueo-pus,  occasionally  tinged  with  blood.  It 
may  continue  from  a  few  weeks  to  two  or  three  months.  It  usually  re- 
quires only  constitutional  treatment,  and  protection  of  the  nostrils  and 
lips  by  the  use  of  the  ointment  of  the  yellow  oxide  of  mercury  diluted 
with  four  parts  of  vaseline.  This  may  be  introduced  with  the  finger  or 
brush  for  some  distance  into  the  nostrils.  When  the  discharge  is  very 
abundant,  any  one  of  the  cleansing  solutions  previously  mentioned  may 
be  used  as  a  spray. 

The  rhinitis  of  late  hereditary  sj^philis  is  a  very  different  patholog- 
ical condition.  There  are  here  gummatous  deposits  which  break  down, 
and  form  ulcers  of  the  mucous  membrane  and  deeper  tissues.  There  is 
also  periostitis,  with  extension  of  the  disease  to  the  cartilages  and  bones 
of  the  nasal  foss^,  particularly  of  the  septum.  There  may  be  perforation 
of  the  triangular  cartilage,  necrosis  of  the  vomer  or  nasal  bones,  perfora- 
tion of  the  hard  or  soft  palate,  and  at  times  extensive  ulceration  of  the 
alae  nasi  and  the  face.  This  may  be  followed  by  cicatrization,  causing  ste- 
nosis of  the  nostril.  These  lesions  in  the  nose  are  generally  accompanied 
by  deep  ulceration  of  the  pharynx  and  soft  palate.  They  usually  occur  in 
children  who  have  presented  the  early  s3'mptoms  of  hereditary  syphilis, 
but  are  occasionally  seen  when  no  such  history  can  be  obtained.  Such 
was  the  case  in  a  patient  recently  under  observation  in  the  Babies"  Hos- 
pital, who  had  perforation  of  the  nasal  septum  and  of  the  floor  of  the 
nasal  fossge,  causing  a  free  communication  with  the  mouth.  These  are 
cases  of  true  ozasna.  The  odour  from  the  discharge  is  at  times  almost 
intolerable.  When  neglected,  these  cases  go  on  from  bad  to  worse,  and 
may  continue  for  years,  producing  unsightly  deformities. 

The  treatment  is,  to  bring  the  patient  fully  under  the  influence  of 
mercury,  first  by  means  of  the  mercurial  ointment  or  by  small  doses  of 
calomel — i.  e.,  one-tenth  grain  four  or  five  times  a  day.  Later  the  bin- 
iodide  or  the  bichloride  should  be  substituted,  and  iodide  of  potassium 
given  in  doses  of  ten  to  twenty  grains  three  times  a  day.  Tonics  are 
needed  in  most  cases,  as  the  general  health  is  frequently  undermined  and 
the  patients  are  usually  angemic. 

Locally  there  may  be  used  a  spray  of  one  of  the  cleansing  solutions 
already  mentioned,  or  black  wash,  or  a  solution  of  bichloride  of  mercury, 
1  to  10,000.  For  purposes  of  deodorization,  listerine  is  one  of  the  best 
remedies.  Although  improvement  may  take  place  quite  promptly,  the 
results  of  treatment  are  often  unsatisfactory,  as  the  disease  has  usually 
progressed  so  far  before  treatment  is  begun  that  some  deformity  of  the 
nose  results,  usually  a  sinking  in  of  the  bridge  and  flattening  of  the  alse, 
giving  rise  to  the  so-called  ''  saddle-back  *'  deformity. 


MEMBRANOUS   RHINITIS.  433 


MEMBRANOUS  RHINITIS. 

The  results  of  bacteriological  examinations  have  shown  that  these 
■cases,  whose  etiology  was  formerly  the  subject  of  considerable  contro- 
versy, are  nearly  always  due  to  the  Klebs-Loeffler  bacillus,  and  hence  are 
to  be  regarded  as  true  nasal  diphtheria.  It  has  been  difficult,  from  clin- 
ical features  alone,  to  establish  this  relationship,  as  the  disease  differs  in 
several  important  particulars  from  diphtheria  of  the  pharynx  and  rhino- 
pharynx — viz.,  its  prolonged  course,  the  absence  of  glandular  enlarge- 
ments, and  the  presence  of  very  mild  constitutional  symptoms,  which  are 
sometimes  altogether  wanting.  These  peculiarities  are  due  to  the  very 
slight  absorption  which  takes  place  from  the  nose,  which  is  in  striking 
contrast  with  that  from  the  rhino-pharynx.  The  importance  of  recognis- 
ing such  cases  as  true  diphtheria  can  not  be  overestimated,  as  they  have 
often  been  the  means  of  spreading  infection  in  schools  and  institutions 
before  their  true  nature  was  determined.  The  possibility  of  membranous 
inflammation  of  the  nose  arising  from  other  micro-organisms  than  the 
diphtheria  bacillus  is  not  to  be  denied,  but  such  cases  are  extremely  rare. 

The  most  striking  clinical  feature  of  primary  nasal  diphtheria  is  a 
nasal  discharge  of  serum  or  sero-mucus,  frequently  streaked  with  blood. 
,  It  is  sometimes  very  abundant,  at  other  times  slight.  There  are  also  the 
symptoms  of  moderate  nasal  obstruction.  The  false  membrane  can  in 
most  cases  be  seen  in  the  anterior  nares  as  a  gray  or  whitish  exudation. 
It  may  cover  the  whole  inner  surface  of  the  nose.  It  often  remains  for 
two  or  three  weeks,  when  it  may  loosen  and  come  away  en  masse,  some- 
times forming  an  entire  cast  of  the  nose.  After  forcible  removal  it  may 
reform.  The  disease  in  very  many  cases  remains  limited  to  the  nose,  but 
it  may  at  any  time  extend  to  the  rhino-pharynx  or  to  the  larynx.  When 
such  an  extension  takes  place  it  is  accompanied  by  an  increase  in  the  con- 
stitutional symptoms,  glandular  swellings,  etc.  A  positive  diagnosis  can 
be  made  only  by  means  of  cultures. 

In  addition  to  the  use  of  antitoxin,  the  nose  in  these  cases  should 
be  syringed  frequently  with  a  warm  saturated  solution  of  boric  acid, 
or  bichloride  of  mercury,  1  to  10,000,  with  5  per  cent  of  glycerin.  Such 
cases  must  be  isolated,  like  ordinary  cases  of  diphtheria. 

EPISTAXIS. 

The  haemorrhage  may  come  from  any  part  of  the  nasal  fossa,  but  it 
is  generally  from  the  anterior  nares,  and  most  frequently  from  the  ves- 
sels of  the  septum.  Epistaxis  is  a  rare  symptom  in  the  haemorrhages 
of  the  newly  born,  and  when  present  indicates  syphilis.  It  is  infrequent 
throughout  infancy,  but  in  childhood  it  is  quite  common,  occurring  in 
boys  more  frequently  than  in  girls.    In  the  latter  it  is  especially  common 


484  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

about  the  time  of  puberty.  Children  who  are  kept  much  indoors  in  over- 
heated apartments,  and  who  have  susceptible  mucous  membranes  and 
flabby  tissues,  are  particularly  prone  to  it.  The  exciting  cause  may  be  a 
local  one,  like  a  fall  or  blow;  it  may  be  due  to  picking  the  nose,  or  to 
any  kind  of  mechanical  irritation;  it  may  be  associated  with  nasal  ca- 
tarrh; and  it  is  often  caused  by  a  small  ulcer  upon  the  septum.  An 
attack  may  be  brought  on  by  mental  or  physical  excitement.  It  occurs 
as  an  occasional,  often  an  early  symptom,  in  typhoid  or  malarial  fever,  in 
measles,  or  during  severe  paroxysms  of  pertussis.  It  is  seen  in  the  hsem- 
orrhagic  form  of  all  the  eruptive  fevers,  in  certain  cases  of  diphtheria,, 
most  commonly  late  in  the  disease,  in  haemophilia  and  scorbutus,  in  grave 
anaemia,  leukaemia,  and  in  diseases  of  the  heart  and  blood-vessels. 

Symptoms. — Epistaxis  is  frequently  preceded  by  a  sense  of  fulness  or 
pain  in  the  head,  which  is  relieved  by  the  bleeding.  The  blood  is  usu- 
ally from  one  nostril,  and  comes  slowly  by  drops.  The  amount  lost  is 
generally  small,  but  it  may  be  large  enough,  when  repeated,  to  produce  a 
serious  grade  of  anemia  even  in  strong  children,  and  the  haemorrhage 
may  prove  fatal.  Epistaxis  may  be  overlooked  if  the  blood  finds  its  way 
into  the  pharynx  and  is  swallowed.  In  most  of  the  cases  the  haemor- 
rhage ceases  spontaneously  in  from  ten  to  twenty  minutes,  recurring  at 
longer  or  shorter  intervals,  according  to  the  nature  of  the  cause.  Hasm- 
orrhage  from  adenoid  growths  of  the  pharynx  may  closely  resemble  that 
from  the  nose,  but  otherwise  there  can  rarely  be  any  difficulty  in  recog- 
nising epistaxis.  In  doubtful  cases  an  inspection  of  the  pharynx  reveals, 
the  presence  of  blood-clots. 

Prognosis. — This  depends  upon  the  cause.  In  the  great  majority  of 
the  so-called  idiopathic  cases  epistaxis  is  not  serious.  Occurring  early  in 
the  course  of  the  infectious  diseases,  it  does  not  ordinarily  affect  the  prog- 
nosis unless  it  is  very  severe.  When  it  occurs  late,  however,  it  is  always 
a  bad  sign,  and  particularly  so  in  diphtheria.  It  may  be  serious  in  any 
of  the  hemorrhagic  diseases  or  in  diseases  of  the  blood,  where  it  is  not  in- 
frequently a  cause  of  death. 

Treatment. — To  remove  the  predisposition,  a  child  should  receive 
general  tonic  treatment,  especially  plenty  of  outdoor  exercise,  and  every 
means  should  be  taken,  by  the  use  of  cold  baths,  friction,  and  proper  food,, 
to  tone  up  the  vascular  system. 

An  efficient  means  of  arresting  the  haemorrhage  is  compression  of  the 
nose  between  th-e  thumb  and  finger.  This  may  be  combined  with  the 
application  of  ice  over  the  nose,  and  sometimes  small  pieces  of  ice  may 
be  introduced  into  the  nostrils.  The  application  of  cold  to  the  back  of 
the  neck  or  its  use  in  the  mouth  may  be  of  service  by  exciting  reflex 
contraction  of  the  capillary  vessels.  All  tight  clothing  or  bands  about 
the  neck  should  be  loosened,  and  the  patient  kept  quiet  in  the  sitting 
posture.     After  the  hemorrhage  has  ceased  the  child  should  not  blow 


CATARRHAL  SPASM   OF   THE   LARYNX.  485 

his  nose  for  some  time.  The  supra-renal  extract  in  solution  is  one  of 
the  most  efficient  local  means  of  checking  the  bleeding.  Another  valu- 
able remedy  is  the  peroxide  of  hydrogen,  used  full  strength.  If  bleeding 
continues  in  spite  of  all  the  above  measures,  the  anterior  nares  should 
be  plugged  with  styptic  cotton,  and  if  this  does  not  control  it,  the  pos- 
terior nares  should  be  plugged.  Usually  very  little  effect  is  seen  from 
drugs  given  internally,  although  in  frequently  recurring  hgemorrhages 
where  no  local  cause  can  be  discovered  ergot  should  be  given  a  trial  in 
full  doses. 

In  severe  cases  of  nasal  haemorrhage  recurring  at  short  intervals  with- 
out any  apparent  cause,  ulcer  of  the  septum  should  be  suspected,  and,  if 
present,  should  be  touched  with  chromic  acid. 


CHAPTEE    II. 

DISEASES  OF   THE  LARYNX. 

The  characteristic  feature  of  laryngeal  disease  in  infants  and  young 
children  is  the  association  of  muscular  spasm  with  all  forms  of  inflam- 
mation. Often  it  is  the  laryngeal  spasm,  rather  than  the  inflamma- 
tion, which  gives  rise  to  the  principal  S3anptoms.  This  spasm  is  only  one 
expression  of  the  great  reflex  irritability  of  young  children. 

CATARRHAL  SPASM   OF  THE  LARYNX. 

Synonyms :  Spasmodic  laryngitis,  spasmodic  croup,  catarrhal  croup  (sometimes 
improperly  called  laryngismus  stridulus). 

The  term  catarrhal  spasm,  first  suggested,  I  think,  by  Goodhart,  is 
fairly  descriptive  of  this  disease,  which  is  characterized  by  a  very  mild 
degree  of  catarrhal  inflammation  associated  with  marked  laryngeal 
spasm. 

Etiology. — It  is  not  often  seen  during  the  first  six  months,  but  is  fre- 
quent from  this  time  up  to  the  third  year.  After  five  years  it  is  rare.  It 
occurs  in  children  who  are  well  nourished,  as  well  as  in  those  who  are 
cachectic.  Certain  children  have  a  predisposition  to  such  attacks ;  those 
who  have  had  one  attack  are  likely  to  have  others.  Heredity  seems  to 
have  some  influence  in  producing  this  susceptibility.  Catarrhal  spasm  of 
the  larynx  is  most  frequently  associated  with  enlarged  tonsils  and  ade- 
noid growths  of  the  pharynx,  sometimes  with  elongated  uvula.  Tlie  ex- 
citing cause  may  be  exposure  to  cold  or  an  attack  of  indigestion. 

Lesions. — The  catarrhal  inflammation  of  the  larynx  affects  chiefly 
the  parts  above  the  cords;  there  is  congestion  and  dryness,  and  later 
increased  secretion  of  mucus.     To  this  there  is  added  a  spasm  of  the 


486  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

muscles  of  the  larynx,  especially  the  adductors.  There  is  no  submucous 
infiltration,  and  no  tendency  to  oedema  glottidis. 

Symptoms. — The  attack  may  be  preceded  for  several  hours  by  slight 
hoarseness,  or  by  a  nasal  discharge.  During  the  day  the  child  may  ap- 
pear perfectly  well.  Usually  there  is  heard  during  the  evening  a  hol- 
low, barking  cough,  at  first  infrequent  and  not  severe.  About  midnight 
this  is  apt  to  increase  in  severity,  and  there  is  now  difficulty  in  breathing. 
As  soon  as  this  becomes  marked  the  child  wakes,  and  presents  the  char- 
acteristic symptoms  of  an  attack.  In  the  mildest  cases  the  dyspnoea  is 
not  sufficient  to  waken  the  child.  In  severe  cases  there  is  marked  dysp- 
noea, especially  on  inspiration,  and  a  loud  stridor  as  the  air  is  drawn 
through  the  narrowed  opening  of  the  glottis.  This  may  often  be  heard 
in  an  adjoining  room.  There  is  seen  on  inspiration  deep  recession  of  tho 
suprasternal  fossa,  the  supraclavicular  spaces,  and  the  epigastrium;  also 
'depression  of  the  intercostal  spaces,  and  even  of  the  walls  of  the  chest. 
The  terror  of  the  child  or  any  excitement  increases  the  spasm  and  aggra- 
Tates  the  dyspnoea.  The  distress  is  very  great;  the  breathing  usually 
slow  and  laboured;  the  voice  hoarse,  but  rarely  lost;  the  cough  stridulous, 
hoarse,  and  metallic;  the  pulse  rapid;  the  temperature  normal  or  slightly 
elevated,  rarely  over  101°  F.  The  child  sits  up  and  struggles  for  breath, 
its  forehead  covered  with  perspiration.  There  may  be  slight  lividity  of 
the  finger-tips  and  of  the  lips,  and  sometimes  considerable  prostration. 
In  the  course  of  three  or  four  hours  the  attack  slowly  wears  away  and 
the  child  falls  asleep.  During  the  following  day,  aside  from  slight 
hoarseness  and  occasional  cough,  the  child  is  apparently  well.  Most  of 
the  cases  are  not  so  severe  as  this;  there  are  the  croujDy  cough,  hoarse- 
ness, and  general  discomfort,  but  not  marked  dyspnoea.  On  the  second 
night  there  is  a  repetition  of  the  experience  of  the  first,  usually  quite  as 
severe  unless  affected  by  treatment;  and  on  the  third  day  a  remission 
^similar  to  that  of  the  day  previous.  On  the  third  night  the  attack,  if  it 
■occurs  at  all,  is  generally  a  mild  one.  Slight  hoarseness  persists  for 
■■several  days,  but  otherwise  the  child  is  apparently  well.  Many  children 
have  such  attacks  every  few  weeks  in  the  course  of  the  cold  season,  the 
slightest  exposure  or  an  indiscretion  in  diet  being  sufficient  to  induce  one. 

Prognosis. — This  is  good,  the  disease  never,  I  think,  proving  fatal, 
although  nothing  is  more  alarming,  at  least  to  parents,  than  to  witness 
for  the  first  time  one  of  these  severe  attacks  of  catarrhal  croup. 

Diagnosis. — Catarrhal  spasm  may  be  confounded  with  laryngismus 
stridulus  and  with  membranous  croup.  Laryngismus  stridulus  is  a  rare 
•disease,  and  occurs  only  in  infancy.  In  it  we  have  not  simply  stridulous 
breathing,  but  periods  of  complete  cessation  of  respiration.  These  may 
be  repeated  many  times  during  the  day.  and  may  continue  for  weeks, 
being  often  complicated  by  carpo-pedal  spasm,  sometimes  by  general 
-convulsions. 


CATARRHAL   SPASM   OF   THE    LARYNX.  487 

From  membranous  laryngitis,  catarrhal  spasm  is  distinguished  by  its 
sudden  onset,  the  mildness  of  the  symptoms  of  inflammation,  the  spas- 
modic character  of  the  dyspnoea,  and  the  daily  remissions.  The  history 
■of  previous  attacks  will  often  aid  in  diagnosis.  In  case  of  doubt,  a  posi- 
tive diagnosis  can  often  be  made  by  allowing  the  child  to  inhale  a  little 
chloroform.  This  at  once  relieves  dyspnoea  due  to  spasm,  while  it  has 
scarcely  any  effect  upon  that  due  to  membrane. 

Treatment. — The  purpose  of  treatment  during  the  attack  is  to  pro- 
duce relaxation  of  the  laryngeal  spasm.  This  is  accomplished  by  the  use 
of  emetics,  steam,  and  hot  fomentations  over  the  larynx.  A  favourite 
■emetic  is  a  tablet  triturate  of  antimony  and  ipecac,  gr.  j^^  each.  To  a 
child  of  two  years,  one  tablet  may  be  given  every  ten  or  fifteen  minutes, 
until  free  vomiting  occurs  ;  or  a  teaspoonful  of  the  syrup  of  ipecac  and 
fifteen  drops  of  the  wine  of  antimony  at  the  same  interval.  When  chil- 
dren do  not  vomit  after  two  or  three  doses  the  antimony  should  not  be  re- 
peated, as  it  may  produce  serious  depression. 

Emetics  have  a  double  value  if  the  attack  is  due  to  indigestion.  If 
there  is  constipation,  an  enema  should  be  given.  Following  the  free 
vomiting  there  is  generalh'  some  improvement  in  the  symptoms,  but 
there  may  be  a  recurrence  of  the  spasm  unless  other  means  are  em- 
ploj^ed.  To  prevent  this,  antipyrine  is  one  of  the  most  useful  drugs. 
Two  grains  may  be  given  to  a  child  two  years  old.  This  may  be  repeated 
in  four  or  five  hours  if  necessary.  Quite  as  much  relief  as  that  obtained 
from  the  drugs  mentioned  is  seen  from  the  use  of  steam  inhalations.  For 
this  purpose  the  child  should  be  jDlaced  in  a  closed  tent,  and  steam  intro- 
duced from  a  croup  kettle  (page  58).  This  may  be  used  in  conjunction 
with  other  measures,  and  continued  as  long  as  necessary.  Poultices  or  hot 
fomentations  over  the  larynx  are  often  useful.  In  one  case  in  which  se- 
vere spasm  had  recurred  for  eight  successive  nights  in  spite  of  everything 
that  was  tried,  the  child  being  in  great  distress  from  the  dyspnoea,  I  per- 
formed intubation,  which  gave  instant  relief.  Tracheotomy,  however, 
would  scarcely  be  advisable. 

During  the  day  following  the  first  night  attack,  it  is  well  to  continue 
the  antimony  and  ipecac  in  doses  too  small  to  produce  vomiting — e.  g., 
gr.  3^  each,  every  four  hours.  After  6  p.  m.  the  doses  should  be 
doubled,  and  at  bedtime  two  grains  of  antipyrine  given.  If  so  treated, 
the  symptoms  may  not  recur  upon  the  second  night,  or  there  may  be 
only  the  cough  without  the  severe  dyspnoea.  The  child  should  be  con- 
fined to  the  house  for  two  or  three  days  after  one  of  these  attacks,  the 
drugs  being  gradually  reduced ;  but  the  antipyrine  should  be  given  at 
bedtime  for  three  or  four  successive  nights. 

To  prevent  a  repetition  of  the  attacks  and  remove  the  tendency  to 
them,  it  is  most  important  that  the  child  should  have  plenty  of  fresh  air 
and  cold  bathing,  especially  cold  sponging  about  the  neck   and  chest. 


488  DISEASES  OF  THE   RESPIRATORY  SYSTEM. 

Everything  which  experience  has  shown  to  bring  on  the  attack  should  be 
carefully  avoided.  Local  causes,  such  as  adenoid  growths,  hjqDertrophied 
tonsils,  elongated  uvula,  etc.,  should  receive  appropriate  treatment.  Gen- 
erally it  is  not  necessary  to  exclude  fresh  air  from  the  sleeping  room. 
Although  an  open  window  on  a  cold,  damp  night  may  sometimes  excite 
the  attack,  plenty  of  fresh  air  tends  rather  to  diminish  the  suscej)- 
tibility.  If  the  child's  condition  is  poor,  general  tonic  treatment  is  to 
be  employed. 

ACUTE  CATARRHAL  LARYNGITIS. 

Acute  laryngitis  is  not  nearly  so  frequent  as  the  disease  just  described, 
although  it  is  much  more  severe,  and  may  even  be  fatal.  It  occurs  espe- 
cially in  children  from  one  to  five  years  of  age,  usually  in  the  cold  season. 
Predisposition  to  attacks  is  induced  by  the  same  conditions  as  in  the  case 
of  acute  rhinitis.  Catarrhal  laryngitis  may  be  primary,  when  it  is  usually 
excited  by  cold  or  exposure,*  or  it  may  be  secondary  to  measles,  influenza^ 
scarlet  fever,  or  other  infectious  diseases.  It  may  also  be  of  traumatic 
origin,  from  the  inhalation  of  steam  or  irritating  gases. 

Lesions. — There  is  a  moderately  intense  congestion  of  the  laryngeal 
mucous  membrane,  sometimes  general  and  sometimes  localized.  This  may 
be  seen  with  the  laryngoscope,  but  is  not  always  visible  after  death.  With, 
the  congestion  there  are  swelling  and  dryness,  followed  by  increased  secre- 
tion. In  the  milder  cases  the  process  is  limited  to  the  mucosa.  In  the 
more  severe  cases  it  involves  the  submucosa  also,  which  is  congested, 
oedematous,  and  may  be  infiltrated  with  cells.  The  changes  are  especially 
marked  in  the  lymphoid  tissue  of  the  subglottic  region.  The  swelling- 
may  be  sufficient  to  produce  a  very  marked  degree  of  laryngeal  stenosis. 
In  many  mild  and  in  all  the  severe  cases  there  is  associated  catarrhal 
inflammation  of  the  trachea,  and  often  of  the  larger  bronchi.  In  young 
children  there  is  very  little  tendency  to  oedema  glottidis,  so  frequent  a. 
complication  in  adults. 

Symptoms. — In  the  mild  form,  such  as  that  which  is  usually  seen  in 
older  children,  there  is  hoarseness,  or  even  loss  of  voice,  and  a  laryngeal 
cough  which  is  sometimes  hard  and  teasing,  always  worse  at  night.  There 
may  be  pain  and  soreness  over  the  larynx.  Constitutional  symptoms 
are  mild  or  absent,  the  patient  not  usually  being  sick  enough  to  go  to  bed, 
and  often  rebelling  even  at  being  kept  indoors.     The  duration  of  the  dis- 

*  The  following  ease  is  a  good  illustration  of  a  severe  attack  excited  bv  cold :  A 
rather  delicate  infant,  eight  months  old,  an  inmate  of  the  New  York  Infant  Asylum, 
was  taken  out  on  a  raw  December  day  with  very  slight  covering.  In  a  few  hours 
hoarseness  and  stridor  were  noticed,  and  the  temperature  was  101°  F. ;  three  hours 
later  it  was  103°,  and  in  spite  of  the  usual  remedies  which  were  employed  the  dyspnoea 
had  reached  such  a  degree  as  to  require  intubation.  The  tube  was  worn  only  three 
days  and  the  case  made  a  prompt  recovery. 


ACUTE   CATARRHAL    LARYNGITIS.  4S9 

ease  is  from  four  to  ten  days,  with  a  strong  tendency  to  relapses  from 
slight  causes. 

The  severe  form  of  catarrhal  laryngitis  is  sometimes  preceded  by  acute 
coryza,  or  there  may  be  mild  laryngeal  symptoms  for  a  few  days  before  the 
development  of  the  more  severe  ones.  In  other  cases  the  disease  develops 
rapidly  and  severe  symptoms  are  jDresent  within  a  few  hours  from  the  onset. 

When  the  case  is  fully  developed  the  voice  is  metallic  and  hoarse, 
and  occasionally  but  not  usually  lost.  There  is  a  hoarse,  dry,  barking 
cough,  which  is  very  distressing,  and  sometimes  almost  constant.  The 
cough,  like  the  voice,  is  stridulous,  and  more  or  less  stridor  is  present  on 
inspiration.  There  is  a  slight  amount  of  constant  dyspncea,  but  this  is 
scarcely  noticeable  unless  the  chest  is  bared.  Severe  dyspnoea  occurs  in 
paroxysms,  usually  at  night.  Then,  we  may  get  the  signs  of  obstructive 
dysjinoea  similar  to  those  mentioned  in  severe  attacks  of  catarrhal  spasm. 
This  dyspnoea  is  chiefly  inspiratory,  but  in  some  cases  it  increases  steadily 
from  the  beginning  of  the  attack,  and  may  be  indistinguishable  from  that 
due  to  membrane.  Constitutional  symptoms  are  usually  present  and 
may  be  severe.  The  temperature  ranges  in  most  cases  from  101°  to 
103°  F.,  but  may  go  to  104°  or  105°.  The  pulse  is  rapid  and  full  and  res- 
piration is  accelerated.  Children  sometimes  complain  of  pain  in  the 
larynx  and  trachea,  increased  by  coughing.  The  s3anptoms  are  severe 
for  two  or  even  three  days,  the  fever  continuing  with  moderate  prostra- 
tion and  paroxysms  of  dyspnoea,  sometimes  even  attacks  of  suffocation  and 
cyanosis.  Usually  after  two  or  three  days  there  is  a  gradual  subsidence 
of  the  dyspnoea  and  inflammatory  symptoms,  and  the  case  goes  on  to  re- 
covery. At  other  times  the  inflammation  extends  downward  to  the  large 
and  then  to  the  small  bronchi,  and  finally  results  in  broncho-pneumonia. 
The  attack  may  prove  fatal  from  laryngeal  obstruction  due  to  swelling 
and  spasm. 

Diagnosis. — This  disease  is  chiefly  to  be  distinguished  from  membra- 
nous laryngitis.  The  onset  of  the  two  diseases  may  be  very  similar,  and 
for  the  first  twelve  hours  we  have  no  absolute  means  of  distinguishing 
between  them,  except  possibly  by  the  use  of  the  laryngoscope,  which  is 
often  conclusive  in  older  children  but  not  usually  so  in  infants.  All  cases, 
therefore,  should  be  looked  ujoon  with  a  degree  of  apprehension.  The 
temperature  in  the  catarrhal  is  usually  higher  than  in  the  membranous 
form.  The  dyspnoea  is  mainly  paroxysmal,  with  daily  remissions  and 
nightly  exacerbations,  and  is  chiefly  inspiratory,  while  that  of  membra- 
nous laryngitis  is  constant,  steadily  and  often  rapidly  increasing,  and  is 
present  both  on  inspiration  and  expiration.  In  catarrhal  laryngitis  the 
voice  is  not  usually  lost,  but  in  the  membranous  form  this  is  the  rule. 
There  can  be  little  room  for  doubt  when  there  are  enlarged  glands,  mem- 
branous patches  on  the  tonsils,  nasal  discharge,  and  albumin  in  the  urine. 
Very  often,  however,  all  these  evidences  of  diphtheria  are  wanting,  the 


490  DISEASES  OP  THE  RESPIRATORY  SYSTEM. 

really  difficult  cases  being  those  in  which  the  process  begins  in  the  larynx. 
The  prevalence  of  diphtheria  and  a  known  exposure  count  for  something 
in  favour  of  membranous  laryngitis.  If  cultures  from  the  pharynx  show 
the  presence  of  Klebs-Loeffler  bacilli,  diphtheria  of  the  larjmx  is  certain ; 
but  no  conclusions  can  be  drawn  when  cultures  give  negative  results. 
In  catarrhal  as  well  as  in  membranous  laryngitis  there  may  be  extreme 
dyspnoea,  cj-anosis,  pallor,  prostration,  and  even  death. 

Prognosis. — This  depends  somewhat  upon  the  cause  of  the  disease  and 
also  upon  the  age  of  the  patient.  It  is  much  worse  when  it  is  secondary 
to  measles  or  scarlet  fever.  It  is  better  in  children  over  three  years  of  age 
than  in  infants,  also  when  the  general  condition  of  the  child  is  good.  The 
prognosis  in  severe  catarrhal  laryngitis  should  always  be  guarded,  not  only 
on  its  own  account,  but  also  because  it  is  impossible  to  be  certain  that 
the  case  may  not  be  one  of  membranous  laryngitis. 

Treatment. — In  all  cases  children  affected  are  to  be  kept  in  bed ;  and 
the  temperature  of  the  room  should  be  between  70°  and  72°  F.  The  diet 
should  be  light  and  fluid,  and  the  bowels  should  be  freely  opened  by  calomel 
or  a  saline.  A  hot  mustard  foot  bath  should  be  given  at  the  outset ;  also, 
benefit  may  sometimes  be  derived  from  aconite,  given  in  one-quarter- 
minim  doses  every  fifteen  minutes  for  the  first  five  or  six  hours.  An- 
tipyrine  (two  grains  every  four  hours  to  a  child  two  years  old)  is  useful  if 
there  is  much  spasmodic  dyspncea.  For  this  symptom  emetics  are  bene- 
ficial, given  as  in  catarrhal  spasm.  The  use  of  ipecac  and  squills  in  smaller 
doses  than  is  required  for  emesis  (five  drops  each  of  the  syrups  of  ipecac 
and  squills  every  two  hours)  may  give  relief,  especially  in  the  early  stage, 
when  the  cough  is  dry,  hard,  and  severe. 

All  the  remedies  mentioned  are  to  be  regarded  as  accessories  to  the 
essential  treatment,  which  consists  in  the  use  of  inhalations.  The  child 
should  be  placed  in  a  tent  (page  58)  into  which  steam  is  introduced  from 
a  croup  kettle  or  vapourizer.  Simple  steam  may  be  used,  or  turpen- 
tine, lime-water,  or  creosote  may  be  added.  In  moderately  severe  cases 
inhalations  should  be  used  for  fifteen  minutes  every  two  hours ;  in  very 
severe  ones  they  should  be  continued  the  greater  part  of  the  time.  Poul- 
tices or  hot  fomentations  may  be  applied  over  the  larynx.  Eelief  is  some- 
times obtained  by  using  counter-irritation  by  a  mustard  paste,  but  blister- 
ing should  never  be  allowed.  In  my  experience  the  local  use  of  cold  is 
very  unsatisfactory,  on  account  of  the  difficulty  of  applying  it  properly,  and 
the  objection  to  it  on  the  part  of  young  children.  Stimulants  may  be  re- 
quired late  in  the  disease,  the  amount  of  prostration  being  the  guide  to 
their  use. 

In  cases  of  extreme  dyspnoea  operative  interference  may  be  needed.  It 
is  required  more  often  in  infants  and  young  children  than  in  those  who 
are  older,  and  especially  in  the  subglottic  form  of  the  disease.  Opinions 
will  of  course  differ  as  to  when  the  dyspncea  has  reached  the  danger  point. 


MEMBRANOUS  LARYNGITIS.  491 

One  should  not  wait  for  general  cyanosis.  If  pallor,  marked  prostration^ 
and  steadily  increasing  dyspnoea  are  present  the  case  should  not  be  al- 
lowed to  go  on  without  interference.  Intubation  has,  to  my  mind,  every 
advantage  over  tracheotomy,  and  is  always  to  be  preferred  in  these  cases. 
One  should  not  hesitate  to  operate,  even  though  he  may  be  perfectly  sure 
that  the  case  is  one  of  catarrhal  inflammation  only.  The  severity  of  the 
dyspnoea  is  the  only  guide,  and  more  than  once  I  have  seen  eases  shown 
at  autopsy  to  be  catarrhal,  which  were  regarded  during  life  as  undoubt- 
edly membranous.  If  intubation  is  done,  the  tube  can  generally  be  dis- 
pensed with  in  two  or  three  days.  Convalescence  is  usually  rapid,  but 
there  is  danger  of  recurring  attacks  during  the  remainder  of  the  cold 
season. 

MEMBRANOUS  LARYNGITIS. 

Synonyms :  Membranous  croup,  true  croup,  laryngeal  diphtheria. 

Bacteriology  has  settled  many  questions  long  debated  with  reference 
to  this  disease.  For  nearly  half  a  century  the  identity  of  membranous 
eroup  and  laryngeal  diphtheria  has  been  contended  for  by  some  observers, 
and  denied  by  others  equally  good.  The  extensive  bacteriological  re- 
searches made  since  1890,  both  in  this  country  and  in  Europe,  have 
yielded  results  sufficiently  uniform  to  warrant  the  following  statements : 

1.  Membranous  inflammation  beginning  in  the  larynx  is  almost  in- 
variably true  diphtheria — i.  e.,  it  is  due  to  the  Klebs-Loeffler  bacillus. 

2.  Membranous  laryngitis  folloAving  a  primary  membranous  inflam- 
mation of  the  tonsils,  pharynx,  or  nose,  is,  in  the  great  majority  of  cases, 
due  to  the  Klebs-Loeffler  bacillus. 

3.  Membranous  laryngitis  following  membranous  inflammation  of 
the  tonsils,  nose,  or  pharynx,  occurring  as  a  complication  of  measles, 
scarlet  fever,  or  influenza,  is  sometimes  due  to  another  kind  of  infection 
(usually  the  streptococcus),  but  more  often  to  the  Klebs-Loeffler  bacillus. 

The  etiology,  lesions,  pathological  relations,  and  bacteriological  diag- 
nosis of  membranous  laryngitis  are  considered  in  the  chapter  devoted  to 
Diphtheria.  In  the  present  chapter  there  will  be  considered  only  the 
clinical  aspect  of  the  cases,  especially  of  those  in  which  the  disease  begins 
in  the  larynx;  for  even  though  in  most  cases  the  cause  is  diphtheria,  the 
clinical  picture  is  that  of  laryngitis. 

In  cases  of  primary  laryngeal  diphtheria  there  are  wanting  most  of 
the  characteristic  clinical  features  which  distinguish  diphtheria  of  the 
pharynx.  There  are  two  reasons  for  this  :  one  is  the  relatively  rapid  course 
of  the  disease,  often  producing  death  from  local  causes  before  the  consti- 
tutional symptoms  resulting  from  the  absorption  of  the  toxin  have  devel- 
oped ;  the  second  reason  is,  that  absorption  of  the  poison  by  the  laryngeal 
mucous  membrane  is  very  feeble  as  compared  witli  that  which  takes  place 
from  the  pharynx.    Hence  it  follows  that  glandidar  enlargements,  albumi- 


492  DISEASES  OP   THE   RESPIRATORY  SYSTEM. 

nuria,  and  asthenic  symptoms  are  generally  wanting ;  also,  that  in  the  cases 
which  come  to  autopsy  early,  the  parenchymatous  degenerations  of  the 
teart,  kidney,  and  other  organs  are  seldom  found,  but  instead  only  such 
lesions  as  are  connected  with  the  laryngeal  disease.  The  feeble  contagion 
is  due  to  the  fact  that  the  course  is  much  shorter,  and  that  the  discharge 
irom  the  nose  and  mouth  is  slight,  or  absent  altogether. 

Symptoms. — In  its  onset,  membranous  inflammation  of  the  larynx  is 
indistinguishable  from  the  catarrhal  form.  It  is  perhaps  a  trifle  less 
abrupt,  and  apparently  not  quite  so  severe  for  the  first  twelve  hours  or 
even  for  a  longer  time.  We  have  the  same  hoarse  cough  and  voice,  with  a 
slight  stridor,  gradually  increasing.  The  constitutional  symptoms  are  . 
usually  not  quite  so  marked,  the  temperature  ranging  from  99°  to  101° 
P.  The  pulse  is  accelerated,  but  not  weak  or  intermittent.  It  is  the 
progress  of  the  disease  which  indicates  its  character,  usually  during  the 
first  twenty-four  hours.  A  child  beginning  in  the  morning  with  such 
symptoms  as  have  been  described,  may  by  evening  show  a  decided  change 
for  the  worse,  or  the  symptoms  may  increase  with  great  rapidity  during  the 
night.  At  first  the  voice  is  hoarse ;  later  it  is  entirely  lost.  Dyspnoea  in 
the  beginning  is  scarcely  noticeable,  but  steadily  increases  hour  by  hour. 
At  times  of  excitement  it  may  be  very  great,  but  as  the  spasm  subsides  it 
diminishes.  During  the  second  twenty-four  hours  all  the  symptoms  are 
usually  well  developed.  The  respiration  is  often  somewhat  accelerated, 
but  it  may  be  slower  than  normal.  The  face  is  pale  and  anxious.  The 
alffi  nasi  dilate  with  each  inspiration.  The  loud,  "sawing,"  stridulous 
breathing  is  present.  As  the  dyspnoea  increases,  all  the  accessory  muscles 
of  respiration  are  brought  into  action.  There  is  now  with  every  inspi- 
ration deep  recession  of  the  suprasternal  fossa,  the  supraclavicular  re- 
gions, and  the  epigastrium.  The  child  tosses  uneasily  from  side  to  side  in 
its  crib,  at  times  struggling  violently  to  get  more  air  into  the  lungs.  The 
pulse  grows  rapid  and  weaker.  There  is  slight  blueness  of  the  finger  nails 
and  the  lips ;  the  face  is  usually  pale ;  but  later  this  too  may  be  cyanotic. 
The  skin  is  covered  with  clammy  perspiration.  On  auscultating  the 
chest,  very  rude  respiratory  sounds  are  heard,  but  no  vesicular  murmur. 
As  the  symptoms  increase  in  severity  the  temperature  usually  rises  gradu- 
ally, in  some  very  severe  cases  at  the  rate  of  a  degree  an  hour,  until  shortly 
before  death  it  reaches  104°  or  even  106°  F.  Late  in  the  disease  the  in- 
tellect becomes  dull,  the  violent  struggles  for  air  cease,  and  the  child  passes 
into  a  condition  of  semi-stupor  which  gradually  deepens  until  death  occurs, 
which  may  be  preceded  by  convulsions. 

Such  is  the  usual  course  of  the  disease  when  unrelieved  by  treatment. 
Its  progress  is  most  rapid  in  infants,  in  whom  death  usually  takes  place  in 
from  thirty-six  to  forty-eight  hours  from  the  first  symptoms.  In  older 
children  the  course  is  rather  slower,  and  the  attack  may  last  from  two 
days  to  a  Aveek,  death  occurring  more  frequently  from  bronchial  croup  or 


MEMBRANOUS  LARYNGITIS.  493 

pneumonia.  These  are  indicated  by  continued  high  temperature,  rapid 
respiration,  cyanosis,  and  increased  prostration. 

The  course  of  the  disease  is  not  always  so  regular.  Occasionally  for  a 
week  or  more  the  symptoms  are  precisely  like  those  of  catarrhal  laryngitis 
of  moderate  severity — hoarseness,  laryngeal  cough,  little  or  no  fever,  and 
slight  or  occasional  dyspnoea.  Then  there  may  be  the  sudden  develop- 
ment of  very  severe  symptoms,  and  death  in  a  few  hours.  Great  improve- 
ment may  follow  the  dislodgment  of  the  membrane  by  vomiting  or  cough- 
ing, although  in  most  cases  it  forms  again. 

Prog^nosis. — The  issue  of  every  ease  of  membranous  laryngitis  is 
doubtful.  The  prognosis  is  worse  in  infants  and  very  young  children 
than  in  those  over  three  years  of  age,  and  worse  when  secondary  to 
measles  or  scarlet  fever  than  when  primary.  Before  the  days  of  antitox- 
in the  mortality  of  cases  not  operated  upon  was  from  80  to  90  per  cent. 
Later  statistics  are  given  in  the  chapter  on  Diphtheria. 

Diagnosis. — The  first  point  to  be  decided  in  any  case  is  whether  the 
dyspnoea  is  due  to  laryngeal  inflammation ;  the  second  whether  this  in- 
flammation is  catarrhal  or  membranous.  The  dyspnoea  of  retro-pharyn- 
geal  abscess,  of  foreign  bodies  in  the  larynx  or  trachea,  or  of  broncho- 
pneumonia, may  be  mistaken  for  that  due  to  laryngitis.  But  in  none  of 
these  conditions  should  there  be  any  doubt  if  a  careful  examination  is 
•made  and  a  history  obtained.  Retro-pharyngeal  abscess  may  be  recog- 
nised by  digital  examination  of  the  phar3mx ;  broncho-pneumonia  by  the 
signs  in  the  lungs,  the  difference  in  the  character  of  the  dyspnoea,  and 
especially  by  the  absence  of  the  noisy  stridor ;  in  the  case  of  foreign  bod- 
ies, whether  they  enter  through  the  mouth  or  consist  of  ulcerating  caseous 
glands  which  have  ruptured  into  the  trachea,  the  dyspnoea  comes  sud- 
denly, and  is  not  accompanied  by  fever.  The  main  points  by  which  ca- 
tarrhal laryngitis  is  distinguished  from  the  membranous  form  have  been 
considered  under  the  former  disease.  In  brief,  membranous  inflamma- 
tion may  be  assumed  if  there  is  severe,  constant,  and  increasing  dyspnoea 
Math  aphonia.  Membranous  laryngitis  should  always  be  regarded  as 
diphtheria  until  the  opposite  has  been  proved  by  repeated  cultures. 

Treatment. — All  cases  of  membranous  laryngitis  should  be  isolated 
like  those  of  diphtheria  of  the  pharynx,  and  should  receive  a  full  dose 
of  antitoxin  upon  a  clinical  diagnosis  without  watiting  for  this  to  be  con- 
firmed by  a  bacteriological  examination.  Nowhere  else  are  the  beneficial 
effects  from  antitoxin  so  evident  and  so  striking  as  in  these  cases.  For 
dosage  and  other  details  regarding  the  use  of  antitoxin  the  reader  is 
referred  to  the  article  on  Diphtheria. 

Emetics,  inhalations  of  steam,  and  solvents  for  the  membrane,  al- 
though they  all  sometimes  give  relief,  are  never  to  be  relied  upon  alone. 
In  fact,  leaving  out  antitoxin  and  surgical  operation,  the  only  thera])eu- 
tic  measure  that  can  be  said  to  bo  of  much  avail  is  calomel  fumigation. 
33 


494  DISEASES   OP   THE   RESPIRATORY   SYSTEM. 

This  is  in  no  sense  a  substitute  for  antitoxin,  but  may  be  employed  where 
the  use  of  antitoxin  is  ini]Dossible,  and  in  the  few  cases  of  membranous 
lar}Tigitis  due  to  streptococci.  From  ten  to  fifteen  grains  of  calomel  are 
vapourized  upon  any  hot  metal  plate  under  a  closed  tent,  in  which  the 
child  is  placed.  This  may  be  repeated  ever}"  one  to  four  hours,  accord- 
ing to  circumstances.  One  should  watch  both  the  child  and  the  attend- 
ants for  symptoms  of  mercurial  poisoning.  This  treatment  was  intro- 
duced by  Corbin,  of  BrookhTi,  and  was  much  in  vogue  from  1890  until 
the  introduction  of  antitoxin. 

Operative  measures. — Opinions  will  always  differ  as  to  the  time  when 
operative  interference  is  called  for.  One  should  never  wait  for  general 
cyanosis,  for  often  this  does  not  occur  until  just  before  death.  It  is  bet- 
ter to  operate  too  early  than  too  late.  If,  in  spite  of  other  measures, 
the  dyspnoea  increases  steadil}^  and  especially  if  the  temperature  begins 
to  rise,  operation  should  not  be  deferred  longer.  When  this  has  been 
decided  upon,  the  physician  has  the  choice  between  intubation  and 
tracheotomy.  In  America  intubation  has  almost  universally  superseded 
tracheotom}'  as  a  primar}^  operation  for  the  relief  of  membranous  laryn- 
gitis. In  Europe  also  its  advantages  are  coming  to  be  appreciated,  and 
its  use  has  extended  greatly  since  the  introduction  of  antitoxin.  Trache- 
otomy is  still  needed  at  times  for  the  cases,  very  few  in  number,  in  which 
intubation  fails  to  give  relief  on  account  of  the  position  of  the  mem- 
brane or  some  other  complication. 

The  general  treatment  of  the  child  is  important,  and  should  not  be 
overlooked.  It  includes  careful  feeding,  and  the  use  of  alcoholic  stimu- 
lants according  to  the  amount  of  prostration  present.  All  patients  with 
membranous  laryngitis  should  be  closely  watched,  for  marked  changes 
may  take  place  in  the  course  of  a  few  hours. 

IXTUBATIOX. 

Intubation  is  the  introduction  of  a  tube  through  the  mouth  into 
the  larynx  for  the  relief  of  laryngeal  d3"spnoea.  For  the  operation,  as 
now  performed,  the  world  is  indebted  to  the  late  Dr.  Joseph  O'Dwj-er, 
of  iSTew  York. 

A  set  of  O'Dwyer's  instruments  (Fig.  85)  consists  of  six  tubes,  an 
introductor,  an  extractor,  a  mouth-gag,  and  a  gauge.  In  the  later  tubes 
the  lower  extremity  is  made  somewhat  bulbous  and  not  straight,  as 
appears  in  the  illustration.  His  latest  tubes  are  made  of  hard  rubber 
and  lined  with  gold-plated  metal,  these  proving  much  less  irritating 
than  the  solid  metal  tubes  formerly  used.  So  carefully  did  O'Dwyer 
perfect  his  instruments  that  nothing  of  importance  has  been  added  by 
others.  It  is  interesting  to  note  that  nearly  all  the  modifications  which 
have  been  suggested  since  his  first  publication  had  already  been  tried 
by  him  and  discarded.    Xo  one  thing  is  more  essential  to  success  with 


INTUBATION. 


495 


intubation  than  properly  constructed  instruments.  The  operation  is  not 
very  difficult,  provided  one  has  had  previous  practice  on  the  cadaver. 
Without  this  it  should  not  be  attempted.  The  tube  is  selected  accord- 
ing to  the  age  of  the  patient,  the  size  for  the  different  years  being  indi- 
cated by  the  gauge.  The  age,  however,  is  not  the  only  guide,  for  a  very 
large  child  will  often  require  a  tube  of  larger  size  than  its  age  would 
indicate. 

Introduction  of  the  Tube. — Two  assistants  are  required,  neither  of 
whom  need  be  skilled.  The  child  is  taken  from  the  bed,  wrapped  in  a 
large  blanket,  and  held  in  a  sitting  position  upon  the  lap  of  the  first 
assistant,  its  head  being  inclined  neither  backward  nor  forward.  The 
arms  may  be  confined  by  the  blanket  or  held  by  the  assistant.  The  second 
assistant,  standing  behind  the  child,  steadies  the  head,  and  with  one 
finger  holds  the  loop  of  braided  silk,  with  which  the  tube  should  be 
threaded.  The  tube  is  attached  to  the  introductor,  and  the  gag  is  in- 
serted into  the  left  angle  of  the  mouth  and  opened  as  widely  as  possible. 
The  slipping  of  the  gag  and  laceration  of  the  mouth  may  be  prevented 
by  using  a  piece  of  rubber  tubing  to  cover  each  arm  of  the  gag  where  it 


Fig.  85. — O'Dwyer's  intubation  set. 
1,  introductor;  2,  gag;  3,  extractor;  4,  gauge;  5,  tube. 


comes  in  contact  with  the  gum.  The  attempts  at  introduction  must  be 
made  quickly,  for  during  them  respiration  is  practically  arrested.  Sev- 
eral short  attempts  are  always  better  than  a  single  prolonged  one.    Very 


496  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

little  force  is  ordinarily  required  in  introducing  the  tube,  that  used  in 
passing  a  catheter  being  a  good  general  guide.  In  cases  of  subglottic 
stenosis,  however,  quite  a  little  force  may  be  necessary. 

The  index  finger  of  the  left  hand  is  used  as  a  guide  in  introduction. 
This  is  passed  well  back  into  the  pharynx,  then  brought  forward  until  a 
hard  nodule — the  upper  border  of  the  cricoid  cartilage — is  encountered. 
This  is  the  best  of  all  landmarks,  since  the  soft  parts  are  often  distorted 
by  swelling.  Directly  in  front  of  the  cricoid  cartilage  may  be  felt  the 
epiglottis  and  the  opening  of  the  larynx,  which  are  readily  recognised 
after  the  touch  has  become  somewhat  educated.  The  tube  is  passed  along 
the  palmar  surface  of  the  left  index  finger,  by  which  it  is  guided  into  the 
larynx;  it  is  then  pushed  off  the  introductor  by  a  thumb-piece  attached 
to  its  handle.  When  it  is  certain  that  the  tube  is  in  position,  and  the 
patient  breathes  properly,  the  loop  of  silk  attached  to  the  head  of  the 
tube  is  cut  off  and  pulled  through,  the  removal  of  the  tube  being  pre- 
vented by  placing  the  left  forefinger  upon  its  head.  The  silk  is  not  usu- 
ally left  attached  unless  there  is  evidence  of  loose  membrane  below  the 
tube.  It  may  be  desirable  to  leave  the  silk  attached  in  case  no  one  can 
be  within  reach  who  is  able  to  remove  the  tube  should  it  become  ob- 
structed. The  child's  arms  and  hands  should  then  be  secured  to  pre- 
vent him  from  seizing  it  himself.  When  not  removed  the  silk  is  fastened 
to  the  cheek  by  a  piece  of  adhesive  plaster.  The  tube  is  known  to  be  in 
place,  first,  by  the  hissing  breathing  sounds,  somewhat  similar  to  what 
is  heard  when  the  trachea  is  opened;  secondly,  by  a  severe  paroxysm 
of  coughing,  which  is  usually  excited  by  a  tube  in  the  larynx;  thirdly, 
by  the  relief  of  the  dyspnoea.  If  this  relief  is  not  very  apparent  the 
physician  may  still  be  in  doubt  as  to  whether  the  tube  is  in  the  larynx 
or  the  oesophagus.  If  in  the  former,  it  can  not  be  pushed  down  by  the 
finger  without  depressing  the  larynx  with  it;  and  by  introducing  the 
finger  into  the  pharynx,  the  posterior  wall  of  the  larynx  can  be  felt 
between  the  finger  and  the  tube.  The  most  common  mistake  made 
is  to  pass  the  tube  into  the  oesophagus.  This  sometimes  happens  be- 
cause the  position  of  the  child's  head  is  improper — too  far  forward 
or  too  far  backward — but  more  often  because  the  operator  has  not 
been  quite  sure  of  his  landmarks.  If  this  has  occurred,  there  is  no 
relief  to  the  dyspnoea,  no  hissing  sound,  and  the  tube  can  be  pushed 
down  indefinitely.  When  this  condition  is  recognised,  the  tube  is  with- 
drawn by  the  loop  of  silk  and  after  a  few  moments  a  second  attempt 
made. 

False  passages  in  the  larynx  are  most  frequently  made  by  employing 
too  much  force  or  because  the  operator  has  worked  at  the  angle  of  the 
mouth  instead  of  keeping  in  the  median  line.  The  tube  usually  goes 
into  one  of  the  ventricles,  and  may  be  pushed  quite  through  the  larynx 
into  the  cellular  tissue.    This  is  not  likely  to  happen  unless  undue  force 


INTUBATION.  497 

has  been  used.  The  production  of  a  false  passage  is  lecognised  by  the 
fact  that;,  although  the  tip  of  the  tube  can  be  felt  to  enter  the  larynx,  it 
does  not  descend,  but  projects  above  the  epiglottis. 

False  membrane  which  has  become  loosened  is  sometimes  crowded 
down  by  the  tube  and  obstructs  the  larynx  just  below  it.  This  is  one  of 
the  most  serious  accidents  that  may  occur,  but  fortunately  it  is  not  a 
frequent  one.  It  is  more  likely  to  happen  where  the  disease  has  existed 
for  several  days  than  in  recent  cases.  The  tube  may  be  in  place  in  the 
larynx  as  shown  by  all  the  signs  above  mentioned,  except  relief  of  the 
asphyxia.  In  such  a  case  the  immediate  withdrawal  of  the  tube  is  neces- 
sary, it  being  often  followed  by  the  discharge  of  masses  of  loose  mem- 
brane. This  is  aided  by  the  administration  of  a  teaspoonful  of  pure 
whisky  or  brandy  to  excite  a  strong  cough.  Artificial  respiration  may  be 
required,  and  if  there  is  no  relief  by  any  of  these  means  tracheotomy  is 
indicated.  Asphyxia  is  sometimes  produced  by  prolonged  and  injudi- 
cious attempts  at  introduction. 

After-treatment. — So  far  as  the  tube  itself  is  concerned  no  treatment 
is  required.  The  original  disease  is  to  be  treated  as  before.  The  opera- 
tion has  removed  only  one  danger  from  the  patient,  viz.,  that  of  asphyxia 
from  mechanical  obstruction  of  the  larynx.  A  good  expulsive  cough 
should  occur  after  the  tube  is  in  place.  This  is  necessary  to  clear  the  tube 
of  mucus,  as  the  pharynx  and  larynx  are  generally  filled  with  it  as  a  re- 
sult of  the  manipulation. 

The  child  should  not  be  allowed  to  lie  upon  its  face,  nor  should  it  be 
held  over  the  nurse's  shoulder  face  downward,  for  in  either  position  a 
slight  cough  is  enough  to  expel  the  tube.  Nursing  infants  may  continue 
at  the  breast  after  the  operation;  ordinarily  they  have  but  little  diffi- 
culty in  swallowing.  Older  children  often  experience  considerable  trou- 
ble in  taking  liquids.  This  may  be  overcome  by  the  device  suggested  by 
Casselberry  (Chicago),  of  having  the  patient's  head  lower  than  his  body 
while  he  drinks.  If  there  is  still  trouble  in  taking  fluids,  semi-solid  arti- 
cles, such  as  condensed  milk,  wine  jelly,  corn  starch,  or  scrambled  eggs, 
may  be  tried.  Feeding  is  always  easier  after  the  first  day  or  two,  and 
patients  who  wear  a  tube  for  chronic  disease  soon  experience  no  trouble 
whatever,  showing  that  the  difficulty  depends  more  upon  the  inability  to 
co-ordinate  the  movements  of  the  muscles  of  deglutition  when  the  tube 
is  in  place  than  upon  mechanical  causes,  for  the  head  of  the  tube  is  effec"- 
tually  covered  by  the  epiglottis. 

It  sometimes  happens  that  the  tube  is  coughed  out  soon  after  its 
introduction,  because  too  small  a  size  has  been  used.  In  some  cases 
this  occurs  repeatedly.  It  happened  in  a  case  of  my  own  twenty-eight 
times  during  four  days.  Sucli  cases  are  probably  due  to  paralysis  of  the 
laryngeal  muscles.  The  dyspnoea  does  not  usually  return  for  two  or  three 
hours  after  the  tube  has  been  coughed  out,  so  there  is  ample  time  to 


498  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

notify  the  physician.  It  may  happen  that  the  tube  is  coughed  up  and 
not  seen  by  the  nurse,  or  it  may  be  coughed  up  and  swallowed  by  the 
child.  When  called  because  of  dysjDnoea  after  operation,  the  physi- 
cian should  make  a  digital  examination  of  the  pharynx  to  be  sure 
that  the  tube  is  still  in  place.  Swallowing  the  tube  generally  causes 
no  harm  to  the  child,  for  tubes  have  repeatedly  passed  through  the  in- 
testines. 

The  entrance  of  food  into  the  bronchi  through  the  tube  is  a  danger 
that  does  not  exist,  as  has  been  shown  by  the  extensive  post-mortem  ob- 
servations of  Northrup  in  the  liew  York  Foundling  Asylum.  My  own 
experience  in  the  New  York  Infant  Asylum  coincides  in  every  particu- 
lar with  his  statement,  that  the  broncho-pneumonia  following  intubation 
does  not  depend  upon  the  entrance  of  food  into  the  bronchi. 

Ulceration  at  the  head  of  the  tube  very  rarely  occurs,  provided  prop- 
erly made  tubes  are  employed.*  The  tube  rests  not  upon  the  vocal  cords, 
but  upon  the  inferior  ventricular  bands.  When  ulceration  occurs,  it  is 
usually  of  the  anterior  wall  of  the  trachea,  at  the  lower  end  of  the  tube, 
and  appears  to  be  produced  by  the  movements  of  the  tube  during  deglu- 
tition. With  O'Dwyer's  latest  tubes  there  is  much  less  liability  of  this 
occurring.  The  ulcers  are  usually  small  and  superficial.  Deep  ulcers 
extending  to  the  tracheal  rings  may  be  seen  in  ill-conditioned  children, 
usually  in  connection  with  other  complications  severe  enough  to  cause 
■death. 

Spontaneous  descent  of  the  tube  into  the  larynx  is  impossible,  and  it 
can  not  be  crowded  down  without  using  considerable  force  and  severely 
lacerating  the  larynx. 

Sudden  blocking  of  the  lower  end  of  the  tube  by  membrane  loosened 
from  the  trachea  or  bronchi  is  an  infrequent  accident.  The  usual  result 
of  this  is  the  immediate  expulsion  of  the  tube  by  coughing,  the  discharge 
of  the  loose  membrane  following.  This  condition  is  one  of  the  safety 
valves  of  the  operation.  One  of  the  strong  points  in  favour  of  intuba- 
tion is  that  the  forcible  cough  which  the  patient  is  able  to  make  on  ac- 
count of  the  narrow  opening  of  the  tube,  often  enables  him  to  expel  large 
accumulations  of  mucus,  and  even  membrane,  more  readily  than  through 
a  much  larger  tracheal  opening. 

The  period  for  which  the  tube  is  required  varies  much  in  different 
cases.  It  is  the  experience  of  practically  all  operators  that  it  has  been 
materially  shortened  by  the  use  of  antitoxin.  According  to  the  statis- 
tics of  Rosenthal  (Philadelphia),  the  average  reduction  amounts  to  two 
and  a  half  days,  the  average  time  of  wearing  the  tube  is  five  days,  and 

*  This  and  many  other  bad  results  obtained  after  intubation  are  due  to  improperly 
constructed  instruments.  Those  made  by  George  Ermold,  201  Bast  Twenty-third 
Street,  New  York,  are  the  most  reliable. 


INTUBATION.  499 

in  many  it  can  be  dispensed  with  in  two  or  three  days.  Should  the 
tube  be  coughed  out  at  any  time,  its  introduction  should  be  delayed  until 
dyspnoea  returns. 

Removal  of  the  Tube — Extubation. — This  is  rather  more  difficult 
than  its  introduction.  The  general  arrangement  of  the  patient  and  as- 
sistants is  the  same  as  for  introduction.  The  left  index  finger  is  placed 
upon  the  head  of  the  tube,  which  is  steadied  externally  by  the  thumb  of 
the  same  hand.  The  beak  of  the  extractor  is  introduced  within  the  open- 
ing of  the  tube,  its  jaws  are  then  separated  by  pressure  upon  the  lever  at 
the  handle,  and  the  instrument  withdrawn,  very  slight  force  being  re- 
quired. 

The  tube  is  first  removed  tentatively,  the  physician  waiting  to  see  if 
dyspncea  returns.  It  is  well  to  give  a  full  dose  of  morphine  an  hour 
before  the  removal  of  the  tube,  since  the  contact  with  the  air  almost 
invariably  excites  a  marked  degree  of  laryngeal  spasm  which  lasts  for 
ten  or  fifteen  minutes.  To  avoid  the  production  of  vomiting  and  the 
entrance  of  food  into  the  larynx,  food  should  not  be  given  for  two  hours 
previously.  If  dyspnoea  does  not  return  in  the  course  of  three  or  four 
Jiours,  the  probabilities  are  that  the  tube  will  no  longer  be  required. 
It  is  very  exceptional  that  the  patient  has  great  difficulty  in  dispensing 
with  the  tube,  as  so  often  happens  after  tracheotomy. 

The  Advantages  over  Tracheotomy. — The  advantages  claimed  by 
O'Dwyer  for  this  operation  over  tracheotomy  are  conceded  by  most  of 
those  who  have  had  any  considerable  experience  in  the  operation,  viz. : 
(1)  It  is  quicker,  simpler,  and  adds  no  danger  to  the  original  disease ;  (2) 
there  is  no  shock  or  haemorrhage;  (3)  no  ansesthetic  is  required;  (4)  no 
fresh  wound  is  made  which  may  prove  an  avenue  of  infection;  (5)  it 
gives  an  opportunity  for  a  better  expulsive  cough,  which  is  of  great  value 
in  dislodging  false  membrane  and  mucus  ;  (6)  there  are  usually  no  objec- 
tions on  the  part  of  the  parents  to  be  overcome — a  point  of  great  impor- 
tance; (7)  the  air  is  warmed  and  moistened  as  it  is  normally,  by  passing 
over  the  nasal  and  buccal  mucous  membranes;  (8)  no  skilled  after-treat- 
ment is  required :  as  the  largest  proportion  of  the  cases  of  diphtheria 
are  among  the  very  poor,  living  under  conditions  in  which  the  careful 
after-treatment  required  in  tracheotomy  is  difficult  or  impossible  to  ob- 
tain, this  is  an  important  point;  (9)  in  infancy,  all  who  have  had  ex- 
perience with  both  operations  admit  the  great  superiority  of  jntuba- 
tion;  (10)  the  intubation  tube  can  be  dispensed  with  earlier  than  the 
tracheal  canula,  and  also  with  much  less  difficulty;  (11)  if  tracheot- 
omy is  subsequently  required,  the  operation  may  be  done  upon  the  tube 
as  a  guide. 

The  only  objection  of  much  force  urged  against  intubation  is  tliat 
asphyxia  may  be  produced  by  crowding  down  loose  membrane  into  the 
larynx.    This  is  a  very  infrequent  accident;  should  it  happen,  and  the 


500  DISEASES   OF   THE  RESPIRATORY   SYSTEM. 

asphyxia  not  be  relieved  by  coughing  up  the  membrane,  tracheotomy  may 
be  performed. 

There  is  always  some  degree  of  hoarseness  following  intubation,  but 
in  the  majority  of  cases  it  disappears  within  a  week,  occasionally  it  con- 
tinues as  long  as  three  or  four  weeks,  but  it  is  very  rarely  if  ever  perma- 
nent. The  duration  of  the  aphonia  seems  to  have  no  relation  to  the 
length  of  time  the  tube  is  worn. 

Experience  has  clearly  proved  that  intubation  relieves  the  dypsnoea. 
due  to  laryngeal  stenosis  promptly,  efficiently,  and  certainly ;  it  does  this 
without  many  of  the  dangers  and  objectionable  features  of  tracheotomy, 
while  at  the  same  time  it  does  not  deprive  the  patient  of  any  essential 
advantage  which  tracheotomy  affords. 

Retained  Intubation  Tubes — Prolonged  Intubation. — Difficulty  is  ex- 
perienced in  dispensing  with  the  intubation  tube  much  less  frequently 
than  with  the  canula  after  tracheotomy;  yet  when  this  condition  occurs 
it  is  the  cause  of  much  concern  and  even  danger.  Trouble  of  this  sort 
is  seen,  according  to  Eogers,  in  about  one  per  cent  of  the  cases  of  in- 
tubation. In  the  majority  of  these  the  patient  is  able  to  do  without  the 
tube  in  a  few  weeks,  and  such  cases  require  very  close  attention,  but 
no  special  treatment  other  than  the  substitution  at  times  of  a  special 
O'Dwyer  tube  with  an  extra  large  "  retaining  swell."  But  occasionally 
there  are  met  with  cases  in  which  every  effort  to  dispense  with  the  tube 
seems  fruitless.  Although  the  children  breathe  well  with  the  tube  in  place,, 
still  if  it  is  removed  or  expelled  by  coughing,  in  a  short  time,  varying 
from  a  few  minutes  to  an  hour  or  two,  the  dyspnoea  returns  with  such 
severity  that  the  tube  must  be  replaced  immediately  to  prevent  asphyxia. 
Inasmuch  as  these  patients  sometimes  expel  the  tube  several  times  a 
day,  surgeons  have  often  resorted  to  tracheotomy  to  avert  the  danger  of 
suffocation,  which  might  easily  occur  if  no  one  were  at  hand  who  could 
replace  the  tube.  This  operation,  however,  gives  only  temporary  relief. 
Many  of  these  children,  after  wearing  tubes  of  one  sort  or  another  for 
years,  ultimately  die  from  some  accident  connected  with  the  tube  or 
from  pneumonia. 

The  causes  and  the  exact  pathological  condition  underlying  this  diffi- 
culty are  subjects  regarding  which  there  has  been  much  difference  of  opin- 
ion. O'Dwyer's  opinion  was  that  the  cause  of  the  returning  dyspnaa  was 
subglottic  swelling  and  oedema  which  occurred  in  tissues  which  were  the 
seat  of  chronic  inflammation  as  soon  as  the  pressure  of  the  tube  was  re- 
moved. The  primary  cause  of  the  condition  he  believed  to  be  the  injury 
inflicted  by  improperly  made  or  badly  fitting  tubes,  or  by  unskilful  ef- 
forts at  introduction.  In  a  few  cases  a  cicatricial  condition,  the' result 
of  previous  ulceration,  has  been  found;  but  it  is  doubtful  if  granulations, 
so  frequent  a  cause  of  retained  canula  after  tracheotomy,  play  any  part 
whatever.     Eogers's  view  is  that  the  chronic  inflammation  of  the  mu- 


SUBMUCOUS  LARYNGITIS.  501 

cons  and  submucous  tissues  of  the  subglottic  region  of  the  larynx  which 
produces  the  symptoms,  is  due  neither  to  a  faulty  tube  nor  to  a  clumsy 
operation,  but  to  the  nature  of  the  pathological  process. 

For  the  relief  of  this  condition,  O'Dwyer  advised  in  recent  cases 
the  application  of  astringents  by  means  of  an  intubation  tube  coated  with 
gelatine  with  which  some  astringent  was  combined.  For  those  pa- 
tients who  cough  out  the  tube  frequently,  tracheotomy  is  at  times  a 
necessity  to  prevent  sudden  death.  But  this  does  not  affect  the  original 
condition,  for  the  same  difficulty  exists  in  doing  without  the  tracheal 
canula.  The  operations  of  laryngotomy,  curetting,  etc.,  have  been  such 
signal  failures  as  to  discourage  one  from  repeating  them. 

The  most  successful  method  of  treatment  thus  far  proposed  is  that  of 
Eogers,*  which  consists  in  increasing  intra-laryngeal  pressure  by  the  in- 
sertion of  larger  and  larger  intubation  tubes.  This  is  not  to  be  adopted 
until  long  after  all  acute  symptoms  have  subsided.  The  first  tube  used  is 
as  large  a  one  as  can  be  introduced  without  force;  after  a  few  weeks,  the 
next  larger  size,  and  after  a  longer  interval,  possibly  a  still  larger  one. 
When  the  very  large  tube  had  been  worn  for  several  weeks  he  was  finally 
able  to  dispense  with  all  tubes.  In  this  way  he  succeeded  in  curing  com- 
pletely and  permanently  several  cases  of  two  or  three  years'  standing. 

True  cicatricial  stenosis  may  best  be  relieved  by  opening  the  trachea 
and  dilating  from  below,  and  afterward  inserting  an  intubation  tube. 
When  there  is  complete  destruction  of  the  cricoid  cartilage,  as  sometimes 
occurs,  tracheotomy  is  the  only  remedy,  but  this  is  only  palliative,  as  the 
tube  must  be  worn  permanently. 

SUBMUCOUS  LARYNGITIS— CEDEMA   OF  THE  GLOTTIS. 

These  two  conditions  are  not  quite  identical,  although  they  are  close- 
ly associated  and  may  be  conveniently  considered  together.  They  are 
both  rare  in  early  life.  In  true  oedema  of  the  glottis  there  is  simply  a 
dropsical  effusion  into  the  submucous  cellular  tissue  of  the  aryteno-epi- 
glottic  folds,  causing  them  to  project  as  large  rounded  swellings  on  either 
side  of  the  superior  isthmus  of  the  larynx.  They  may  be  of  sufficient  size 
to  cause  serious  or  even  fatal  obstruction  to  respiration.  With  the  laryn- 
goscope they  appear  as  pale  red  tumours,  lying  usually  in  contact  near 
the  base  of  the  tongue.  By  the  finger  their  presence  can  be  quite  as 
readily  distinguished.  (Edema  of  the  glottis  occurs  principally  in  the 
late  stages  of  nephritis. 

In  the  inflammatory  form  of  oedema,  or  true  submucous  laryngitis, 
there  is  the  same  sort  of  swelling  of  those  structures,  but  in  this  case  it  is 

*  Posl-Diphtheritic  Stenosis  of  the  Larynx,  Jolui  Rogers,  M.  D.,  Annals  of  Surgery, 
May,  1900.  See  also  monograph  by  von  Bokay,  Ueber  das  Intubations-trauma,  Leip- 
zig, 1901. 


502  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

due  to  some  active  inflammation  in  the  neighbourhood.  The  swelling  is 
partly  from  the  cedema  and  partly  from  cell  infiltration.  Usually  all  the 
parts  surrounding  the  upper  opening  of  the  larynx  are  in  a  state  of  acute 
inflammation.  The  epiglottis  may  be  swollen  to  the  thickness  of  a  finger, 
and  easily  seen  by  depressing  the  tongue. 

The  exciting  causes  may  be  the  mechanical  irritation  of  foreign  bodies, 
the  inhalation  of  steam  or  irritating  gases,  erysipelas  of  the  neck,  primary 
catarrhal  laryngitis,  or  retro-pharyngeal  abscess. 

The  symptoms  in  both  cases  consist  of  great  inspiratory  dyspnoea 
with  attacks  of  suffocation,  while  expiration  may  be  quite  easy.  In  true 
cedema  there  are  in  addition  the  symptoms  of  the  primary  disease.  In 
the  inflammatory  form  there  are  the  evidences  of  local  inflammation — 
hoarseness,  cough,  pain,  and  difficulty  in  swallowing.  A  positive  diag- 
nosis may  be  made  by  a  digital  examination.  The  symptoms  develop  with 
great  rapidity  in  either  variety,  and  frequently  prove  fatal  in  a  few  hours. 

The  treatment  of  true  oedema  consists  in  scarification  or  multiple 
puncture,  the  application  of  ice  externally,  and  even  the  swallowing  of 
ice  ;  in  the  inflammatory  form,  in  addition,  local  blood-letting  by  leeches 
and,  as  a  last  resort,  tracheotomy.     Intubation  is  useless  in  either  form. 

CHRONIC  LARYNGITIS. 

The  following  varieties  are  seen :  (1)  a  simple  form  usually  associated 
with  adenoid  vegetations  of  the  pharynx ;  (2)  tuberculous ;  (3)  syphilitic ; 
(4)  that  associated  with  new  growths. 

1.  With  Adenoid  Vegetations  of  the  Pharynx. — This  is  not  very  uncom- 
mon. The  larynx  is  kept  in  a  state  of  chronic  congestion  by  the  adenoid 
growth,  and  there  finally  develops  a  sight  superficial  catarrhal  inflamma- 
tion. The  symptoms  may  continue  for  many  months.  These  cases  are 
often  treated  for  a  long  time  unsuccessfully  by  the  use  of  sprays,  inhala- 
tions, etc.,  but  the  symptoms  disappear  rapidly  after  the  removal  of  the 
adenoid  growth.  Similar  symptoms  may  be  associated  with  hypertrophic 
rhinitis.  In  this  also  the  treatment  should  be  directed  to  the  primary 
condition. 

2.  Tuberculous  Laryngitis. — This  belongs  to  later  childhood,  and  is  rare 
even  then.  In  infancy  it  is  almost  unknown.  Rheindorf  *  has  reported 
a  case  in  a  child  of  thirteen  months,  which  was  regarded  during  life  as 
syphilitic,  but  was  shown  by  autopsy  to  be  tuberculous.  Of  sixteen  cases 
in  children,  reported  by  Rilliet  and  Barthez,  none  occurred  during  the 
first  three  years,  and  oidy  four  before  the  seventh  year.  The  larynx  alone 
may  be  affected,  or  the  larynx  and  trachea,  or  the  larynx,  trachea,  and 
lungs.     Pulmonary  tuberculosis  is  usually  found  to  be  present  at  autopsy, 

*  Jahrbuch  fur  Kinderh.,  Bd.  xxxiii,  p.  71. 


CHRONIC  LARYNGITIS.  503 

even  though  there  maj^  have  been  no  puhnonary  symptoms.  Demme  has 
reported  a  case  of  tuberculous  laryngitis  in  a  boy  of  four  years,  whose 
lungs  were  healthy,  death  resulting  from  tuberculous  meningitis. 

The  symptoms  are  hoarseness,  aphonia,  laryngeal  cough,  and  muco- 
purulent, sometimes  bloody,  expectoration.  The  sputum  may  contain 
tubercle  bacilli.  With  the  laryngoscope  tuberculous  deposits  may  be 
seen,  but  more  frequently  tuberculous  ulceration  of  the  mucous  mem- 
brane. In  children  this  is  usually  superficial,  the  deep  destructive  ulcera- 
tion seen  in  adults  being  very  rare. 

It  is  to  be  differentiated  from  syphilis  chiefly  by  the  general  symptoms, 
as  the  laryngoscopic  appearances  may  be  very  similar.  The  treatment  con- 
sists in  keeping  the  ulcers  as  clean  as  possible  by  the  use  of  sprays  and 
the  local  application  of  astringent  powders,  like  nitrate  of  silver  and  sul- 
phate of  zinc  or  iodoform. 

3.  Syphilitic  Laryngitis. — In  the  early  stage  of  syphilis  the  larynx  is 
often  the  seat  of  a  catarrhal  inflammation,  which  presents  nothing  espe- 
cially characteristic  except  its  protracted  course.  The  laryngitis  of  late 
hereditary  syphilis  is  quite  rare,  and  is  liable  to  be  overlooked  because  of 
the  difficulties  in  the  way  of  a  thorough  examination,  and  because  the  dis- 
ease is  usually  painless. 

Strauss  *  has  collected  fourteen  cases  between  the  ages  of  three  and 
fifteen  years,  and  added  three  of  his  own.  He  states  that  deep-seated  pro- 
cesses are  much  more  rare  than  among  adults.  The  parts  most  frequently 
affected  are,  first,  the  epiglottis  ;  secondly,  the  aryteno-epiglottic  folds  ; 
thirdly,  the  posterior  laryngeal  wall.  The  epiglottis  was  involved  in 
twelve  of  fourteen  cases.  Usually  there  was  only  perichondritis ;  in  the 
more  severe  cases  there  was  partial  or  complete  destruction  of  the  cartilage. 
In  four  cases  papillomatous  masses  were  seen.  In  five  cases  the  process 
extended  from  the  epiglottis  to  the  epiglottic  folds  of  one  or  both  sides. 
In  several  instances  the  superior  vocal  cords  were  thickened  from  hyper- 
plasia, and  occasionally  small  tumours  were  formed.  In  only  one  case  was 
there  ulceration  of  these  folds.  Changes  in  the  vocal  cords  and  the  aryte- 
noid cartilages  were  rare,  occurring  only  with  extensive  inflammation. 
The  symptoms  are  those  of  chronic  laryngitis ;  hoarseness,  sometimes 
aphonia,  and  in  a  few  cases  chronic  laryngeal  stenosis.  Tlie  diagnosis 
can  be  made  only  by  means  of  the  laryngoscope.  In  most  of  the  cases 
there  are  present  ulcerations  of  tbe  palate  or  uvula,  or  scars  from  pre- 
vious ulcers ;  sometimes  the  disease  extends  into  the  nose.  Serious 
symptoms  often  result  when  to  old  syphilitic  lesions  there  is  added  acute 
laryngitis  or  oidema. 

In  addition  to  the  usual  constitutional  remedies  for  tertiary  syphilis, 
and  to  the  means  ordinarily  employed  for  the  relief  of  chronic  laryngitis, 

*  Archiv  fijr  Kindcrh.,  Bd.  xiii. 


504  DISEASES  OP  THE  RESPIRATORY  SYSTEM. 

intubation  may  be  required  in  these  cases  for  the  relief  of  laryngeal  ste- 
nosis. Nowhere  are  its  advantages  over  tracheotomy  more  striking  than 
here.     The  tube  must  usually  be  worn  for  many  months. 

NEW  GROWTHS. 

New  growths  of  the  larynx  are  not  very  rare  in  children.  Excluding 
the  granulations  which  follow  the  use  of  the  tracheal  canula,  the  only  one 
that  is  likely  to  be  met  with  is  papilloma.  This  may  occur  even  in  in- 
fancy. According  to  Eauchfuss,  the  majority  of  the  cases  begin  during 
the  first  year.     Boys  are  more  frequently  affected  than  girls. 

The  symptoms  depend  upon  the  size  and  location  of  the  tumour.  The 
earlier  manifestations  are  usually  ascribed  to  chronic  laryngitis.  There 
is  hoarseness,  sometimes  loss  of  voice,  and  a  paroxysmal  cough  ;  later, 
dyspnoea  develops.  The  symptoms  are  slowly  progressive,  and  it  may  be 
several  months  before  they  are  sufficiently  severe  to  attract  special  atten- 
tion. A  positive  diagnosis  is  made  only  by  the  laryngoscope.  There  is 
seen  a  whitish  granular  tumour,  sometimes  pedunculated,  sometimes  with 
a  broad  base,  attached  to  any  part  of  the  larynx. 

The  treatment  of  these  cases  belongs  to  the  specialist.  Small  pedun- 
culated growths  may  be  removed  through  the  mouth  by  means  of  the 
forceps  or  snare.  Larger  ones  require  thyrotomy.  The  prognosis  is 
generally  unfavourable,  on  account  of  the  danger  of  recurrence  after 
operation.  Operative  measures  are  very  frequently  followed  by  bron- 
chitis or  broncho-pneumonia. 

FOREIGN  BODIES  IN  THE  LARYNX. 

The  aspiration  of  foreign  substances  into  the  larynx  is  not  a  very  rare 
accident  in  children.  It  usually  happens  from  an  attempt  to  cough, 
laugh,  or  cry  while  the  child  has  something  in  its  mouth.  If  the  body  is 
sharp  and  irregular,  like  a  pin,  the  shell  of  a  nut,  or  a  fragment  of  bone, 
it  is  liable  to  become  impacted  in  the  larynx.  If  smooth,  like  a  pea  or 
a  bead,  it  is  usually  drawn  into  one  of  the  bronchi,  generally  the  right. 

When  the  body  enters  the  larynx  there  is  immediately  excited  a  violent 
paroxysmal  cough,  with  dyspnoea  amounting  almost  to  suffocation.  Often 
the  body  is  dislodged  by  this  initial  attack  of  coughing.  If  it  becomes 
impacted  in  the  larynx,  it  may  cause  sudden  death  by  occluding  the 
glottis ;  elsewhere  it  may  excite  acute  laryngitis,  usually  of  considerable 
severity. 

The  impaction  of  a  foreign  body  in  one  of  the  primary  bronchi,  or  one 
of  the  lobar  divisions,  is  indicated  by  cough  and  a  severe  localized  pain  in 
the  chest.  There  may  be  expectoration  of  blood.  On  auscultating  the 
chest,  there  is  found  an  absence  of  respiratory  murmur  over  one  lung  or 
one  lobe,  according  to  the  situation  of  the  foreign  body.    Percussion  gives 


THE  LUNGS  IN   INFANCY  AND  CHILDHOOD.  505 

increased  resonance,  which  may  even  be  tympanitic,  owing  to  emphysema 
which  rapidly  develops.  If  the  foreign  body  remains  impacted  in  one  of 
the  bronchi,  it  usually  excites  a  localized  inflammation,  which  extends  to 
the  surrounding  lung  and  terminates  in  the  formation  of  an  abscess. 
This  may  result  fatally,  or  there  may  follow  a  prolonged  illness,  with 
hectic  symptoms  resembling  pulmonary  tuberculosis  ;  and  finally,  after 
weeks  or  months,  the  foreign  body  may  be  expelled  by  an  attack  of  cough- 
ing, and  the  patient  recover  completely. 

The  diagnosis  of  a  foreign  body  in  the  larynx  is  made  by  the  sudden- 
ness of  tlie  attack  and  the  violence  of  the  early  symptoms.  In  older  chil- 
dren the  body  may  be  seen  with  the  laryngoscope,  but  in  young  children 
this  is  very  difficult.  The  prognosis  is  always  doubtful,  and  depends  upon 
the  nature  of  the  foreign  body  and  the  point  at  which  it  has  been  arrested. 

Treatment.- — -The  first  thing  to  be  tried  is  inversion  of  the  patient. 
By  this  means,  assisted  by  the  cough,  the  foreign  body  is  not  infrequently 
expelled,  even  though  it  has  passed  below  the  larynx.  The  symptoms  of 
laryngeal  obstruction  may  call  for  immediate  tracheotomy  or  laryngotomy, 
intubation  not  being  applicable  to  these  cases.  If,  after  tracheotomy,  the 
foreign  body  can  be  located  in  the  larynx,  but  can  not  be  extracted  through 
the  tracheal  wound,  the  thyroid  cartilage  should  be  divided  in  the  median 
line.  The  removal  of  a  foreign  body  from  the  bronchi  or  the  tracheal 
'bifurcation  should  be  attempted  only  by  a  skilled  surgeon. 


CHAPTER  III. 

DISEASES  OF  THE  LUNGS. 

THE   PECULIARITIES  OF  THE  LUNGS  IN  INFANCY  AND  EARLY 

CHILDHOOD. 

Thorax. — The  general  shape  of  the  thorax  is  somewhat  cylindrical, 
the  conical  or  dome-shape  of  the  adult  thorax  not  being  attained  until 
puberty.  The  antero-posterior  and  the  transverse  diameters  are  nearly 
equal  in  the  newly  born,  but  after  the  third  year  the  transverse  diameter 
is  always  greater,  the  difference  increasing  steadily  up  to  adult  life.  On 
account  of  the  shape  of  the  chest,  the  lungs  are  situated  rather  more 
posteriorly  in  the  infant  than  in  the  adult. 

The  thoracic  walls  are  very  elastic  and  yielding,  owing  to  the  carti- 
laginous condition  of  a  large  part  of  the  framework.  They  are  rela- 
tively thinner  than  in  the  adult,  chiefly  from  the  imiicrfect  develop- 
ment of  the  thoracic  niu.selcs.  The  greater  part  of  tlif  thickness  of  the 
thoracic  walls  is  due  to  the  deposit  of  fat,  generally  abundant  in  well- 
nourished  infants;  but  wlicrc  the  fat  is  scantv  the  walls  are  extremely 


506  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

thin.  The  capacity  of  the  thorax  is  considerably  encroached  upon  by  the 
high  position  of  the  diaphragm,  the  large  size  of  the  thymus  gland,  and 
the  frequent  distention  of  the  stomach  and  intestines. 

Respiration. — According  to  Uffelmann,  the  rapidity  of  respiration  dur- 
ing sleep  at  the  different  ages  is  as  follows : 

At  birth 35  per  minute. 

At  the  end  of  the  first  year 27    "        " 

At  two  years 25    "        " 

At  six  years 22    " 

At  twelve  years 20    "        " 

During  waking  hours  this  rate  is  very  materially  increased,  and  from  com- 
paratively slight  disturbance  it  may  be  nearly  twice  as  rapid. 

The  type  of  respiration  in  infants  is  diaphragmatic,  and  it  continues  to 
be  chiefly  so  until  after  the  seventh  year,  -when  the  costal  element  grad- 
ually becomes  more  and  more  prominent.  The  rhythm  of  respiration  is 
easily  disturbed.  In  very  young  infants  the  regular  rhythm  is  seen  only 
in  sleep.  The  lungs  do  not  always  expand  equally ;  at  certain  times  and 
in  certain  positions  respiration  may  be  carried  on  for  a  few  moments 
almost  entirely  with  one  lung.  For  some  moments  it  may  be  very  super- 
ficial, and  then  quite  deep.  The  length  of  the  interval  between  inspira- 
tion and  expiration  varies  much  at  different  times.  Eegular  rhythmical 
respiration  is  not  fully  established  before  the  end  of  the  second  year. 
After  this  time  disturbances  of  rhythm  are  chiefly  due  to  pulmonary  or 
cerebral  disease ;  but  in  infancy  quite  marked  irregularity  may  have  little 
or  no  significance.     It  is  very  common  in  all  asthenic  conditions. 

Structure. — As  compared  with  the  adult,  the  trachea  of  the  young 
child  is  larger ;  the  bronchi  are  larger,  more  numerous,  and  occupy  a 
greater  space ;  the  air  cells  are  much  smaller  and  occupy  less  space ;  and 
the  interstitial  tissue  is  much  more  abundant. 

Physical  Examination. — This  requires  tact  and  time,  but  yields  results 
which  are  quite  as  satisfactory  as  in  adults.  It  should  be  undertaken  only 
in  a  room  having  a  temperature  of  about  72°  F.,  or  before  an  open  fire. 

Inspedimi. — This  should  be  made  Avith  the  chest  bare.  There  should 
be  noted,  the  shape  of  the  chest,  the  presence  of  deformities  from  rickets, 
the  want  of  symmetry  in  the  two  sides,  bulging  of  the  intercostal  spaces, 
whether  the  two  lungs  expand  equally  or  not,  also  variations  in  rhythm, 
and  the  presence  and  extent  of  any  recession  of  the  soft  parts  or  bony 
walls  as  an  indication  of  obstructive  dyspnoea. 

Palpation. — This  also  should  be  made  upon  the  bare  skin,  always  with 
the  hand  well  warmed.  Although  we  can  not  get  the  fremitus  of  the 
voice,  we  can  get  that  of  the  cry.  This  is  usually  more  intense  than  in 
adults,  on  account  of  the  thinness  of  the  chest  walls.  We  frequently  get 
a  bronchial  fremitus — a  vibration  produced  by  mucus  in  the  tubes.  This 
may  enable  one  to  recognise  bronchitis  quite  as  positively  as  by  the  ear. 


THE  LUNGS   IN   INFANCY   AND   CHILDnOOD.  507 

The  position  of  the  apex  beat  of  the  heart  should  be  determined,  it  being 
remembered  that  in  infancy  this  is  normally  in  the  mammary  line,  or  just 
outside  of  it,  and  usually  in  the  fourth  intercostal  space. 

Percussion. — For  the  examination  of  the  back,  the  child  may  be  laid 
face  downward  upon  the  nurse's  lap,  or  be  seated  upon  her  arm.  For  the 
front  and  the  lateral  regions  of  the  chest,  the  child  is  most  conveniently 
placed  \\])o\\  its  side  across  a  hard  pillow.  The  percussion  blow  must  be 
light,  either  with  a  single  finger  or  a  small  percussion  hammer,  using  a 
finger  of  the  opposite  hand  as  a  pleximeter.  Percussion  should  be  made 
both  during  inspiration  and  expiration.  The  normal  percussion  note  is 
somewhat  tympanitic,  this  being  due  to  the  relatively  large  bronchi  and 
the  thin  chest  walls.  This  note  is  exaggerated  in  the  interscapular  region 
and  beneath  the  clavicle,  especially  upon  the  right  side.  Here  cracked- 
pot  resonance  may  be  obtained  even  in  health.  In  early  infancy  the 
thymus  gives  dulness  over  the  sternum  as  low  as  the  third  rib,  sometimes 
even  below  this  point,  this  gradually  diminishing  as  age  advances. 

Auscultation. — This  may  be  practised  with  the  naked  ear  or  with  the 
stethoscope.  A  stethoscope  is  absolutely  necessary  for  a  thorough  exam- 
ination of  the  apices  of  the  lungs  in  front  and  in  the  axillary  regions. 
Most  children  are  less  frightened  by  the  instrument  than  by  the  head  of 
the  physician  during  anterior  auscultation.  For  the  posterior  part  of  the 
lungs,  the  stethoscope  may  be  dispensed  with.  One  with  a  small  bell 
from  one-half  to  three-fourths  of  an  inch  in  diameter  is  of  great  advan- 
tage. In  auscultating  with  the  ear  it  is  not  necessary  to  bare  the  skin. 
The  physician  should  always  auscultate  the  posterior  part  of  the  chest 
first,  because  he  is  most  likely  to  find  signs  of  disease  there,  and  also 
because  this  is  not  so  apt  to  frighten  the  infant.  Every  part  of  the  chest 
should,  however,  be  thoroughly  auscultated,  not  omitting  the  high  axil- 
lary regions.  A  convenient  position  for  posterior  auscultation  is  to  have 
the  child  held  over  the  nurse's  shoulder. 

The  normal  respiratory  murmur  of  the  infant  is  generally  described  as 
puerile.  In  quality  this  has  been  likened  to  the  bronchial  breathing  of 
the  adult,  but  the  resemblance  is  not  a  very  close  one.  It  is  rude,  rather 
loud,  and  seems  very  near  the  ear.  Its  peculiar  character  is  due  to  the 
fact  that  the  tracheal  and  bronchial  sounds  are  more  distinct,  because 
not  transmitted  through  so  thick  a  layer  of  lung  and  chest  wall.  It  is 
especially  loud  in  the  regions  where  the  bronchi  are  superficial,  as  between 
the  shoulder-blades  and  beneath  the  clavicles,  particularly  of  the  right 
side.  A  careful  comparison  of  the  two  sides  of  the  chest  will  generally 
enable  an  observer  to  avoid  errors.  The  irregularity  of  rhythm  which 
occurs  from  slight  causes  should  be  remembered,  and  the  infant's  position 
changed  several  times  during  auscultation,  to  avoid  the  mistake  of  at- 
taching too  much  importance  to  a  feeble  respiratory  murmur  of  one  side. 

On  account  of  the  thinness  of  the  chest  walls,  there  is  always  great 


508  DISEASES  OF   THE   RESPIRATORY  SYSTEM. 

difficulty  in  distinguishing  between  rales  produced  in  the  bronchi  and 
pleuritic  friction  sounds.  Before  drawing  any  inference  from  the  auscul- 
tatory signs,  both  lungs  must  be  examined  for  several  minutes,  changing 
the  child's  position,  and  often  inducing  a  cry  or  compelling  a  deep  inspi- 
ration by  other  means,  in  order  to  bring  out  signs  which  otherwise  may 
be  overlooked.  As  auscultation  is  extremely  difficult  or  impossible  in  a 
crying  infant,  this  part  of  the  physical  examination  should  first  be  made 
if  the  child  is  quiet,  since  upon  it  we  must  chiefly  depend  for  diagnosis. 
Inspection  and  percussion  can  be  deferred  until  later. 

Peculiarities  in  Disease. — There  are  several  peculiarities  connected 
with  the  respiratory  organs  in  infancy  and  early  childhood  which  must  be 
constantly  borne  in  mind  in  studying  their  diseases.  The  muscular  de- 
velopment of  the  thoracic  wall  is  feeble.  The  soft,  yielding  character  of 
the  thoracic  framework  causes  the  chest  to  sink  in  readily  from  atmos- 
pheric pressure  whenever  there  is  obstructive  dyspnoea.  On  account  of 
the  small  size  of  the  air  vesicles,  acute  congestion  may  interfere  with  their 
function  almost  as  completely  as  does  consolidation.  Because  of  the 
delicate  walls  of  the  air  vesicles,  emphysema  is  readily  produced  in  ob- 
structive dyspncea,  but  it  is  rarely  permanent.  There  is  a  tendency  to 
collapse,  either  on  the  part  of  lobules  or  groups  of  lobules,  but  very 
rarely  of  an  entire  lobe.  This  is  a  much  less  important  factor  in  the 
production  of  symptoms  in  acute  pulmonary  disease  than  many  writers 
would  lead  us  to  suppose.  The  tendency  of  inflammation  to  spread 
from  the  large  to  the  small  bronchi  is  very  much  greater  than  in  adults. 
In  all  forms  of  pulmonary  disease  the  rapidity  of  respiration  is  much 
greater  than  in  adults,  on  account  of  the  rapid  metabolism  of  the  child. 
Areas  of  consolidation  often  exist  without  appreciable  changes  in  the 
percussion  note,  because  they  are  superficial  and  are  surrounded  by 
healthy  or  emphysematous  lung.  Flatness  should  always  suggest  the 
presence  of  fluid.  Disease  is  often  overlooked,  from  a  failure  to  examine 
the  whole  chest. 

Probably  the  most  common  mistakes  are  to  confound  bronchial  rales 
with  friction  sounds,  exaggerated  puerile  breathing  with  bronchial  breath- 
ing, and  to  overlook  the  existence  of  fluid  because  of  the  presence  of 
bronchial  breathing. 

ACUTE  CATARRHAL  BRONCHITIS. 

Acute  catarrhal  bronchitis  is  one  of  the  most  frequent  conditions  for 
which  the  physician  is  called  upon  to  prescribe  in  children.  It  occurs  at 
all  ages,  from  early  infancy  up  to  puberty.  Its  frequency,  however,  di- 
minishes steadily  after  the  second  year.  The  predisposition  to  acute 
bronchitis  exists  with  the  same  constitutional  conditions,  and  is  acquired 
in  the  same  manner  as  the  predisposition  to  the  acute  catarrhal  inflam- 
mations of  the  upper  respiratory  tract.    ^^See  Acute  Rhinitis).    Bronchitis  is 


ACUTE   CATARRHAL   BRONCHITIS.  509 

very  common  in  children  who  are  suffering  from  rickets  and  malnutrition. 
It  is  much  more  frequent  in  the  cold  months,  especially  in  the  late  winter 
and  early  spring,  when  there  are  sudden  atmospheric  changes  and  high 
winds. 

Bronchitis  may  be  a  primary  or  a  secondary  disease.  The  primary  form 
is  excited  by  cold,  exposure  with  insufficient  clothing  in  severe  weather, 
wetting  of  the  feet,  or  chilling  of  the  surface  in  any  manner.  Under 
these  conditions  it  may  occur  alone,  or  be  associated  with  or  preceded 
by  acute  catarrh  of  the  nose,  pharynx,  or  larynx.  In  rare  cases  it  is 
caused  by  the  inhalation  of  irritants.  Bronchitis  is  an  almost  invariable 
accompaniment  of  measles  and  influenza.  It  is  very  common  in  pertussis, 
in  scarlet  and  typhoid  fevers  and  diphtheria,  and  may  occur  in  any  acute 
infectious  disease ;  it  also  complicates  pneumonia  and  pleurisy.  The  rela- 
tion of  micro-organisms  to  the  other  etiological  factors  is  the  same  as  in 
the  other  acute  catarrhs.     (See  Rhinitis). 

Lesions. — Acute  catarrhal  bronchitis  is  an  inflammation  of  the  mucous 
membrane  of  the  bronchi.  As  a  rule  it  is  bilateral,  both  sides  being 
involved  to  the  same  degree.  Localized  bronchitis  is  secondary  to  some 
other  pathological  process  in  the  lungs,  usually  tuberculosis  or  pneumonia. 
In  acute  bronchitis  only  the  larger  tubes  may  be  affected,  this  usually 
being  complicated  with  inflammation  of  the  trachea  (ordinary  tracheo- 
bronchitis) ;  or,  in  addition,  the  process  may  extend  to  the  medium-sized 
tubes  (severe  bronchitis) ;  oi*,  in  infants  especially,  it  may  extend  to  the 
smallest  tubes  (capillary  bronchitis).  In  the  last-mentioned  form  there 
are  invariably  changes  in  the  zones  of  air  vesicles  surrounding  the  bron- 
chi, and  these  cases  are  therefore  more  properly  classed  as  broncho-pneu- 
monia. In  the  first  form  the  inflammation  is  superficial,  and  affects  only 
the  mucous  membrane  of  the  bronchi.  In  the  second  form  it  may  involve 
the  entire  thickness  of  the  bronchial  wall,  and  in  the  third  form  it  does  so 
regularly. 

The  pathological  changes  consist  in  congestion  and  swelling  of  the 
mucous  membrane,  desquamation  of  the  epithelium,  and  an  exudation  of 
mucus  and  pus-cells.  iVt  autopsy  the  injection  of  the  mucous  membrane 
is  usually  distinct ;  pus  and  mucus  line  the  walls  of  the  larger  bronchi, 
and  by  pressure  ooze  from  the  cut  extremities  of  the  smaller  tubes.  The 
chief  lesion  of  the  walls  of  the  bronchi  consists  in  an  infiltration  with  leu- 
cocytes. In  infants  dying  from  bronchitis,  the  lungs  are  much  more  fre- 
quently emphysematous  than  collapsed.  There  is  swelling  of  the  lymph 
glands  at  the  root  of  the  lungs,  which  in  most  of  the  acute  cases  is  slight, 
but  in  protracted  cases,  and  after  recurring  attacks,  may  be  quite  marked. 
Symptoms. — It  is  convenient  to  consider  separately  the  symptoms  in 
infants  and  in  older  children. 

The  bronchitis  of  infants. — 1 .  Tlie  mild  form  (bronchitis  of  the  larger 
tubes). — The  onset  is  generally  gradual,  and  tlie  symptoms  of  bronchitis 
may  be  preceded  by  those  of  catarrh  of  the  nose,  pharynx,  or  larynx.    The 
34 


510  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

change  in  the  character  of  the  cough,  the  slightly  accelerated  breathing, 
and  a  further  rise  in  temperature,  indicate  an  extension  to  the  bronchi. 
The  cough  may  be  constant  and  severe,  or  very  slight.  There  is  no  ex- 
pectoration. The  secretions  are  usually  coughed  up  into  the  mouth  or 
pharynx,  and  swallowed.  This  sometimes  excites  vomiting.  At  other 
times  the  mucus  is  coughed  only  into  the  trachea  or  larynx,  and  aspirated 
again  into  the  lungs.  The  respirations  are  from  40  to  50  a  minute,  and 
often  accompanied  by  a  rattling  sound,  due  to  mucus  in  the  large  bron- 
chi or  trachea.  The  general  symptoms  are  not  severe,  and  unless  the  in- 
fant is  very  young  or  very  delicate  no  apprehension  need  be  felt  as  to  the 
outcome.  The  temperature  is  generally  from  100°  to  102°  F.  for  two  or 
three  days,  then  below  100°  F.  There  are  a  moderate  amount  of  restless- 
ness dependent  upon  the  severity  of  the  cough,  usually  anorexia,  and 
sometimes  vomiting  and  diarrhoea. 

The  physical  signs  in  the  first  stage  are  dry,  sonorous  rdles  over  the 
whole  chest.  A  little  later  these  give  place  to  coarse  mucous  rdles  heard 
everywhere,  but  especially  distinct  between  the  scapulae  and  in  the  infra- 
clavicular regions.  On  palpation  there  is  usually  a  marked  bronchial 
fremitus.  Often  there  is  not  enough  dyspnoea  to  cause  recession  of  the 
soft  parts  of  the  chest.  Unless  the  disease  extends  to  the  smaller  bronchi 
and  the  air  vesicles,  the  illness  usually  lasts  about  a  week.  Coarse  rales 
in  the  chest  may  remain  for  some  time  after  the  symptoms  have  subsided. 
Eelapses  are  exceedingly  common.  In  a  delicate  or  susceptible  child,  or  in 
one  whose  surroundings  are  bad,  one  attack  is  likely  to  be  followed  by  a 
succession  of  others,  so  that  the  child  may  not  be  really  well  until  warm 
weather  comes.  The  general  health  may  suffer  from  the  prolonged  con- 
finement to  the  house,  although  the  patient  may  never  have  been  seri- 
ously ill. 

2.  The  severe  form  (bronchitis  of  the  smaller  tubes). — This  differs 
from  the  preceding  variety  mainly  in  the  greater  severity  of  all  its  symp- 
toms. The  onset  may  be  like  that  just  described,  the  severe  symptoms  not 
appearing  until  the  patient  has  been  sick  two  or  three  days,  or  they  may 
be  severe  from  the  outset.  If  the  latter,  it  is  indistinguishable  from 
broncho-pneumonia.  There  is  cough;,  dyspncEa,  accelerated  breathing, 
fever,  and  moderate,  sometimes  severe,  prostration.  The  cough  is  tighter, 
and  more  frequently  of  a  short,  teasing  character  than  severe  and  parox- 
ysmal. There  is  difficulty  in  nursing.  Dyspnoea  may  be  quite  marked 
and  is  shown  by  the  active  dilatation  of  the  alse  nasi  and  the  recession  of 
all  the  soft  parts  of  the  chest  on  inspiration.  The  respirations  as  a  rule 
are  from  50  to  80  a  minute.  The  temperature  for  the  first  day  or  two  is- 
usually  101°  or  102°,  but  it  may  be  103°  or  104°  F.  So  high  a  tempera- 
ture does  not  continue  unless  pneumonia  develops.  The  prostration  is  in 
most  cases  more  closely  related  to  the  dyspnoea  and  the  rapidity  of  respi- 
ration than  to  the  temperature.    Often  there  is  slight  cyanosis. 


ACUTE   CATARRHAL  BRONCHITIS.  511 

In  the  beginning  the  chest  is  filled  with  sibilant  and  sonorous  rdles, 
many  of  them  of  a  musical  character.  In  twelve  or  twenty-four  hours 
these  are  replaced  by  moist  rales — coarse  or  fine,  according  as  they  are 
produced  in  the  large  or  medium-sized  tubes.  There  are  often  loud, 
wheezing  rales  on  expiration.  The  respiratory  murmur  is  feeble ;  the 
resonance  on  percussion  is  normal  or  slightly  exaggerated.  As  the  case 
progresses  toward  recovery,  the  finer  rales  are  the  first  to  disappear.  The 
rdles  are  always  best  heard  behind,  but  they  are  present  all  over  the  chest. 

At  the  onset  of  such  a  case  it  is  impossible  to  say  whether  the  disease 
will  be  limited  to  the  medium-sized  bronchi  or  will  extend  to  the  smallest 
bronchi  and  air  vesicles.  In  young  or  very  delicate  infants,  and  during 
measles,  it  is  very  common  for  the  disease  to  spread  rapidly  to  the  air  vesi- 
cles. In  other  cases,  usually  in  infants  under  six  months  old,  there  may 
develop  attacks  of  respiratory  failure  or  suffocation.  These  may  occur  in  a 
severe  case  at  any  time,  and,  because  of  the  infant's  inability  to  empty  the 
tubes  of  secretion,  the  dyspnoea  steadily  increases  until  the  respiratory  mus- 
cles are  exhausted,  the  inspiratory  force  being  too  feeble  to  overcome  the 
obstruction  in  the  tubes.  The  symptoms  which  follow  are  usually  ascribed 
to  pulmonary  collapse.  I  am,  however,  by  no  means  certain  that  this  is  the 
correct  explanation,  for  in  autopsies  made  in  such  cases  I  have  usually 
found  the  lungs  to  be  the  seat  of  acute  emphysema.  The  clinical  picture  is 
a  clear  one.  There  is  no  disposition  to  cough  or  cry ;  the  pulse  is  feeble ; 
the  respiration  very  rapid,  superficial,  often  irregular ;  the  skin  cyanotic, 
and  often  clammy.  Finally,  there  may  be  added  to  the  others  signs  of  car- 
bonic-acid poisoning— dulness,  apathy,  and  stupor.  Such  attacks  may 
come  on  quite  suddenly  even  in  robust  infants,  and  unless  the  treatment 
is  energetic,  even  heroic,  death  often  follows  in  a  few  hours,  beino-  fre- 
quently preceded  by  convulsions. 

The  usual  course  of  the  disease  in  infants  previously  in  good  health 
is  that  the  severe  symptoms  continue  for  two  or  three  days  only,  after 
which  the  temperature  falls  to  100°  or  100-5°  F.,  and  gradually  becomes 
normal.  The  constitutional  symptoms  usually  decline  with  the  tempera- 
ture, and,  except  during  the  first  thirty-six  hours,  they  rarely  give  cause 
for  anxiety.  Recovery  almost  invariably  occurs  unless  the  disease  ex- 
tends to  the  finer  bronchi. 

Bronchitis  is  principally  to  be  distinguished  from  broncho-pneumonia. 
The  differential  diagnosis  is  more  fully  considered  under  that  disease.  The 
most  important  points  are  that  in  pneumonia  the  temperature  is  hio-her 
and  more  prolonged,  the  prostration  greater,  the  rdles  very  often  localized 
—being  heard  only  behind,  often  over  only  one  lung— the  duration  is 
more  protracted,  and  all  the  symptoms  are  more  severe. 

The  bronchitis  of  older  children.— This  is  not  nearly  so  serious  as  in 
infants,  because  the  same  danger  does  not  exist  of  extension  of  the  inflam- 
mation to  the  finer  bronchi  and  air  cells. 


512  DISEASES   OF   THE   RESPIRATORY  SYSTEM. 

1.  The  mild  form. — This  is  very  common.  The  constitutional  symp- 
toms are  slight,  and  often  entirely  absent  after  the  first  day.  The  patient 
is  never  sick  enough  to  go  to  bed.  The  first  symptoms  are  cough  and 
soreness  or  a  sense  of  oppression  beneath  the  sternum.  The  cough  is 
always  worse  at  night.  It  is  at  first  tight,  hard,  and  racking ;  later  it  is 
loose,  and  in  children  over  five  years  old  there  is  usually  expectoration — 
first  of  white,  frothy  mucus,  but  after  a  few  days  it  becomes  more  abun- 
dant, and  of  a  yellow  or  yellowish-green  colour,  from  the  presence  of  pus. 
The  physical  signs  are  only  coarse  rales,  at  first  dry,  and  later  moist,  but 
heard  over  both  sides  of  the  chest,  in  front  and  behind.  There  may  be 
some  disturbance  of  digestion,  anorexia,  constipation,  or  diarrhoea.  The 
usual  duration  of  the  attack  is  from  one  to  two  weeks.  If  the  patient  is 
not  kept  indoors  the  disease  may  pass  into  a  subacute  form,  lasting  for 
several  weeks  as  a  protracted  "  winter  cough,"  but  without  any  other  im- 
portant symptoms. 

2.  The  severe  form. — The  onset  is  abrupt,  with  fever,  chill,  pains  in 
the  back,  headache,  cough,  and  sometimes  pain  in  the  chest.  There  is  a 
feeling  of  tightness  or  constriction  beneath  the  sternum.  The  onset  re- 
sembles that  of  pneumonia,  except  that  the  symptoms  are  less  severe. 
The  temperature  for  the  first  two  or  three  days  ranges  between  100°  and 
103°  F.  It  is  generally  highest  in  the  first  twenty-four  hours.  The 
cough  resembles  that  of  the  mild  form,  but  it  is  usually  more  severe. 
The  expectoration  is  more  profuse,  and  occasionally,  in  the  early  stage,  it 
may  be  streaked  with  blood. 

The  coarse  rales  of  the  mild  form  are  present,  and  in  addition  there 
are  finer  rales— at  first  dry,  and  later  moist — heard  all  over  the  chest.  Fre- 
quently, wheezing  rales  are  heard  on  expiration.  The  duration  of  the  at- 
tack is  ordinarily  from  two  to  three  weeks,  the  patient  being  sick  enough 
to  be  confined  to  bed  for  three  or  four  days  only.  There  is  frequently 
a  cough  for  some  time  after  all  physical  signs  have  disappeared.  Eelapses 
are  easily  excited  by  any  indiscretion  before  the  patient  has  quite  recovered. 

The  prognosis  in  the  primary  cases  is  good,  such  almost  invariably  ter- 
minating in  recovery,  and  very  exceptionally  passing  into  broncho-pneu- 
monia; but  this  not  infrequently  happens  when  the  attack  complicates 
measles  or  pertussis. 

Treatment  of  BroncMtis.  Prophylaxis.— To  remove  the  predisposition 
to  bronchitis  the  same  means  should  be  employed  as  those  mentioned 
in  acute  rhinitis  (page  476).  General  measures  also  should  be  adopted 
to  build  up  the  health  of  delicate  infants.  Those  with  tuberculous 
antecedents,  and  those  Avho  are  especially  prone  to  pulmonary  disease, 
should  if  possible  spend  the  winter  in  a  warm  climate.  In  all  such  pa- 
tients the  systematic  administration  of  cod-liver  oil  should  be  continued 
throughout  every  cold  season.  The  sleeping  apartments  of  susceptible 
infants  should  not  be  too  cold— never  below  G0°  F.— but  they  must  be 


ACUTE  CATARRHAL  BRONCHITIS.  513 

well  ventilated,  best  by  an  open  fire.  Sucb  children  should  sleep  in  flan- 
nel night  clothes,  care  being  taken  to  see  that  the  feet  are  always  warm. 
While  bronchitis  of  the  large  tubes  is  not  per  se  a  serious  disease,  it  may 
become  so  by  extension  to  the  smaller  tubes.  It  is  consequently  very  im- 
portant in  infants  and  young  children  that  these  apparently  mild  attacks 
should  not  be  neglected. 

General  management. — Every  young  child  who  has  an  acute  catarrh  of 
the  nose,  pharynx,  larynx,  or  bronchi  should  be  kept  indoors.  In  every 
such  catarrh  accompanied  by  fever  the  child  should  be  kept  in  bed  while 
the  fever  lasts,  even  if  the  temperature  does  not  go  above  100-5°  F.,  and  is 
accompanied  by  no  other  constitutional  symptoms.  In  infants  and  young 
children,  many  cases  of  bronchitis  result  from  an  extension  of  an  acute 
rhinitis  or  laryngitis,  hence  this  precaution  is  of  more  importance  than 
everything  else  in  preventing  the  extension  downward  of  a  catarrhal  in- 
flammation. A  very  large  number  of  the  cases  will  recover  promptly  when 
no  other  treatment  is  employed  than  to  keep  the  child  in  bed.  The  tem- 
perature of  the  room  should  be  about  70°  or  72°  F.  It  should  be  well 
ventilated  and  frequently  aired,  the  child  being  removed  to  another  room 
while  this  is  done.  Infants  should  not  be  allowed  to  lie  for  hours  in  the 
same  position  as  there  is  a  great  advantage  in  changing  from  the  crib  to 
the  nurse's  arms.  Careful  attention  should  be  given  to  feeding  and  to 
the  condition  of  the  bowels.  A  cathartic,  preferably  castor  oil,  should 
be  administered  at  the  outset.  Distention  of  the  stomach  and  bowels 
with  gas  adds  greatly  to  the  discomfort  of  the  patient,  and  may  cause 
serious  symptoms. 

Abortive  measures  are  rarely  successful,  for,  by  the  time  the  physician 
is  summoned,  the  disease  is  generally  so  well  established  that  they  are 
futile.  Mild  cases  may  sometimes  be  cut  short  by  a  hot  foot-bath,  free 
catharsis,  and  diaphoresis,  especially  by  the  use  of  one  or  two  doses  of 
phenacetine  and  Dover's  powder  (phenacetine  two  grains,  Dover's  pow- 
der one  grain,  to  a  child  of  three  years). 

Local  applications. — Poultices  are  objectionable  on  account  of  their 
weight  and  the  difficulty  in  getting  them  properly  applied.  For  infants 
the  oiled-silk  jacket  (page  59)  is  decidedly  preferable.  This  should  be 
applied  in  the  beginning,  and  may  be  worn  throughout  the  attack.  It  ac- 
complishes all  that  a  poultice  does,  with  much  less  disturbance  to  the 
patient.  Counter-irritation  is  very  valuable.  In  infants  the  best  results 
are  obtained  by  the  frequent  use  of  a  mustard  paste  (page  52) .  It  should 
be  large  enough  to  envelop  the  chest,  and  covered  by  a  towel,  so  as  not  to 
soil  the  oiled-silk  jacket  or  the  clothing.  The  paste  is  removed  as  soon  as 
the  skin  is  thoroughly  reddened,  which  ^\\\\  he  in  from  five  to  ten  min- 
utes, according  to  the  strength  of  the  iiiusiard  and  the  condition  of  the 
child's  skin.  The  skin  should  then  be  powdered  and  the  oiled-silk  jacket 
again  pinned  snugly  about  the  chest.    This  may  he  repeated,  according  to 


514:  DISEASES  OP  THE  RESPIRATORY  SYSTEM. 

indications,  from  two  to  eight  times  a  day.     If  properly  used,  it  may  be 
continued  for  a  week  without  causing  any  soreness  of  the  skin. 

Inhalations. — The  value  of  these  is  not  sufficiently  appreciated.  They 
may  in  the  great  majority  of  cases  take  the  place  of  the  administration  of 
drugs  by  the  mouth,  a  very  great  advantage  in  infants.  They  may  be 
used  by  means  of  the  croup  kettle  or  vapourizer  (pages  58  and  59),  the 
child  always  being  placed  in  a  tent.  In  the  early  part  of  the  disease 
relaxing  inhalations,  like  simple  watery  vapour  or  lime-water,  may  be 
used.  Later  turpentine,  creosote,  terebene,  or  eucalyptol  may  be  added. 
Of  these,  creosote  has  given  me  the  most  satisfaction.  Inhalations  are 
to  be  used  for  ten  or  fifteen  minutes  from  four  to  twelve  times  a  day. 

Expectorants.— In  infancy  this  class  of  drugs  may  usually  be  advan- 
tageously dispensed  with.  For  older  children  the  relaxing  expectorants, 
especially  antimony  and  ipecac  in  combination,  may  be  used  in  the  first 
stage.  When  the  secretion  is  more  abundant,  either  the  alkaline  or  the 
stimulating  expectorants  may  be  given.  Of  the  former,  the  best  are  liquor 
potassge,  citrate  of  potassium,  and  muriate  of  ammonia ;  of  the  latter,  creo- 
sote, turpentine,  terebene,  and  squills.  Small,  frequently  repeated  doses 
usually  give  the  best  results. 

Opium. — This  should  be  given  very  cautiously  to  young  infants,  as  it 
is  capable  of  doing  great  harm.  The  dry,  harassing  cough  of  the  early 
stage  sometimes  yields  to  nothing  so  quickly  as  to  small  doses  of  Dover's 
powder  (e.  g.,  one  tenth  of  a  grain  every  two  hours  to  a  child  of  one  year). 
In  the  case  of  infants,  late  in  the  disease,  and  especially  in  severe  cases, 
opium  should  be  withheld  altogether.  It  disturbs  the  stomach,  consti- 
pates the  bowels,  and,  most  of  all,  it  greatly  depresses  the  respiration. 

Emetics  may  sometimes  be  used  with  advantage  when  the  secretion  is 
very  abundant  and  the  cough  feeble,  but  they  should  be  avoided  with  weak 
pulse,  great  prostration,  and  slight  stupor.  Syrup  of  ipecac  is  the  best 
emetic  under  these  conditions. 

Cardiac  stimulants. — These  are  required  in  most  of  the  severe  cases. 
The  best  is  alcohol.  It  should  be  begun  as  soon  as  indicated  by  weak 
pulse  and  general  prostration.  For  a  child  a  year  old,  half  an  ounce  of 
brandy,  diluted  with  from  six  to  eight  parts  of  w^ater,  may  be  given  in 
each  twenty-four  hours,  in  small  doses  at  short  intervals. 

Respiratory  stimulants. — The  most  valuable  drugs  are  strychnine 
and  atropine.  To  an  infant  of  six  months  -^^  grain  of  str3^chnine  and 
TFTO"  grain  of  atropine  may  be  given  every  two  hours.  For  a  short  time 
twice  these  doses  may  be  used.  They  are  needed  only  in  the  most  severe 
cases,  and  may  be  used  in  combination  or  alternately.  An  important  re- 
spiratory stimulant  is  counter-irritation  over  the  entire  body  by  the  mus- 
tard paste  or  hot  mustard  bath. 

The  management  of  mild  cases  in  infants. — In  the  great  majority  of 
cases  the  disease  is  self-limited,  tending  to  spontaneous  recovery.    Often 


ACUTE   CATARRHAL  BRONCHITIS.  515 

no  treatment  is  needed,  except  the  hygienic  measures  mentioned.  An 
oiled-silk  jacket  should  be  applied.  If  the  cough  is  excessive,  inhalations 
of  creosote  or  tur|)entine  three  or  four  times  a  day  may  be  used,  or  small 
doses  of  Dover's  powder  or  phenacetine.  The  oppression  which  often 
comes  on  toward  evening  may  be  relieved  by  a  mustard  paste  at  bedtime. 
Stimulants  are  not  required.  All  other  drugs  may  be  advantageously 
omitted,  but  during  convalescence  cod-liver  oil  should  be  given. 

The  management  of  severe  cases  in  infants. — These  must  be  treated 
very  much  like  cases  of  broncho-pneumonia.  The  temperature  is  rarely 
high  enough  to  require  interference,  but  the  chief  danger  is  due  to  the 
inability  of  the  child  to  get  rid  of  the  secretion  by  the  cough.  In  my 
experience  the  two  most  valuable  means  of  treatment  have  been  the  use 
of  inhalations  and  counter-irritation.  The  former  should  be  repeated  for 
ten  or  fifteen  minutes  every  two  hours,  and  for  a  short  period  may  often 
be  given  with  advantage  every  hour.  Early  in  the  disease,  vapour  of 
plain  water  or  limewater  may  be  used  ;  later,  creosote  is  best.  Counter- 
irritation  by  the  mustard  paste  should  be  repeated  every  three  hours, 
and  the  oiled-silk  jacket  worn  continuously.  Alcoholic  stimulants  are 
usually  needed  in  delicate  children,  and  in  secondary  bronchitis  accom- 
panying the  infectious  diseases.  In  most  of  the  cases  the  medication 
should  consist  only  of  cardiac  and  respiratory  stimulants.  In  strong  chil- 
dren the  occasional  use  of  an  emetic  at  bedtime  is  admissible. 

Attacks  of  suffocation  and  respiratory  failure. — The  indications  here 
are  to  get  as  much  blood  as  possible  to  the  surface  and  to  the  extremities, 
in  order  to  relieve  the  overloaded  right  heart,  and  to  compel  the  child  to 
make  full  and  deep  inspiratory  efforts.  One  plan  of  treatment  (Jacobi's) 
is  to  induce  frequent  crying  by  flagellation  or  spanking,  this  being  kept 
up  for  several  hours.  Another  (H.  C.  Wood's)  is  to  use  alternately  hot 
and  cold  douches  to  the  chest  until  some  reaction  is  obtained,  and  then  to 
follow  up  this  by  the  occasional  use,  for  a  few  moments,  of  a  very  hot  bath 
(120°  F.).  Both  these  means,  but  especially  the  first  mentioned,  are  of 
great  value,  as  I  have  had  abundant  opportunity  to  verify.  Another  use- 
ful measure  is  the  hot  mustard  bath,  or  the  hot  mustard  pack  applied  to 
the  entire  body.  In  conjunction  with  the  above  means,  both  heart  and 
respiratory  stimulants  should  be  given  in  full  doses.  If  possible,  oxygen 
should  be  administered.  As  these  symptoms  are  liable  to  recur  every  few 
hours  for  a  day  or  two,  a  repetition  of  the  treatment  will  be  needed,  and 
if  possible  the  physician  should  remain  with  the  patient. 

If  a  young  infant  can  be  tided  over  these  critical  attacks,  recovery  is 
probable.  After  this  danger  is  past,  the  treatment  previously  indicated 
may  be  pursued.  The  use  of  expectorants,  particularly  the  composite 
cough  mixtures  containing  opium,  can  not  be  too  strongly  condemned 
in  all  severe  cases  of  infantile  bronchitis. 

The  managejiient  of  cases  in  older  children. — In  the  non-febrile  cases 


516  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

confinement  in  bed  is  unnecessary,  but  children  should  be  kept  indoors. 
In  the  early  stage,  with  hard,  dry  cough,  one  of  the  best  remedies  is  brown 
mixture  (the  mistura  glycyrrhizse  composita  of  the  U.  S.  P.).  It  will 
be  found  advantageous  in  most  cases  to  have  the  formula  made  up  with 
one  half  the  usual  amount  of  opium.  When  the  cough  is  especially  hard 
and  dry,  a  single  inhalation  may  be  used  at  bedtime.  In  the  second  stage, 
muriate  of  ammonia  may  be  added  to  the  mixture ;  or  terebene,  two  or 
three  drops  upon  sugar,  may  be  given  four  or  five  times  a  day.  In- 
halations of  creosote  or  turpentine  should  be  used. 

In  the  more  severe  cases  accompanied  by  fever  the  patients  should  be 
kept  in  bed  and  an  oiled-silk  jacket  applied.  In  the  beginning  the  liquor 
ammonite  acetatis  and  spiritus  ^etheris  nitrosi  may  be  given  for  their  effect 
upon  the  skin  and  kidneys.  For  the  general  discomfort,  pain,  headache,_ 
etc.,  nothing  is  better  than  phenacetine  and  Dover's  powder  (three  grains 
of  the  former  to  one  grain  of  the  latter  to  a  child  of  five  years),  repeated 
every  three  to  six  hours.  Heroin  is  a  most  valuable  remedy  for  the  relief 
of  troublesome  cough;  gr.  -gV  may  be  given  every  three  hours  to  a  child 
of  five.  All  patients  should  be  kept  in  bed  as  long  as  the  temperature 
is  above  normal. 

The  protracted  cough  of  convalescence. — It  often  happens,  both  in 
infants  and  in  older  children,  that  after  all  physical  signs  and  constitu- 
tional symptoms  have  disappeared,  a  cough  continues  sometimes  for  weeks. 
Expectoration  is  scanty,  or  is  wanting  altogether ;  the  cough  is  hard,  dry, 
often  paroxysmal,  and  in  some  cases  occurs  at  night  only.  For  this  con- 
dition the  best  remedies  are  quinine,  cod-liver  oil,  and  creosote.  The  last 
named  may  easily  be  given  to  young  infants  as  well  as  to  older  children,  in 
combination  with  liquid  beef  peptonoids.*  It  may  be  also  used  in  pill  form 
or  by  inhalation.  These  measures  may  be  tried  alternately  or  in  combina- 
tion.    Where  they  are  not  effective  a  change  of  climate  should  be  advised. 

FIBRINOUS  BRONCHITIS  (BRONCHIAL   CROUP). 

Fibrinous  bronchitis  is  seen  in  diphtheria,  usually  as  an  extension  from 
the  larynx  or  trachea.  There  is,  however,  another  form  of  bronchitis 
attended  by  a  fibrinous  exudate,  which  occurs  as  a  primary  disease.  This 
is  very  rare  in  children.  Weil  has,  however,  collected  twenty  cases  of  the 
primary  form.  The  etiology  is  obscure.  It  is  seen  at  all  ages,  from  in- 
fancy up  to  puberty,  and  it  may  be  either  acute  or  chronic.  From  the  cases 
thus  far  reported  it  would  appear  that  the  acute  form  is  relatively  more 
common  in  children  than  in  adults.  The  disease  may  be  confined  to  cer- 
tain branches  of  the  bronchial  tree,  or  it  may  affect  all  the  bronchi,  even 
to  the  minute  subdivisions.     The  fibrinous  membrane  is  found  loose  in 

*  A  preparation  put  up  by  the  Arlington  Chemical  Company,  and  a  very  palatable 
way  of  giving  creosote. 


CHRONIC  BRONCHITIS.  517 

the  tubes  or  adherent.  There  are  generally  associated  other  pulmonary 
changes,  such  as  emphysema,  areas  of  atelectasis  or  of  broncho-pneumonia. 

The  acute  form  somewhat  resembles  ordinary  catarrhal  bronchitis. 
The  diagnostic  features  are  the  severity  of  the  dyspnoea  and  the  expectora- 
tion of  tube  casts  from  the  larger  bronchi,  or  elongated  cylinders  from 
the  smaller  ones,  the  former  resembling  macaroni,  the  latter  vermicelli. 
The  expectorated  masses  are  often  in  balls  or  plugs,  and  their  peculiar 
character  is  not  recognised  until  they  are  placed  in  water.  The  casts 
are  dissolved  by  alkalies,  especially  by  lime-water.  After  the  expulsion  of  a 
large  cast,  improvement  in  all  the  symptoms  occurs.  These,  however, 
return  as  the  exudate  reappears.  The  ordinary  duration  of  acute  cases 
is  from  one  to  three  weeks. 

In  the  chronic  form  there  are  no  constitutional  symptoms,  but  only 
dyspnoea  and  cough,  often  recurring  in  paroxysms,  with  the  expectoration 
of  fibrinous  casts.  The  patient  may  have  these  attacks  at  intervals  of  a 
few  days  or  weeks,  extending  over  a  period  of  months,  or  even  years. 
There  are  no  characteristic  physical  signs.  The  diagnosis  rests  upon  the 
peculiar  character  of  the  expectoration.  The  prognosis  in  acute  cases  is 
unfavourable,  the  mortality  being  75  per  cent  (Weil).  Chronic  cases  are 
not  dangerous  to  life. 

Treatment. — This  is  quite  unsatisfactory.  To  loosen  the  membrane  and 
facilitate  its  expulsion,  the  most  efficient  means  are  inhalations  of  the 
vapour  of  limewater  and  the  internal  administration  of  pilocarpine.  Oc- 
casionally emetics  are  of  value.  Improvement  in  some  of  the  chronic 
cases  has  resulted  from  the  use  of  iodide  of  potassium. 

CHRONIC  BRONCHITIS. 

Chronic  bronchitis  is  not  a  common  disease  in  children,  particularly 
in  young  children,  one  reason  being  that  chronic  emphysema,  so  fre- 
quently an  associated  condition  in  adults,  is  rare  in  early  life.  Chronic 
bronchitis  always  accomjoanies  chronic  pulmonary  tuberculosis  and  chronic 
interstitial  pneumonia,  with  or  without  the  occurrence  of  bronchiectasis. 
It  is  seen  in  chronic  cardiac  disease,  especially  with  lesions  of  the  mitral 
valve.  It  may  occur  as  a  late  symptom  of  hereditary  syphilis.  Excluding 
the  varieties  mentioned,  it  usually  follows  attacks  of  acute  bronchitis,  (he 
process  becoming  chronic  because  of  the  patient's  constitutional  condition 
or  his  unhygienic  surroundings.  The  acute  attack  may  be  primary,  but  it 
often  follows  measles  and  whooping-cough.  Rickets,  general  malnutrition, 
and  lymphatism  are  the  constitutional  conditions  in  which  acute  bronchitis 
is  most  likely  to  pass  into  the  chronic  form.  Deformities  of  the  chest, 
the  result  either  of  rickets  or  of  Pott's  disease,  are  occasionally  a  cause. 

Symptoms. — The  only  constant  symptom  is  cough,  which  is  persistent, 
obstinate,  and  nearly  always  worse  at  night  or  early  in  the  morning.  It 
often  occurs  in  paroxysms  strongly  suggestive  of  pertussis.     Expectora- 


518  DISEASES  OP  THE  EESPIRATORY  SYSTEM. 

tion  is  not  generally  abundant,  but  in  older  ebildren  it  is  usually  present, 
and  in  a  few  cases  it  is  profuse.  A  copious  morning  expectoration  of 
fetid  pus  or  muco-pus  indicates  bronchiectasis.  There  is  no  fever,  little 
or  no  dyspnoea,  and  although  the  patients  are  thin  they  are  not  emaci- 
ated, and  in  many  cases  the  general  health  is  not  much  affected.  There 
may  be  coarse  mucous  rales,  or  no  physical  signs  whatever.  The  dura- 
tion of  the  disease  is  indefinite,  depending  upon  the  cause.  All  these 
patients  are  better  in  summer  and  worse  in  winter,  and  suffer  frequently 
from  exacerbations  of  acute  or  subacute  bronchitis. 

The  diagnosis  is  to  be  made  mainly  from  pertussis  and  tuberculosis. 
From  mild  attacks  of  pertussis  the  diagnosis  may  be  impossible  except  by 
the  course  of  the  disease.  Tuberculosis  may  be  suspected  if  the  thermom- 
eter shows  regularly  a  slight  evening  rise  of  temperature,  if  there  is  much 
anaemia,  and  steady  loss  of  flesh.  A  positive  diagnosis  can  be  made  only 
by  the  discovery  of  tubercle  bacilli  in  the  sputum. 

Treatment. — The  first  indication  is  to  treat  the  primary  disease.  In 
cardiac  cases  digitalis  is  the  best  remedy,  and  all  sedatives  are  to  be 
avoided.  Attention  should  be  directed  to  the  general  condition — rickets, 
malnutrition,  and  lymphatism  each  receiving  its  appropriate  treatment. 
In  most  cases  a  general  tonic  plan  of  treatment  is  best,  particularly  the 
continuous  use  of  cod-liver  oil.  In  many  cases  a  change  of  climate  is  the 
only  thing  which  is  really  curative.  For  the  relief  of  cough,  opiates  are 
to  be  avoided  as  much  as  possible.  The  main  reliance  should  be  upon 
potassium  iodide,  heroin,  creosote  and  terebene,  the  last  two  being  given 
both  by  mouth  and  by  inhalation. 

REFLEX  COUGH— NERVOUS  COUGH. 

Strictly  speaking,  all  cough  is  reflex  and  of  nervous  origin.  The  term 
"  reflex  cough  "  is,  however,  commonly  used  to  denote  that  which  occurs 
without  any  evidence  of  disease  in  the  larynx,  trachea,  bronchi,  lungs,  or 
pleura.  On  account  of  the  close  connection  through  the  vagus  and  its 
branches  between  the  mouth,  ear,  throat,  stomach,  and  thoracic  organs, 
it  is  possible  for  cough  to  be  produced  by  many  forms  of  irritation  in 
these  organs  or  cavities.  Clinically,  the  following  varieties  of  nervous 
cough  are  observed : 

1.  That  dependent  upon  rhino-phar}T.igeal  irritation.  This  is  the 
most  frequent  form,  and  is  sometimes  caused  by  an  elongated  uvula, 
but  is  usually  due  to  adenoid  growths  of  the  pharynx,  though  enlarge- 
ment of  all  the  lymphoid  tissues  of  the  neighborhood  no  doubt  have  a 
part.  The  cough  is  generally  excited  by  an  accumulation  of  mucus  in 
the  posterior  pharynx,  and  is  dry,  tickling,  or  hemming  in  character. 
It  occurs  chiefly  at  night  and  in  some  patients  only  then;  it  may  begin 
soon  after  the  child  falls  asleep  and  continue  the  greater  part  of  the 


REFLEX  COUGH.  519 

night,  often  for  months,  especially  in  the  cold  season.  Formerly,  such 
coughs  were  often  ascribed  to  disorders  of  digestion,  to  dentition,  to 
inflammation  of  the  ears,  etc. 

2.  Cardiac  cough.  This  is  usually  associated  with  mitral  disease, 
and  is  due  to  pulmonary  congestion.  The  cough  is  dry,  hard,  and  often 
severe. 

3.  The  variety  which  occurs  usually  about  the  time  of  puberty,  and 
often  associated  with  anaemia,  chorea,  or  spinal  irritation.  It  is  a  short, 
hacking,  or  teasing  cough,  sometimes  very  distressing,  and  it  seems  to 
be  a  manifestation  of  extreme  nervous  irritability. 

4.  The  periodical  night  cough,  which  is  generally  ascribed  to  irrita- 
tion of  the  vagus  or  its  branches  by  enlarged,  sometimes  caseous,  lymph 
nodes  of  the  tracheo-bronchial  group.  This  often  occurs  in  severe 
paroxysms,  the  character  of  which  is  very  much  like  pertussis.  The 
attacks  are  apt  to  come  on  about  the  middle  of  the  night  and  last  for 
several  hours.  Vomiting  is  rare.  The  cough  may  recur  regularly  every 
night  for  months.  On  account  of  the  loss  of  sleep  the  jDatient's  general 
health  may  be  considerably  undermined. 

5.  A  very  similar  cough  may  occur  in  connection  with  abscesses  in 
the  posterior  mediastinum  due  to  Pott's  disease. 

Symptoms  and  Diagnosis. — These  cases  are  not  common  in  infants, 
but  are  quite  frequent  in  older  children.  In  nearly  all  the  varieties 
the  cough  is  worse  at  night,  and  in  many  it  may  be  confined  to  that 
time.  The  influence  of  habit  is  often  seen,  the  attacks  coming  on  regu- 
larly at  certain  periods.  The  general  health  may  not  be  affected,  except 
from  the  disturbance  of  sleep.  The  diagnosis  between  the  different 
forms  is  often  very  difficult.  The  precise  cause  in  a  given  case  is  discov- 
ered only  by  a  careful  examination  of  the  ear,  nose,  pharynx,  heart,  stom- 
ach, lungs,  and  a  consideration  of  the  patient's  general  condition.  The 
existence  of  enlarged  or  tuberculous  bronchial  glands  may  be  suspected  in 
patients  of  tuberculous  antecedents,  in  those  who  have  previously  suffered 
from  measles,  pertussis,  or  repeated  attacks  of  bronchitis,  and  when  the 
cough  is  very  severe  and  paroxysmal.  A  similar  group  of  symptoms  may 
exist  with  abscesses  from  Pott's  disease.  In  either  of  these  conditions 
there  may  be  attacks  of  suffocation. 

Treatment. — Opium  and  expectorants  are  not  indicated,  and  inhala- 
tions are  of  little  value.  The  only  successful  treatment  is  that  which  is 
directed  to  the  cause  of  the  disease.  If  no  cause  can  be  found,  and  the 
cough  appears  to  be  of  purely  nervous  origin,  the  best  results  follow  the 
use  of  the  bromides  or  the  administration  of  antipyrine  at  bedtime. 

ASTHMA. 

Asthma  may  be  defined  as  a  vaso-motor  neurosis  of  the  respiratory 
tract.     It  is  characterized  by  attacks  of  severe  spasmodic  dyspnoea,  which 


520  DISEASES  OP  THE  RESPIRATORY  SYSTEM. 

may  be  preceded,  accompanied,  or  followed  by  bronchial  catarrh  of  greater 
or  less  severity.  In  the  asthmatic  attacks  of  infancy  the  catarrhal  ele- 
ment is  very  prominent,  and  these  cases  present  quite  a  different  clinical 
picture  from  the  disease  as  seen  in  older  children,  which  differs  in  no 
essential  points  from  the  asthma  of  adults. 

Writers  differ  very  much  in  their  statements  regarding  the  frequency 
of  asthma  in  early  life,  mainly  because  of  a  want  of  agreement  in  re- 
gard to  what  shall  be  included  under  this  term.  The  asthmatic  attacks 
of  infants  are  considered  by  some  as  a  stage  of  bronchitis,  by  others  as 
distinct  from  that  disease.  Typical  attacks  resembling  those  of  adult  life 
are  rare  in  children,  and  extremely  so  before  the  seventh  year.  How- 
ever, of  225  cases  of  asthma  reported  by  Hyde  Salter,  the  disease  began 
before  the  tenth  year  in  nearly  one  third  the  number. 

Etiology. — The  general  or  constitutional  causes  are  the  same  in  chil- 
dren as  in  adults.  Asthma  may  be  hereditary.  It  occurs  especially  in 
children  whose  antecedents  have  suffered  from  gout  or  from  other  neu- 
roses. The  local  cause  may  be  any  form  of  irritation  in  the  nose  or 
pharynx — hypertrophic  rhinitis,  adenoid  growths  of  the  pharynx,  hyper- 
trophied  tonsils,  or  elongated  uvula — or  in  the  bronchial  mucous  mem- 
brane, as  a  result  of  previous  attacks  of  acute  bronchitis.  It  is  probable 
that  it  may  also  be  caused  by  the  irritation  of  enlarged  bronchial  glands. 
In  susceptible  persons  a  paroxysm  may  be  excited  by  cold  or  damp  air^ 
indigestion,  constipation,  or  the  inhalation  of  various  irritating  sub- 
stances, such  as  dust,  the  pollen  of  certain  plants,  etc.  First  attacks  of 
asthma  in  children  are  apt  to  follow  bronchitis. 

Symptoms. — Four  quite  distinct  clinical  types  of  asthma  are  seen  in 
children  :  (1.)  Cases  which  in  their  onset  simulate  attacks  of  capillary 
bronchitis.  (2.)  Those  in  which  asthmatic  symptoms  follow  an  attack  of 
bronchitis,  continuing  for  weeks  or  months,  but  not  necessarily  recur- 
ring. (3.)  Hay  fever,  or  the  periodical  form  which  occurs  every  summer. 
(4.)  That  which  resembles  the  ordinary  adult  asthma,  with  the  nervous 
element  predominating.  The  prominence  of  the  catarrhal  symptoms  is 
characteristic  of  all  asthma  in  children,  the  first  two  varieties  mentioned 
being  peculiar  to  early  life. 

Attacks  resembling  capillary  hronchitis.. — These  cases  are  rare,  but 
may  be  seen  even  in  infants.  The  onset  is  sudden,  with  moderate  fever, 
incessant  cough,  severe  dyspnoea,  and  sometimes  symptoms  of  suffocation 
— cyanosis,  prostration,  and  cold  extremities.  The  chest  is  filled  with 
sonorous,  sibilant,  and  soon  with  subcrepitant  rales.  Instead  of  running 
the  usual  course  of  bronchitis  of  the  finer  tubes,  the  symptoms  may  pass 
away  very  rapidly,  and  in  forty-eight,  sometimes  in  twenty-four  hours 
the  patient  may  be  quite  well.  It  is  only  by  the  course  of  the  disease  and 
by  recurring  attacks  that  their  true  nature  can  be  recognised.  In  infants 
this  form  of  asthma  may  be  fatal. 


ASTHMA.  521 

Cases  following  attachs  of  h'oiichitis — Catarrlial  asthma. — This  form  is 
not  uncommon,  though  it  is  frequently  designated  by  some  other  term  than 
asthma — sometimes  as  spasmodic  bronchitis,  or  catarrhal  spasm  of  the  bron- 
chi. The  symptoms  are,  however,  indistinguishable  from  asthma,  and 
they  evidently  belong  in  the  same  category.  This  form  is  usually  seen  in 
infants,  being  rare  after  the  third  year.  Many  of  the  patients  are  rachitic  ; 
others  have  large  tonsils,  or  adenoid  growths  of  the  pharynx ;  while  in 
still  others  there  is  every  reason  to  suspect  the  presence  of  large  bronchial 
glands.  Usually  there  is  nothing  peculiar  about  the  antecedent  bronchitis ; 
in  most  cases  it  is  not  especially  severe,  and  is  limited  to  the  larger  tubes. 
The  febrile  symptoms  subside  in  a  few  days,  but  the  cough  continues, 
as  do  also  the  dyspnoea  and.  wheezing.  When  the  symptoms  are  fairly 
established  they  are  very  uniform  and  characteristic.  The  respiration  is 
accelerated,  usually  to  50  or  60,  sometimes  to  70  or  80,  a  minute.  The 
temperature  from  time  to  time  may  be  very  slightly  elevated,  or  it  may 
remain  normal.  The  respiration  is  noisy,  laboured,  and  accompanied  by 
distinct  wheezing. 

On  auscultation,  there  is  prolonged  expiration  accompanied  by  loud, 
wheezing  rales,  either  sonorous,  sibilant,  or  musical,  and  occasionally 
moist  rales  are  heard.  In  cases  which  have  lasted  some  time  a  moderate 
amount  of  emphysema  can  be  inferred  from  prominence  of  the  infra- 
clavicular regions,  and  exaggerated  resonance  over  the  chest  in  front. 

These  symptoms  and  signs  may  continue  for  three  or  four  weeks  only, 
and  gradually  wear  off,  or  they  may  last  as  many  months — if  they  begin  in 
the  winter  or  spring,  often  continuing  until  the  middle  of  the  summer. 
While  they  are  constantly  present,  they  vary  in  intensity  from  time  to  time, 
being  usually  much  worse  at  night.  The  symptoms  are  always  increased 
by  exposure  to  a  cold,  damp  atmosphere,  by  any  fresh  accession  of  bron- 
chitis, and  often  by  trivial  digestive  disturbances.  The  usual  duration 
of  the  cases  I  have  seen  has  been  two  to  six  weeks.  The  cough  is  not 
usually  severe,  and  expectoration  in  most  cases  is  absent.  The  general 
health  is  often  but  little  affected.  With  recovery  from  the  asthmatic 
symptoms  the  emphysema  usually  disappears  gradually,  although  I  have 
seen  one  severe  case  in  Avliich  it  persisted. 

What  proportion  of  these  children  afterward  develop  ordinary  asthma, 
from  personal  experience  I  am  unable  to  say.  Some  undoubtedly  do,  but 
in  others  which  I  have  been  able  to  follow,  recovery  has  seemed  to  be 
permanent.  This  would  appear  more  likely  in  those  cases  closely  associ- 
ated with  rickets,  or  with  other  causes  which  disai^pear  spontaneously 
with  time  or  as  a  result  of  treatment. 

Hay  fever. — This  is  very  rare  before  the  seventh,  and  but  few  well- 
marked  cases  are  seen  before  the  tenth  year.  In  its  clinical  aspects  it  does 
not  differ  essentially  from  the  disease  as  seen  in  adults,  except  possibly 
by  the  greater  prominence  of  the  bronchial  catarrh. 


522  DISEASES  OF   THE   RESPIRATORY  SYSTEM. 

Ordinary  attacks  of  the  adult  type. — These  usually  occur  at  inter- 
vals of  a  few  weeks  or  months,  depending  upon  the  nature  of  the  exciting 
cause.  The  beginning  is  usually  at  night,  with  dyspnoea,  a  short,  dry 
cough,  and  loud,  wheezing  respiration.  Deep  recession  of  the  soft  parts 
of  the  chest  is  seen,  as  in  laryngeal  stenosis.  There  is  prolonged  ex- 
piration, accompanied  by  loud,  sonorous,  sibilant  and  wheezing  rales,  and 
the  vesicular  murmur  is  very  feeble.  Later,  moist  rales  may  be  heard. 
After  many  attacks  emphysema  is  present.  This  occurs  more  rapidly  than 
in  adults,  and  may  be  extreme,  giving  rise  in  marked  cases  to  serious 
thoracic  deformity.  On  account  of  the  loss  of  sleep  and  interference  with 
nutrition,  the  general  health  may  become  seriously  impaired. 

Diagnosis. — Typical  attacks  of  asthma  are  easily  recognised.  Some  of 
the  catarrhal  forms  seen  in  infancy,  however,  present  great  difficulty,  and 
a  positive  diagnosis  may  be  impossible  except  by  the  progress  of  the  case. 

Prognosis. — This  is  best  in  the  cases  of  catarrhal  asthma  in  infants, 
and  in  older  patients  when  it  depends  upon  some  local  cause  which  can 
be  removed,  as  when  the  disease  is  due  to  reflex  nasal  or  pharyngeal  irrita- 
tion. In  the  majority  of  other  cases,  asthma  is  likely  to  become  chronic 
unless  the  child  is  removed  to  some  climate  in  which  the  attacks  do  not 
occur.  The  younger  the  child,  the  shorter  the  duration  of  the  disease, 
and  the  less  marked  the  hereditary  tendency,  the  better  the  prognosis. 

Treatment. — The  nose  and  the  Thino-phar}Tix  should  be  carefully 
examined  in  every  case  of  asthma,  and  any  pathological  condition  there 
present  should  receive  attention  as  the  first  step  in  the  treatment.  Spe- 
cial importance,  in  children,  should  be  attached  to  the  removal  of  ade- 
noid growths  of  the  pharynx.  During  attacks,  the  best  means  of  reliev- 
ing the  symptoms  is  the  inhalation  of  fumes  of  nitre  paper  or  stramoni- 
um leaves.  Most  of  the  proprietary  remedies  (Papier  de  Fruneau,  Him- 
Tod's  cure,  and  Kidder's  pastilles)  contain  these  ingredients.  The  two 
preparations  last  mentioned  are  by  most  children  particularly  well  toler- 
ated. The  sleeping  room  may  be  filled  with  the  fumes  of  these  sub- 
stances, or  the  child  may  be  placed  in  a  tent  into  which  the  fumes  are 
introduced.  Emetics  should  be  employed  when  the  attack  is  brought 
on  by  indigestion.  Lobelia  is  the  most  satisfactory  remedy  for  this  pur- 
pose. To  prevent  the  recurrence  of  night  attacks,  nothing  in  my  experi- 
ence has  been  so  valuable  as  a  full  dose  of  antipjTine  at  bedtime — four 
grains  at  five  years  and  six  grains  at  ten  years.  Between  the  attacks  the 
main  reliance  should  be  upon  the  syrup  of  hydriodic  acid  and  potassium 
iodide,  which  are  to  be  given  for  a  long  time  in  full  doses.  Tonics  are 
to  be  used  in  nearly  all  cases.  Those  especially  valuable  in  asthmatic 
patients  are  cinchonidia  and  arsenic. 

In  the  cases  of  catarrhal  asthma  following  bronchitis,  expectorants 
and  ordinary  cough  remedies  are  useless.  Cod-liver  oil  and  the  iodide  of 
potassium  are  valuable  in  some  of  the  cases.    Others  are  greatly  relieved 


PNEUMONIA.  523 

by  the  regular  use  of  creosote  inhalations  several  times  a  day,  with  a 
nightly  dose  of  antipyrine.  The  fumes  of  nitre  and  stramonium  often 
afford  no  relief,  and  sometimes  the  cases  are  made  distinctly  worse  by 
them.  The  best  of  all  measures  is  to  send  the  child  at  once  to  a  warm, 
dry  climate. 

For  all  children  who  have  had  repeated  attacks,  whether  in  the  form 
of  hay  fever  or  the  ordinary  variety,  the  most  important  thing  is  removal 
to  a  place  where  they  do  not  have  the  disease,  and  a  residence  there  long 
enough  to  break  up  the  tendency  to  recurrence.  This  will  usually  require 
at  least  three  or  four  years.  The  region  best  suited  to  most  asthmatics  is 
one  which  is  high,  dry,  and  moderately  warm.  Patients  often  suffer  less 
in  cities  than  in  the  country.  If  taken  early,  asthma  in  children  is  fre- 
quently curable  by  these  means ;  if  neglected,  the  disease  is  almost  sure 
to  continue  until  adult  life. 


CHAPTER   IV. 

DISEASES  OF  THE  LUNOS.— {Continued.) 
PNEUMONIA. 

In"  early  life  the  lungs  are  more  frequently  the  seat  of  organic  disease 
than  any  other  organs  in  the  body.  Pneumonia  is  very  common  as  a  pri- 
mary disease,  and  ranks  first  as  a  complication  of  the  various  forms  of 
acute  infectious  disease  of  children.  It  is  one  of  the  most  important 
factors  in  the  mortality  of  infancy  and  childhood  (page  39). 

Cases  of  acute  pneumonia  are  divided,  from  an  anatomical  point  of 
view,  into  two  principal  groups  :  (1.)  Broncho-pneumonia,  also  known  as 
catarrhal  and  as  lobular  pneumonia.  (2.)  Lobar  pneumonia,  also  known 
as  croupous  and  as  fibrinous  pneumonia.  These  differ  from  each  other 
as  to  the  products  of  inflammation,  the  distribution  of  the  disease  in  the 
lung,  and  somewhat  as  to  the  parts  involved  and  the  nature  of  the  changes 
in  them. 

In  broncho-pneumonia  the  large  bronchi  are  the  seat  of  a  superficial 
inflammation,  while  in  those  of  small  size  the  entire  bronchial  wall  is 
affected  ;  the  exudation  into  the  air  vesicles  is  mainly  cellular,  being 
made  up  of  epithelial  cells,  leucocytes,  and  red  blood-cells  (Fig.  86), 
fibrin  being  either  absent,  or  present  only  in  small  amount.  In  many 
cases  there  are  marked  changes  both  in  the  alveolar  septa  and  in  the  in- 
terstitial tissue  of  the  lung ;  resolution  is  often  imperfect,  and  there  is  a 
strong  tendency  of  the  inflammation  to  pass  into  a  chronic  form,  in- 
volving the  connective-tissue  framework  of  the  lung.  The  lesion  is 
widely  and  often  irregularly  distributed,  usually  being  most  marked  in 


524 


DISEASES  OF  THE  RESPIRATORY   SYSTEM. 


the  vicinity  of  the  small  bronchi  from  which  the  inflammation  spreads, 
and  in  the  most  superficial  lobules  of  the  lung. 

In  lobar  pneumonia,  bronchitis,  when  present,  is  usually  superficial, 
the  walls  of  the  bronchi  being  very  slightly  or  not  at  all  afiiected;  the 
same  is  true  of  the  alveolar  septa.  The  principal  product  of  the  inflam- 
mation is  fibrin  (Fig.  87),  which  fills  the  alveoli  and  the  terminal  bron- 
chi, the  cells  being  relatively  few  and  chiefly  leucocytes.  The  process  is 
usually  sharply  circumscribed,  involving  an  entire  lobe  or  a  part  of  a  lobe. 
In  most  cases  it  clears  up  rapidly  and  completely,  there  being  but  little 
tendency  to  involve  the  framework  of  the  lung  in  a  chronic  process. 

While  in  typical  cases  the  two  forms  of  inflammation  are  quite  dis- 
tinct, there  are  seen  many  intermediate  forms  which  partake  of  the  char- 
acters of  both,  and  one  may  be  in  doubt,  even  after  a  microscopical  ex- 
amination, into  which  group  to  place  a  case.    It  not  infrequently  happens 


^'^. 


^*^^, 


■  ■■ « 


ft 


Fig.  86. — Broncho-pneumonia.  The  picture  shows  at  its  centre  one  entire  air  vesicle,  and  at  its 
margin  parts  of  four  or  live  other  ve^^icles;  they  are  filled  with  large  epithelial  cells  having 
small  nuclei.  There  are  also  seen  leucocytes  with  intensely  lilack  nuclei  and  narrow  proto- 
plasm. Between  the  cells  is  a  finely  granular  material,  which  is  the  exudation  fluid  coagu- 
lated during  the  hardening  process.  The  alveolar  septa  are  somewliat  infiltrated. — From 
Karg  and  Schmorl. 

that  both  varieties  of  pneumonia  are  present  in  different  parts  of  the 
same  lung  or  in  both  lungs  at  the  same  time.  These  mixed  forms  are 
especially  frequent  during  the  second  and  third  years;  but  during  the 
first  year,  and  after  the  third,  the  types  are  usually  well  marked. 


PNEUMONIA.  525 

The  following  table  shows  the  relative  frequency  of  lobar  and  broncho- 
pneumonia in  three  hundred  and  seventy  cases,*  nearly  all  taken  from 


>i;li3&*^- 


Fig.  87. — Lobar  pneumonia.  In  the  air  vesicle  shown  in  the  picture  there  is  a  firm,  close  net- 
work of  fibrin,  in  the  meshes  of  which  are  leucocytes.  At  the  lower  part  the  exudation  has 
contracted  away  from  the  wall  in  consequence  of  the  process  of  hardening. — From  Karg 
and  Schmorl. 

one  institution  (New  York  Infant  Asylum).  There  are  included  all  the 
cases  of  acute  primary  pneumonia  occurring  during  a  period  of  seven 
years  : 

Under    six    months,  broncho-pneumonia,  73  cases;  lobar  pneumonia,  11  cases. 
Six  to  twelve      "  "  96      "  "  "  29     " 

Second  year,  "  73      "  "  "  40     " 

Third       "  "  19      "  "  "  23     " 

Fourth     "  "  0      "  "  "  6     " 

Totals,  "  261      "  "  "         109     " 

Thus  it  will  be  seen  that,  of  the  cases  of  acute  pneumonia  occurring 
during  the  first  two  years,  25  per  cent  were  lobar  and  75  per  cent  were 
broncho-pneumonia. 

When  we  come  to  a  consideration  of  the  micro-organisms  with  which 
the  different  forms  of  pneumonia  are  associated,  we  find  that  they  do  not 

*  The  division  was  here  made  according  to  the  predominant  clinical  or  pathological 
features.     Most  of  the  doubtful  cases  were  classed  as  broncho-pneumonia. 


526  DISEASES   OP   THE  RESPIRATORY   SYSTEM. 

correspond  to  the  anatomical  varieties.  Lobar  pneumonia  is  regularly 
associated  with  the  presence  of  the  pneumococcus  (micrococcus  lanceo- 
latus),  which  in  most  cases  is  found  pure.  In  broncho-pneumonia  no 
one  form  is  always  present.  In  the  primary  cases  the  pneumococcus  is 
usually  found,  and  in  many  cases  it  is  alone.  In  the  secondary  cases 
there  is  almost  always  mixed  infection.  In  measles  and  diphtheria  the 
streptococcus  is  usually  present,  such  eases  being  generally  of  the  worst 
type.  In  other  secondary  cases  there  are  found  the  staphylococcus,  and 
sometimes  Friedlander  s  bacillus.  Each  of  these  varieties  of  bacteria  may 
be  found  alone,  but  they  are  often  associated,  and  with  any  of  them  may 
be  found  the  pneumococcus,  or  other  specific  germs,  most  frequently  the 
bacillus  of  influenza,  diphtheria,  or  tuberculosis. 

Why  the  same  cause — the  pneumococcus — in  one  case  produces  bron- 
cho-pneumonia and  in  another  lobar  pneumonia,  is  in  part  owing  to 
the  difference  in  the  structure  of  the  lung  at  the  different  ages — that  of 
infancy  being  more  bronchial,  and  that  of  older  children  more  vesicular 
(page  506).  Another  reason  is  to  be  found  in  the  constitution  of  the 
patient :  in  the  very  young  and  in  feeble  and  delicate  children,  the  pro- 
cess tends  to  become  diffuse  and  the  products  are  chiefly  cellular;  in 
those  who  are  older  and  more  vigorous  it  is  likely  to  be  circumscribed, 
with  fibrin  as  its  chief  product ;  in  the  intermediate  ages  and  interme- 
diate conditions  the  types  are  often  mingled. 

Etiologically  as  well  as  clinically,  lobar  pneumonia  is  a  single  disease, 
usually  running  a  regular  self-limited  course.  Broncho-pneumonia,  on 
the  other  hand,  includes  a  number  of  quite  distinct  diseases,  which  are 
not  only  etiologically  but  clinically  different.  Sometimes  when  it  is  due 
to  the  pneumococcus  it  has  more  features  in  common  with  lobar  pneu- 
monia than  with  cases  of  broncho-pneumonia  due  to  another  kind  of 
infection,  such  as  the  streptococcus. 

The  immediate  source  of  infection  of  the  lungs  is  the  mouth,  the 
nose,  or  the  pharynx.  All  the  forms  of  bacteria  found  in  pneumonia  are 
found  in  these  cavities,  some  of  them  constant^,  others  only  at  certain 
times,  especially  during  an  attack  of  any  of  the  acute  infectious  diseases. 
What  part  direct  contagion  plays  in  the  spread  of  pneumonia  can  not  be 
settled  without  fuller  data  than  at  present  exist.  There  seems  to  be  no 
doubt,  from  clinical  observations  alone,  that  the  secondary  forms,  espe- 
cially those  complicating  measles  and  diphtheria,  are  sometimes  com- 
municated in  this  way.  This  is  probably  not  often  true  of  primary  cases 
except  in  hospitals  for  infants  where  the  rapid  development  of  case  after 
case  in  the  same  ward  can  not  be  well  explained  on  any  other  hypothesis. 

The  different  forms  of  i)neumonia  which  will  be  considered  are :  ( 1 ) 
Acute  broncho-pneumonia.  (2)  Acute  fibrinous  pneumonia.  (3)  Acute 
pleuro-pneumonia.  (-i)  Hypostatic  pneumonia.  (5)  Chronic  broncho- 
pneumonia. 


ACUTE   BRONCHO-PNEUMONIA.  527 

Tiiberculons  broncho-pneumonia  will  be  discussed  in  the  chapter  de- 
voted to  Tuberculosis. 


ACUTE  BRONCHO-PNEUMONIA. 

Synonyms:  Catarrhal  pneumonia,  lobular  pneumonia,  capillary  bronchitis. 

This  is  essentially  the  pneumonia  of  infancy.  Under  two  years,  the 
great  majority  of  the  cases  of  primary  pneumonia  are  of  this  variety,  and 
throughout  childhood  nearly  all  the  cases  of  secondary  pneumonia.  The 
term  broncho-pneumonia  describes  a  lesion  rather  than  a  disease,  several 
quite  distinct  forms  of  infection  being  included  under  this  head.  Its  mor- 
tality is  high,  because  of  the  tender  age  of  the  patients  in  which  the  pri- 
mary cases  occur,  and  also  because  when  secondary  it  complicates  the 
most  severe  forms  of  the  acute  infectious  diseases  of  children. 

Etiology. — Age. — The  426  cases  of  broncho-pneumonia  of  which  I 
have  notes  occurred  as  follows : 

During  the  first  year 224  cases,  or  53  per  cent. 

"         "     second  year 142     "       "   33   "       " 

"         "     third        "    46      "       "    11    "       " 

"     fourth      "    10     "       "     2   "       " 

"     fifth         "    4      "       "     1   "       " 

426  100 

After  four  years  broncho-pneumonia  is  very  infrequent  as  a  primary 
disease,  although  it  is  seen  throughout  childhood  as  a  complication  of  the 
infectious  diseases. 

Sex. — In  the  primary  cases  males  are  more  frequently  affected  than 
females,  the  proportion  being  five  to  four.  In  the  secondary  cases  the 
sexes  are  about  equally  affected. 

Season. — Of  the  cases  referred  to,  38  per  cent  occurred  during  the  win- 
ter months,  31  per  cent  during  the  spring,  13  per  cent  during  the  sum- 
mer, and  18  per  cent  during  the  autumn.  While,  therefore,  nearly  70  per 
cent  of  the  cases  occurred  in  the  cold  months,  broncho-pneumonia  is  seen 
throughout  the  year. 

Previous  condition. — Broncho-pneumonia  affects  all  classes,  but  is 
most  frequent  in  children  having  poor  hygienic  surroundings,  especially 
in  inmates  of  institutions,  and  in  those  previously  debilitated  by  constitu- 
tional or  local  disease.  In  246  consecutive  cases  of  primary  pneumonia, 
110  were  in  good  condition  prior  to  the  attack,  and  126  were  delicate, 
rachitic,  or  syphilitic. 

Previous  disease. — The  following  table  gives  a  good  idea  of  the  condi- 
tions with  which  acute  bronclio-pueuraonia  is  most  frequently  seen ;  443 
cases  were  classed  as  follows : 


528  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Primary  * 164 

Secondai'y  to  bronchitis  of  the  large  tubes 41 

Complicating  measles 89 

"             pertussis 66 

"             diphtheria 47 

"             acute  ileo-colitis 19 

"             scarlet  fever 7 

"             influenza 6 

"             A^aricella 2 

"             erysipelas 2 

443 

A  large  number  of  the  patients  had  previously  suffered  from  one  or 
more  attacks  of  bronchitis,  and  fifteen  previously  had  broncho-pneumonia. 
As  an  exciting  cause,  exposure  to  cold  must  still  be  classed  among  the 
potent  factors  of  primary  pneumonia. 

Bacteriology. — Much  light  has  already  been  thrown  upon  broncho- 
pneumonia by  bacteriology,  but  many  points  still  remain  to  be  settled. 

In  1892  ISTetter  published  a  report  upon  42  cases.  He  did  not  sepa- 
rate the  primary  and  secondary  cases.  Of  25  cases  in  which  but  one 
form  of  bacteria  was  found,  the  pneumococcus  was  present  in  10,  the 
streptococcus  in  8,  the  staphylococcus  in  5,  and  Friedlander's  bacillus  in 
2.  In  the  17  cases  of  mixed  infection,  the  streptococcus  was  present  in 
15,  the  pneumococcus  in  9,  the  staphylococcus  in  8,  and  Friedlander's 
bacillus  in  4. 

In  1897  Pearce  (Boston)  published  a  report  upon  82  cases  of  bron- 
cho-pneumonia complicating  various  infectious  diseases :  62  were  asso- 
ciated with  diphtheria  alone;  9  with  diphtheria  and  scarlet  fever;  2 
with  diphtheria  and  measles;  9  with  scarlet  fever  alone.  In  the  73 
diphtheria  cases  the  Ivlebs-Loeffler  bacillus  was  present  in  63,  and  in  17 
it  occurred  alone.  The  streptococcus  was  present  in  38  cases,  27  of  these 
being  in  diphtheria  uncomplicated  by  scarlet  fever  or  measles,  and 
in  7  of  these  it  was  the  only  organism  found.  The  staphylococcus 
aureus  was  present  in  26  cases,  but  never  alone.  It  is  surprising  that  the 
pneumococcus  was  present  in  but  8  cases,  5  of  these  being  scarlet  fever. 

I  am  indebted  to  Dr.  Martha  Wollstein,  Pathologist  to  the  Babies' 
Hospital,  for  permission  to  include  here  the  results  of  observations 
made  by  her  but  not  yet  published.  I  had  the  opportunity  of  observing 
most  of  the  cases  clinically,  they  having  been  treated  in  my  wards. 
Thus  far  100  cases  have  been  studied,  all  under  three  years  old;  in  33 
the  pneumonia  was  primary  and  in  67  secondary.  Of  the  latter,  25  com- 
plicated tuberculosis,  19  marasmus,  5  diphtheria,  3  measles,  3  malaria, 
4  septicaemia,  2  pyemia,  2  meningitis,  3  intestinal  disease,  1  abscess  of 
the  brain. 

*  It  is  probable  that  a  number  of  cases  complicating  influenza  were  included 
among  these  primary  cases. 


ACUTE  BRONCHO-PNEUMONIA.  529 


37 

12 

25 

29 

10 

19 

3 

'          —          " 

3 

2 

'          —          ■' 

2 

2 

'          _ 

2 

2 

—          " 

2 

4 

—          " 

4 

1 

'          —          " 

1 

3 

1 

2 

Cases.  Cases.  Cases. 

The  pneumococcus  was  present  in  67 — priniai-)',  24 ;  secondary,  43 — alone  in  31 

"    streptococcus  "        " 

"  staphylococcus  aureus  "  " 
"  staphylococcus  albus  "  '" 
"   bacillus  pyoeyaneus  "        " 

"   bacillus  diphtherite  "         " 

"  bacillus  lactis  aerogenes  "  " 
"  bacillus  coli  communis  "  " 
*'   proteus  vulgaris  "        " 

•'   sacchyromyces  albicans    "        " 

The  absence  of  the  bacillus  of  Pfeiffer  is  explained  by  the" fact  that 
cases  of  influenza  are  rarely  seen  at  the  hospital. 

Our  present  knowledge  of  the  bacteriology  of  broncho-pneumonia 
may  be  summarized  as  follows :  In  the  primary  cases  the  pneumococcus 
is  nearly  always  present,  and  in  a  large  proportion  of  the  cases  it  occurs 
alone.  In  cases  of  mixed  infection  it  is  most  frequently  associated  with 
the  streptococcus,  and  next  to  this  the  staphylococcus  pyogenes  aureus. 
In  the  secondary  cases  a  large  variety  of  bacteria  may  be  concerned. 
In  the  pneumonia  of  diphtheria  and  influenza  it  would  appear  from 
present  knowledge  that  only  the  specific  organisms  of  these  diseases  are 
necessary.  In  most  cases  of  secondary  pneumonia  an  important  part  is 
played  by  the  streptococcus  pyogenes,  particularly  when  it  complicates 
the  acute  infectious  diseases.  In  many  cases  it  is  found  with  the  staphy- 
lococcus aureus.  The  pneumococcus  may  be  associated  with  any  of  these 
bacteria  or  with  almost  any  combination  of  them.  All  other  forms  of 
infection  are  relatively  infrequent.  The  secondary  cases  are  usually  due 
to  a  mixed  infection.  The  association  of  the  ^pneumococcus  in  18  of  25 
tuberculous  cases  studied  by  Dr.  Wollstein  is  of  interest,  as  it  explains 
the  clinical  fact  that  in  cases  of  tuberculous  broncho-pneumonia  the 
symptoms  are  often  indistinguishable  from  the  simple  form. 

We  have  not  yet  sufficient  data  definitely  to  connect  the  different 
forms  of  infection  either  with  any  set  of  lesions  or  with  any  group  of 
clinical  symptoms.  The  cases  due  to  streptococcus  infection  are  usually 
the  worst  forms,  and  are  apt  to  show  widely  disseminated  lesions.  The 
cases  in  which  the  onset  and  clinical  history  resemble  lobar  pneumonia, 
and  where  there  are  found  extensive  areas  of  consolidation,  and  often 
excessive  pleurisy,  are  usually  due  to  the  pneumococcus. 

Lesions. — The  term  broncho-pneumonia  is  uoav  generally  adopted  as 
a  generic  one,.and  it  is  to  be  preferred  either  id  lolmlar  or  catarrhal  pneu- 
monia, as  it  gives  prominence  to  the  bronchial  element  in  the  inflam- 
mation. The  process  may  begin  in  the  larger  tubes  and  gradually  extend 
to  those  of  smaller  calibre,  finally  involving  the  pulmonary  lobules  in 
which  tliese  tubes  terminate;  or  it  may  extend  to  the  air  vesicles  which 
surround  the  tube  in  its  course  through  the  lung,  so  that  in  whatever 


530 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


direction  the  lung  is  cut,  there  are  seen  surrounding  the  small  bronchi,  zones 
of  pneumonia  (Fig.  88).  In  other  cases  the  process  seems  to  begin  alniost 
at  the  same  time  in  the  small  bronchi  and  the  air  vesicles,  as  both  are  found 
involved,  even  when  death  occurs  within  a  few  hours  of  the  first  symptoms. 
There  are,  however,  cases  in  which  the  parts  of  the  lung  affected  bear 
no  relation  to  the  bronchi — where  there  are  found  simply  smaller  or  larger 


Fig.  88. — Broncho-pneumonia,  with  thickening  of  a  small  bronchus.  In  the  centre  of  the  pic- 
ture is  seen  a  small  bronchus,  B,  which  is  cut  somewhat  obliquely,  so  that  the  degree  to  which 
its  wall,  C,  is  thickened  is  well  shown.  It  is  partially  tilled  with  pus,  its  mucous  membrane 
is  nearly  destroyed,  and  its  walls  greatly  thickened  from  infiltration  with  leucocytes.  This 
infiltration  extends  to  the  lung  tissue  in  the  neighbourhood ;  it  forms  a  peri-bronchitic  zone 
of  pneumonia.  Elsewhere  in  the  picture  the  lung  tissue.  A,  is  practically  normal.  D  is  a 
small  blood-vessel.  E  is  another  smaller  bronchus.  Throughout  the  lung  everywhere  accom- 
panying the  small  bronchi  similar  changes  were  seen,  in  addition  to  which  there  were  present 
some  large  areas  of  consolidation.  The  disease  was  of  four  and  a  half  weeks'  duration ;  the 
child,  five  months  old. 


areas  of  pneumonia  irregularly  scattered  through  tlie  lung,  usually  near 
the  surface  (Plate  XIII).  From  the  distribution  of  the  lesions  such  cases 
might  better  be  termed  lobular  than  broncho-pneumonia. 

Much  has  been  said  in  the  past  about  pulmonary  collapse  from  ob- 


PLATE    XIII. 


Acute  Bronciio-Pxkvmonia. 

Primary  pneumonia  in  a  child  two  years  old,  showin.s,'  tlie  irrepruhir  distribution  of 
the  hepatization  and  its  incomplete  character.  A  is  the  pleura  somewhat  thickened  ; 
B  lung  tissue  which  is  practically  normal ;  C  C  are  hepatized  areas,  scattered  through 
which  are  groups  of  air  vesicles  still  containing  air.     (Slightly  magnified.) 


ACUTE   BRONCHO-PNEUMONIA.  531 

struction  of  the  small  bronchi,  as  a  condition  antecedent  to  this  form  of 
pulmonary  inflammation.  So  far  as  my  own  observations  go,  there  has 
been  adduced  but  little  evidence  that  this  is  the  rule,  or,  indeed,  that  it 
often  occurs.  Even  in  autopsies  made  very  early  in  the  disease,  but  little 
collapse  was  found,  most  of  the  cases  supporting  the  view  of  Delafield,that 
when  the  disease  extends  from  the  bronchi  to  the  air  cells  it  involves  those 
surrounding  the  tube  quite  as  regularly  as  those  to  which  the  tube  leads. 

The  following  observations  are  made  from  a  study  of  170  autopsies  of 
which  I  have  records,  microscopical  examinations  having  been  made  in 
about  one  third  of  the  number. 

Seat  of  the  disease. — In  82  per  cent  of  the  autopsies  extensive  disease 
was  found  in  both  lungs.  The  parts  most  affected  were  the  lower  lobes 
posteriorly ;  next  to  this  the  posterior  jaart  of  both  the  upper  and  lower 
lobes.  The  left  lower  lobe  was  more  extensively  diseased  than  the  right 
in  over  two  thirds  of  the  cases.  Only  a  single  lobe  was  involved  in  but  9 
per  cent  of  the  cases.  It  is  not  common  for  the  disease  to  be  situated  in 
the  anterior  portion  of  the  lung  only,  but  when  this  occurs  the  right 
apex  is  the  most  frequent  seat. 

Just  as  the  clinical  symptoms  of  broncho-pneumonia  follow  no  regular 
type,  so  the  pathological  process  does  not  pass  through  a  regular  order  of 
changes  such  as  are  seen  in  lobar  pneumonia.  There  are  a  certain  number 
of  cases  which  appear  to  follow  tolerably  well-defined  stages  of  conges- 
tion, red  hepatization,  gray  hepatization,  and  resolution ;  but  the  dis- 
ease may  be  arrested  at  any  of  the  stages  and  the  case  recover,  or  death 
may  occur  at  any  stage  and  there  may  be  found  at  autopsy  different  por- 
tions of  the  lung  representing  all  the  stages  mentioned.  In  considering, 
therefore,  the  lesions  of  broncho-pneumonia,  it  seems  best  to  describe  the 
condition  in  which  the  lungs  are  found  at  the  various  periods  when  death 
is  likely  to  occur,  rather  than  to  attempt  to  describe  the  different  stages  of 
the  disease,  as  in  lobar  pneumonia. 

1.  The  acute  congestive  form  {acute  red  jineumonia). — This  is  the  con- 
dition in  which  the  lung  is  usually  found  if  death  occurs  during  the  first 
two  or  three  days  of  the  disease.  In  the  cases  severe  enough  to  cause 
death  in  the  first  twenty-four  hours,  very  little  can  be  seen  by  the  naked 
eye  except  acute  congestion.  The  vessels  of  the  pleura  are  distended, 
and  there  may  be  small  superficial  haemorrhages.  15oth  lower  lobes  are 
usually  heavy  and  dark-coloured.  There  is  to  the  naked  eye  no  consolida- 
tion. All,  or  nearly  all,  the  lung  can  be  inflated.  On  section,  there  is 
found  intense  congestion  with  some  oedema.  When  the  process  has  lasted  a 
little  longer  the  affected  areas  are  more  sharply  defined.  These,  usually  the 
posterior  portions  of  both  lungs,  are  of  a  brownish-red  colour,  and  appear 
partially  hepatized,  although  with  a  little  force  they  may  in  most  cases  be 
infiated.  After  section,  pus  and  mucus  flow  from  the  divided  bronchi, 
and  the  whole  lunir  niav  be  more  or  less  congested  or  o^dematous. 


532 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


The  microscope  alone  reveals  the  fact  that  these  are  not  cases  of  sim- 
ple pulmonary  congestion  or  bronchitis  of  the  finer  tubes.  In  one  case  in 
which  death  occurred  twelve  hours  from  the  first  symptoms,  I  found  well- 


5    > 

•* 


*.* 


plr-  ^^W^ 


^ 


~-%N»- 


^^ 


,  t 


*,     ^ 


*   -♦«./■*  ""Mr 


S^^.^'i 


,♦>*►' 


Fig.  89. — Acute  broncho-piieiiinonia  ■n'ith  intra-alveolar  haemorrhage  (highly  magnified).  In  the 
pictm-e  is  shown  a  small  vein,  which,  as  well  as  the  surrounding  alveoli,  is  filled  with  blood- 
cells.  In  other  respects  the  lung  shown  is  normal.  This  is  from  the  border  of  a  consoli- 
dated area.  Child  fifteen  months  old :  pneumonia  of  ten  days'  duration,  with  a  severe  ex- 
acerbation forty-eight  hours  before  death,  temperature  lOB"  F.  Extensive  hsemoi-rhagic  areas 
■were  scattered  through  the  lung  moat  affected. 


marked  evidences  of  inflammation  of  the  air  vesicles.  In  these  hyper-aciite 
cases,  the  microscope  shows  great  distention  of  all  the  small  blood-vessels 
of  the  affected  area,  and  small  or  large  extravasations  of  blood  just  be- 
neath the  pleura,  into  the  alveoli  (Fig.  89)  and  interstitial  tissue  of  the 
lung.  In  some  cases  these  haemorrhages  form  the  most  striking  feature 
of  the  lesion.  The  air  vesicles  are  partially,  some  almost  completely,  filled 
with  red  blood-cells,  swollen  and  desquamated  epithelial  cells,  and  a  few 
leucocytes  (Fig.  86).  The  red  blood-cells  predominate.  The  inflamma- 
tion may  be  diffuse,  involving  nearly  a  whole  lobe,  or  in  small  areas  in  the 


ACUTE  BRONCHO-PNEUMONIA. 


533 


neigliboTirhood  of  the  small  bronchi.  The  mucous  membrane  of  the  large 
and  small  bronchi  is  the  seat  of  catarrhal  inflammation,  and  the  walls 
of  the  latter  are  infiltrated  with  round  cells. 

When  the  process  has  lasted  from  twenty-four  to  forty-eight  hours 
all  the  changes  described  are  more  marked,  but  the  red  colour  of  the  in- 
flammatory products  still  persists.  Such  cases  give  during  life  only  the 
signs  of  congestion  and  bronchitis. 

2.  The  mottled,  red  and  gray  pneumonia. — This  is  the  usual  appear- 
ance when  the  disease  has  lasted  somewhat  longer,  and  is  found  in  most 
of  the  cases  dying  between  the  fourth  and  fourteenth  days.  There  are 
usually  at  this  time  quite  large  areas  of  consolidation,  sometimes  affect- 
ing nearly  an  entire  lobe,  so  that  at  first  sight  the  case  may  resemble  lobar 
pneumonia.  This  is  sometimes  described  as  the  "  pseudo-lobar  "  form. 
The  extent  of  these  areas  depends  largely  upon  the  duration  of  the  dis- 
ease.    In  most  cases  there  is  pleurisy  over  the  consolidated  portions. 


-B 


Fig.  90. — Acute  bronclio-pnounionia.  In  the  centre  is  slmw  n  a  simill  broncluis,  B,  with  a  zone 
of  pneumonia  about  it.  The  greater  part  of  the  seetion  is  made  up  of  empliysematous  lung 
tissue,  E  E,  showinLr  dilatation  of  the  alveolar  spaces  and  rupture  of  some  of  the  alveolar 
septa.     At  the  border,  A  A  A,  are  seen  the  margins  of  consolidated  areas  of  lung. 


This  may  cause  the  lung  to  adhere  to  the  chest  wall,  the  firmness  of  the 
adhesions  depending  upon  tlie  duration  of  tlie  process.  The  surface  of 
the  luno-  is  usually  ol:  a  mottled  red  and  iirnv  colour;  it  often  has  a  gran- 


534 


DISEASES  OF  THE  EESPIRATORY  SYSTEM. 


ular  feel,  due  to  the  consolidation  of  some  of  the  superficial  lobules  of 
the  lung.  On  section,  it  is  rarely  found  that  an  entire  lobe  is  consoli- 
dated, the  superficial  portion  being  most  afi:ected,  while  the  central  part 
is  normal  or  only  congested.  The  colour  is  mottled,  like  that  of  the  sur- 
face. In  some  places  the  hepatization  appears  complete;  in  others  the 
hepatized  areas  are  separated  by  healthy,  congested,  or  emphj^sematous 


'^-m 


Fig.  91. — Broncho-pneumonia.  Dense  infiltration  of  pus  cells  in  and  about  a  small  bronchus; 
under  a  low  power.  The  cavity  shown  in  the  specimen  is  a  cross-section  of  one  of  the  small 
bronchi,  which  is  partially  filled  with  pus  cells ;  the  epithelium  is  destroyed.  The  bron- 
chial wall  and  the  pulmonary  tissue  in  the  neighboui'liood  are  so  densely  infiltrated  with 
leucocytes  that  almost  every  trace  of  normal  structure  is  efl'aced.  Child  fifteen  iiKinths  old, 
disease  of  four  weeks'  duration.     Extensive  areas  like  this  were  found  in  both  lungs. 


lung  tissue  (Fig.  90).  The  gray  areas  surround  the  small  bronchi  and 
vary  in  size.  The  smallest  ones  look  very  much  like  miliary  tubercles. 
The  larger  ones  are  seen  where  the  process  has  existed  for  a  longer  time 
and  has  gradually  invaded  the  contiguous  air  cells.  If  the  lung  is  cut 
parallel  with  the  bronchi,  there  may  be  seen  small  gray  striae  of  pneu- 
monia along  their  course  (Fig.  88,  C).    From  the  cut  bronchi,  pus  flows 


ACUTE  BRONCHO-PNEUMONIA.  535 

quite  freely  on  pressure.  The  bronchial  walls  can  often  be  seen  to  be 
thickened  even  by  the  naked  eye.  The  parts  affected  are  usually  the  pos- 
terior portions  of  the  lower  lobes  of  one  side,  the  remainder  of  the  lobes 
being  congested  or  oedematous,  while  in  front  the  lung  is  emphysematous. 

Under  the  microscope  the  smaller  bronchi  (Fig.  88)  are  seen  to  be 
much  thickened  and  infiltrated  with  leucocytes.  The  gray  areas  sur- 
rounding the  bronchi  are  made  up  of  groups  of  air  vesicles,  which  are 
packed  with  leucocytes  (Fig.  91).  Fibrin  is  sometimes  seen  in  small 
amount,  also  red  blood-cells  and  desquamated  epithelial  cells,  but  the 
leucocj^tes  predominate.  Surrounding  the  areas  densely  infiltrated  are 
groups  of  air  vesicles  which  are  normal  or  congested,  or  which  show  only 
the  earlier  stages  of  the  inflammatory  process. 

3.  Gray  jmeumonia  {persistent  broncho-pneumonia). — This  form  is 
seen  in  protracted  cases  where  there  have  been  continuous  symptoms 
usually  for  from  three  to  six  weeks.  The  pleuritic  adhesions  are  more 
general  and  firmer.  The  amount  of  lung  involved  may  be  very  great, 
often  nearly  the  whole  of  both  lungs  posteriorly.  The  affected  lung  ap- 
pears completely  consolidated  and  slightly  enlarged.  On  section,  it  is 
of  a  nearly  uniform  gray  colour,  sometimes  of  a  yellowish-gray.  On 
pressure,  pus  exudes  from  the  smaller  and  larger  bronchi.  The  bron- 
chial walls  are  markedly  thickened,  and  in  some  places  there  may  be  a 
slight  dilatation  of  the  smaller  bronchi.  The  part  of  the  lung  not  con- 
solidated may  be  almost  Avhite,  owing  to  vesicular  emphysema.  In  some 
cases  there  is  also  interstitial  emphysema.  Small  cavities  containing 
pus  may  be  found  in  the  lung.  The  bronchial  glands  are  frequently 
swollen  to  the  size  of  a  large  bean,  and  are  of  a  reddish-gray  colour. 

The  microscope  shows  that  the  air  vesicles  of  the  consolidated  por- 
tions are  distended  chiefly  with  leucocytes,  but  there  are  also  epithelial 
and  connective-tissue  cells.  The  alveolar  septa  may  be  so  much  thick- 
ened as  to  encroach  upon  the  alveolar  spaces  (Fig.  92).  Complete  reso- 
lution is  then  impossilfle. 

Terminations. — Death  nay  occur  at  any  stage,  or  the  pathological 
process  may  be  arrested  at  any  stage  and  the  case  go  on  to  recovery. 
Eesolution  may  take  place  before  any  consolidation  recognisable  by  phys- 
ical signs  has  occurred;  in  such  cases  it  is  usually  rapid  and  complete. 
If  there  has  been  consolidation,  resolution  may  take  place  after  two  or 
three  weeks  and  be  complete,  or  it  may  be  delayed  for  five  or  six  weeks 
and  still  be  complete.  In  many  cases,  especially  those  in  which  it  is  de- 
layed, resolution  is  only  partial,  and  there  are  relapses  or  recurring  at- 
tacks. After  the  first,  or  after  several  attacks,  there  may  develop  a 
chronic  interstitial  pneumonia;  or  simple  pneumonia  may  be  followed 
by  tulicrculosis.  Such  cases  as  these  are  to  be  carefully  distinguished 
from  the  much  more  frequent  ones  in  which  the  bronclio-})neuiiionia  is 
tuberculous  from  the  outset. 


536 


DISEASES  0\P  THE   RESPIRATORY  SYSTEM. 


Associated  Lesions  of  the  Lungs. — Pleurisy  is  almost  invariably  found 
over  every  large  area  of  consolidation,  and  in  cases  of  more  than  four 
days'  duration ;  while  in  most  of  those  fatal  within  the  first  two  or  three 
days  the  pleura  is  normal  or  only  congested.  It  is  seen  in  all  grades  of 
severity,  from  a  slight  gray  film  of  fibrin  that  can  hardly  be  stripped  off, 
to  a  yellowish-green  exudation  one  fourth  of  an  inch  thick.  A  small 
amount  of  serum — one  or  two  ounces — in  the  pleural  sac  is  not  uncom- 
mon, but  a  large  serous  effusion  is  very  rare.     Cases  in  which  there  is  an 


"""^^mL^lA 


Fig.  92. — Persistent  broncho-pneumonia;  highly  niagnitied.  There  is  shown  at  A  A  marked 
thickening  of  the  alveolar  septa,  encroaching  upon  the  alveolar  spaces.  All  the  alveoli,  B  B, 
are  densely  packed  with  leucocytes.  A  similar  condition  also  through  nearly  the  whole  of 
the  att'ected  lung.     (For  history  and  temperature,  see  Fig.  101.) 

excessive  inflammation  of  the  pleura  are  considered  elsewhere  under  the 
head  of  Pleuro-Pneumonia.  Empyema  occurs  both  during  the  stage  of 
acute  inflammation  of  the  lung  and  while  this  is  subsiding,  but  it  is  less 
frequent  than  in  lobar  pneumonia. 

Bronchial  glands. — In  all  the  recent  acute  cases  these  are  swollen  and 
red ;  the  usual  size  is  that  of  a  pea  or  a  bean.     They  show  microscopically 


ACUTE   BRONCHO-PNEUMONIA.  537 

the  usual  changes  of  acute  hyperplasia.  In  protracted  cases,  and  after 
repeated  attacks,  they  may  be  two  or  three  times  the  size  mentioned,  and 
of  a  gray  colour.  It  is  rare  that  they  are  large  enough  to  give  rise  to 
symptoms  unless  they  become  the  seat  of  tuberculous  deposits. 

Emphysema. — In  almost  all  cases  a  certain  amount  of  emphysema  is 
present,  it  being  more  marked  in  the  protracted  cases.  It  is  usually  vesic- 
ular, involving  the  greater  part  of  the  upper  lobes  in  front  and  the  ante- 
rior margin  of  the  lower  lobes.  Occasionally  interstitial  emphysema  is 
seen,  forming  either  large  strise  upon  the  surface  of  the  lung,  or  blebs  of 
considerable  size  along  the  anterior  margin.  This  may  occur  even  in 
cases  uncomplicated  by  pertussis  or  laryngeal  stenosis. 

Gangrene. — Gangrenous  areas  were  found  in  six  of  my  cases.  In  four 
of  these  the  pneumonia  was  primary,  in  one  it  followed  diphtheria,  and  in 
one  ileo-colitis.  It  occurred  in  scattered  areas  of  a  grayish-green  colour, 
varying  from  one  fourth  of  an  inch  to  two  inches  in  diameter. 

Abscesses  of  the  lung  are  by  no  means  uncommon.  They  were  noted 
in  seven  per  cent  of  my  autopsies.  They  are  usually  minute  and  multiple, 
varying  in  size  from  one  sixth  to  one  half  inch  in  diameter.  Sometimes 
a  portion  of  a  lobe  is  fairly  honeycombed  with  minute  abscesses.  In  one 
case  a  large  abscess  was  found  occupying  the  greater  part  of  a  lobe,  the 
symptoms  resembling  those  of  empyema.  Abscesses  are  usually  found  in 
regions  where  the  inflammatory  process  has  been  especially  intense.  They 
may  be  found  in  prolonged  cases,  in  those  of  unusual  severity,  as  shown 
by  excessively  high  temperature  and  rapid  extension  of  the  disease,  and 
in  very  delicate  subjects.  The  microscope  shows  that  these  abscesses  usu- 
ally begin  as  an  accumulation  of  pus  in  the  small  bronchi,  whose  walls 
become  softened  and  break  down  on  account  of  the  intensity  of  the  in- 
flammation. They  may  be  superficial,  but  are  more  commonly  in  the 
interior  of  the  lung;  they  contain  yellow  pus  and  sometimes  broken- 
down  lung  tissue.  Small  abscesses  can  not  be  recognised  clinically; 
the  large  ones  give  the  symptoms  and  signs  of  empyema.  In  several 
instances  they  have  been  successfully  operated  on,  though  wrongly  diag- 
nosticated. 

The  lesions  in  other  organs  will  be  considered  under  Complications. 

Symptoms. — Broncho-pneumonia  has  no  typical  course.  The  cases 
difi'er  from  each  other  very  markedly,  but  they  may  be  divided  into  a  few 
quite  distinct  groups. 

1.  The  acute  congestive  type. — This  may  be  seen  at  any  age,  but  is 
more  frequent  in  young  infants.  It  may  be  either  primary  or  secondary, 
being  not  uncommon  in  either  form.  Its  symptoms  are  few  and  irregular, 
and  the  disease  is  often  unrecognised.  Tlic  entire  duration  may  be  only 
twenty-four  hours.  High  temperature,  extreme  prostration,  cyanosis,  and 
rapid  respiration  may  be  the  only  symptoms.  The  temperature  varies  be- 
tween 104°  and  107°  F.,  usually  rising  steadilv  until  death  occurs.    The 


538  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

prostration  is  extreme  from  the  outset,  the  patient  being  overwhelmed  by 
the  suddenness  and  severity  of  the  attack.  Cyanosis  is  frequently  present, 
and  is  almost  always  seen  shortly  before  death.  The  respirations  are  from 
60  to  80  a  minute,  but  in  most  cases  not  strikingly  laboured.  Cough  is 
frequently  absent.  Cerebral  symptoms  are  often  marked.  There  are  dul- 
ness  and  apathy,  sometimes  quite  profound  stupor,  and  not  infrequently 
convulsions  just  before  death.  The  physical  signs  are  few  and  inconclu- 
sive. There  is  often  nothing  abnormal  except  very  rude  breathing  over 
both  lungs  behind  ;  sometimes  the  breathing  on  one  side  is  feeble,  and  on 
the  other  much  exaggerated.  There  may  be  no  rales  whatever,  and  no 
change  in  the  percussion  note. 

The  suddenness  and  severity  of  these  symptoms  are  something  which, 
it  is  hard  for  one  who  has  not  observed  them  to  appreciate.  I  have  known 
an  infant  to  die  in  twelve  hours  from  the  time  in  which  it  was  apparently 
in  perfect  health,  and  had  an  opportunity  to  confirm  the  diagnosis  of 
pneumonia  by  a  microscopical  examination  of  the  lung.  The  diagnosis 
can  not  be  positively  made  during  life,  and  in  most  of  the  cases  the  disease 
passes  under  some  other  name.  It  is  often  regarded  as  malignant  scarlet 
fever  or  measles  with  suppressed  eruption,  or  cerebro-spinal  meningitis. 

If  the  children  are  sufficiently  strong  to  withstand  the  onset  of  vio- 
lent symptoms,  they  may  recover  completely  in  four  or  five  days,  the 
lung  clearing  up  very  rapidly.  In  other  cases  these  grave  symptoms  may 
abate  in  a  day  or  two,  to  be  followed  by  those  of  ordinary  broncho-pneu- 
monia, which  runs  its  usual  course. 

The  symptoms  of  some  of  these  cases  may  be  explained  by  the  suddeiL 
intense  engorgement  of  the  lung,  which,  owing  to  the  small  size  of  the 
air  vesicles,  interferes  with  its  function  almost  as  much  as  does  consoli- 
dation. In  other  cases  the  symptoms  are  due  not  so  much  to  the  pulmo- 
nary condition  as  to  a  general  pneumococcus  infection.  A  case  lately 
came  under  my  notice  in  which  death  occurred  after  a  thirty  hours'  ill- 
ness, where  the  pneumococcus  was  found  by  culture  in  both  kidneys,  the 
spleen,  heart's  blood,  and  both  lungs. 

2.  Acute  disseminated  broncho-pneumonia  (capillary  bronchitis). — 
Although  the  symptoms  in  this  class  of  cases  are  chiefly  due  to  the  bron- 
chitis, I  have  never  failed  to  find  at  autopsy  evidences  of  pneumonia  also. 
These  are  not  very  common  cases.  The  process  begins  as  an  inflamma- 
tion of  the  medium-sized  and  small  bronchi,  but  not  of  the  finest  bronchi. 
The  onset  is  acute,  with  fever,  very  rapid  and  laboured  breathing,  severe 
cough,  moderate  prostration,  and  in  most  cases  cyanosis. 

The  temperature  is  not  high,  usually  only  from  100°  to  102°  F.,  and  it 
often  continues  so  for  three  or  four  days.  The  pulse  is  rapid,  and  at  first 
is  full  and  strong.  The  respirations  are  exceedingly  rapid,  often  from  80- 
to  100  a  minute.  There  is  dyspnoea  with  marked  recession  of  all  the  soft 
parts  of  the  chest  during  inspiration.     Cough  is  always  present,  usually 


ACUTE   BRONCHO-PNEUMONIA.  539 

severe,  and  sometimes  almost  incessant.  The  prostration  is  not  so  great 
as  in  the  cases  previously  described,  and  the  development  of  the  symptoms 
is  much  less  rapid. 

There  are  at  first  sibilant  and  afterward  subcrepitant  rdles  over  the 
entire  chest,  with  which  are  usually  mingled  coarser  moist  rales.  There 
are  no  evidences  of  consolidation.  The  respiratory  murmur  is  everywhere 
feeble,  but  not  otherwise  altered.  Percussion  generally  gives  exaggerated 
resonance,  owing  to  the  emphysema  which  is  present,  the  note  being  some- 
times almost  tympanitic. 

The  symptoms  may  gradually  increase  in  severity  until  death  takes 
place  by  the  third  or  fourth  day,  from  respiratory  and  cardiac  failure. 
There  is  usually  marked  cyanosis,  and  toward  the  end  rapidly  increasing 
prostration.  Just  before  death  the  temperature  often  rises  rapidly  to  106° 
or  107°  F.  At  the  autopsy  there  are  found  evidences  of  bronchitis  of  the 
tubes  of  all  sizes,  and  minute  zones  of  pneumonia  about  the  smaller 
bronchi.  The  lungs  are  generally  in  a  state  of  hyper-inflation,  on  account 
of  which  they  do  not  collapse  on  opening  the  chest.  There  may  be  in 
addition  extensive  congestion  or  oedema,  the  development  of  which  has 
been  the  immediate  cause  of  death. 

In  cases  which  do  not  prove  fatal  there  is  usually  by  the  third  or  fourth 
day  great  improvement  in  the  general  symptoms ;  the  finer  rales  may  dis- 
appear, and  the  coarse  ones  become  more  and  more  prominent.  By  the 
end  of  a  week  there  may  be  complete  recovery.  Instead  of  this,  there 
may  be  a  continuance  of  the  constitutional  symptoms,  and  disappearance 
of  the  fine  rales  in  front  only,  while  behind  there  are  gradually  added  to 
them  the  signs  of  consolidation  in  one  of  the  lower  lobes  near  the  spine. 
From  this  time  the  case  may  progress  as  one  of  ordinary  broncho-pneu- 
monia. 

The  prognosis  in  this  class  of  cases  is  very  much  better  than  in  the 
congestive  variety,  recovery  being  probable  unless  the  patients  are  very 
young  or  very  delicate  infants. 

3.  Broncho- pneumonia  of  the  common  type. — When  primary,  this  usu- 
ally begins  suddenly  with  symptoms  not  nnlike  those  of  lobar  pneumonia. 
This  was  the  mode  of  onset  in  two  thirds  of  my  cases.  In  only  ten  per 
cent  was  the  pneumonia  preceded  by  bronchitis  of  the  large  tubes.  In 
these  the  symptoms  of  bronchitis  may  slowly  (Fig.  102,  p.  5-18)  or  i-np id- 
ly (Fig.  93)  merge  into  those  of  pneumonia.  When  the  onset  is  sudden 
it  is  marked  by  high  fever,  frequently  by  vomiting,  rarely  by  convul- 
sions. In  addition  there  are  rapid  respiration,  cough,  prostration,  and 
sometimes  cyanosis.  The  symptoms  are  more  distinctly  pulinoiiiii-v  llinn 
is  generally  the  case  in  lobar  pneumonia. 

The  temperature,  as  a  rule,  is  high  :  rarely  is  it  continuously  so,  but 
it  is  of  a  remittent  type.  The  daily  fluctuations  often  amount  to  four  or 
five  degrees.    The  fevci-  usually  (•(uitiiuics  fi'oni  oii(>  to  three  weeks,  and 


540  DISEASES   OF   THE   EESPIRATORY   SYSTEM. 

gradually  subsides.  It  is  rare  for  it  to  terminate  by  crisis.  Although, 
as  a  rule,  we  expect  a  high  temperature  with  acute  pneumonia,  this 
is  not  invariable.  Primary  cases  may  run  their  course,  and  even  ter- 
minate fatally,  although  the  temjDerature  has  not  been  above  101°  F. 
I  have  records  of  several  such  cases.  A  low  temperature  is  more  often 
seen  in  young  and  delicate  infants  than  in  those  who  are  older  and  more 
robust. 

The  respirations  are  frequent  and  laboured  ;  there  is  real  dyspncea. 
On  inspiration,  there  are  marked  recessions  of  all  the  soft  parts  of  the 
chest,  and  the  alaj  nasi  dilate  actively.  The  usual  rapidity  of  the  respira- 
tions is  from  60  to  80  per  minute  ;  very  often,  however,  it  rises  to  100,  and 
on  several  occasions  I  have  seen  it  even  120.  Eespii'ation  generally  seems 
more  embarrassed  than  the  action  of  the  heart,  and  respiratory  failure  is 
a  more  frequent  cause  of  death  than  cardiac  failure.  The  pulse  is  always 
rapid — from  150  to  300  a  minute — and  when  so  it  is  often  irregular.  The 
pulse  rate  is  of  much  less  importance  than  its  character.  Early  it  is  full 
and  strong,  but  soon  it  becomes  soft,  compressible,  and  weak. 

The  prostration  is  usually  moderate  for  the  first  day  or  two,  but 
steadily  increases  as  the  lung  becomes  more  and  more  involved.  Toward 
the  close  of  the  disease  there  may  be  present  all  the  symptoms  of  the 
typhoid  condition. 

Cough  is  much  more  constant  than  in  lobar  pneumonia,  and  more  dis- 
tressing ;  sometimes  it  is  almost  incessant.  It  disturbs  rest  and  sleep,  and 
may  cause  vomiting  if  the  paroxysm  occurs  soon  after  eating.  There  is 
no  expectoration.  Mucus  is  sometimes  coughed  up  into  the  trachea,  or 
even  the  pharynx,  to  be  swallowed  again,  or  more  frequently  aspirated 
into  the  lung.  If  during  a  severe  paroxysm  the  patient  is  turned  upon 
his  face  or  inverted,  much  of  this  mucus  may  be  dislodged.  A  strong 
cough  is  a  good  symptom  :  suppression  of  the  cough  is  always  a  bad 
symptom,  indicating  a  loss  of  the  reflex  sensibility  of  the  bronchial  mucous 
membrane  and  feeble  respiratory  m.uscles. 

Pain  in  the  chest  is  not  common,  and  is  rarely  an  annoying  symptom. 

Cvanosis  is  present  at  some  time  in  most  of  the  severe  cases.  It  may 
occur  at  the  onset,  or  at  any  time  during  the  course  of  the  disease.  It  is 
usually  due  to  sudden  congestion  of  a  portion  of  the  lung  not  previously 
involved.  Even  when  slight,  it  is  always  a  danger-signal  of  respiratory 
failure,  and  when  present  only  in  the  finger  tips  or  lips  indicates  that  the 
patient  must  be  carefully  watched  and  energetically  treated.  In  the  severe 
cases  the  whole  body  may  be  of  a  dull  leaden  hue. 

Nervous  symptoms  at  the  onset  are  not  so  frequent  as  in  lobar  pneu- 
monia, convulsions  being  rare ;  but  late  convulsions,  particularly  in  the 
pneumonia  which  complicates  pertussis,  are  exceedingly  frequent,  and 
usually  fatal.  Delirium  may  be  present  at  any  time  during  the  attack. 
In  infants  this  shows  itself  by  excitement  and  inability  to  recognise  the 


ACUTE   BRONCHO-PNEUMONIA. 


541 


nurse  or  mother.  Occasionally  patients  present  marked  cerebral  s)'mptoms 
throughout  the  disease.  In  one  of  my  cases  nearly  every  symptom  of 
tuberculous  meningitis  was  present,  the  autopsy  revealing  only  an  extreme 
degree  of  cerebral  anEemia.  As  elsewhere  stated,  the  nervous  symptoms 
depend  not  upon  the  location  of  the  disease,  but  upon  its  extent,  the 
intensity  of  the  infection,  and  upon  the  susceptibility  of  the  patient,  such 
symptoms  being  especially  common  in  rachitic  children  and  in  those  suf- 
fering from  pertussis. 

Gastro-enteric  symptoms  are  frequent  in  infancy,  and  are  of  much 
importance.  Often  there  are  from  four  to  six  stools  a  day,  of  a  green 
colour,  containing  mucus  and  undigested  food.  These  symptoms  depend 
upon  the  feeble  digestion  which  is  associated  with  the  febrile  process, 
and  are  often  from  improper  feeding.  This  may  lead  to  vomiting,  which 
is  also  due  to  over-medication  or  to  severe  paroxysms  of  coughing.  Vom- 
iting and  diarrhoea  add  much  to  the  danger  of  the  attack,  and  not  in- 
frequently, when  the  issue  is  doubtful,  turn  the  scale  against  the  patient. 
In  summer  this  complication  is  more  frequent  and  is  likely  to  be  more 
severe.  Distention  of  the  stomach  or  intestines  from  gas  may  be  the 
cause  of  severe  symptoms,  owing  to  the  added  embarrassment  of  respira- 
tion produced  by  this  upward  pressure.  In  infants  it  may  lead  to  attacks 
of  cyanosis,  and  even  convulsions. 

The  urine  in  most  cases  is  scanty,  high-coloured,  and  loaded  with 
urates.  A  trace  of  albumin  is  often  present  when  the  temperature  is 
very  high ;  but  casts,  renal  epithelium,  and  a  large  amount  of  albumin 
are  rare. 

The  following  temperature  chart  (Fig.  93)  is  a  good  example  of  a  very 
frequent  course  of  primary  pneumonia  of  moderate  severity  terminating 


105° 

1 

2 

.3 

i 

5 

0 

7 

8 

9 

10 

U 

12 

IS 

u 

15 

16 

101° 
103° 
102° 
101° 
100° 
99° 

|\ 

h 

A 

/I 

^ 

/ 

■^ 

J 

/^ 

•v 

/ 

\ 

\ 

r 

\l 

/ 

\l 

A 

r^ 

1' 

•v. 

^ 

\ 

« 

L 

V 

^J/VI 

Fig.  'j3.— Temperature  curve  in  typical  broncho-pneumonia  of  the  milder  form. 

Hintory.—^AaXa,  si.xteen  months  old;  delicate  child;  previous  bronchitis;  onset  gradual; 
signs  of  consolidation  at  left  base  on  tifth  day,  but  iine  rales  over  both  lower  lobes  behind  ;  reso- 
lution slow,  rales  persisting  for  a  long  time  in  both  lungs. 


in  recovery.     In  cases  of  this  type  the  constitutional  symptoms  are  not 
grave,  and  follow  very  closely  the  temperature  curve. 

The  next  chart  (Fig.  94)  illustrates  a  more  severe  but  not  uncommon 
course  of  the  disease  in  which  the  fever  is  prolonged.  The  usual  duration 
of  cases  of  this  type  is  between  three  and  four  weeks.  The  irregular  fluc- 
tuations of  the  temperature,  rarely  touching  the  normal  line,  are  exceed- 
ingly characteristic  of  broncho-pneumonia. 
3G 


542 


DISEASES   OF   THE   RESPIRATORY  SYSTEM. 


The  chart  shown  in  Fig.  95  is  that  of  relapsing  pneumonia.     The  first 
attack  was  fairly  typical,  with  about  the  usual  duration.      Eesolution 


107° 
106° 
105° 
10i'= 
103° 
102° 
101° 
100° 
99° 

1 

2 

lLi  1  |5 

6 

"T" 

s 

9 

10 

u 

12 

13 

11 

15 

16 

17 

18 

19 

20 

21 

22 

23 

21 

25 

26 

27 

28 

29 

30 

31 

32 

1 

1 

K  A   A    .  A        A  «    A              /\ 

/ 

_AA  \\I\l\  l\l\  WWl/l  A  ,,     n^ 

I 

_« 

H' 

^ 

i 

I 

/ 

\\H          ^\     'h 

m 

1\   ^l\ 

V 

V 

V  V '  V  iV    \     \  / 

/ '  \  7  \  /\/  I  /  \ 

t 

J    1    i 

1 

1 

V 

J 

\    ij       \  /  ly  V  'VJ  \ 

1 

Wj         \\J,    >     \    \'\\ 

•-^^^ 

98° 

I     :    i 

_ 

1 

!    ; 

'       i        ,        i       i              ^        i        1       ;       i                     '        1 

Fig.  94. — Temperature  curve  of  bronclio-pneumonia  ^vitli  a  prolonged  course  ;  recovery. 

History. — Female,  eiarhteen  months  old ;  in  fair  condition  ;  sudden  onset.  Early  signs  were 
localized,  tine  rales  over  left  base :  on  fifth  day  signs  of  consolidation  at  left  base,  with  rales  on 
both  sides  behind.  General  symptoms  of  moderate  severity.  Signs  of  consolidation  disappeared 
about  a  week  after  cessation  of  fever ;  rales  persisted  nearly  two  weeks  longer. 

had  begun,  and  was  apparently  progressing  favourably,  when  there  was  a 
return  of  the  fever,  accompanied  by  new  signs  in  the  chest,  the  second 


107  = 

1     2     3     4     5     6     7     8     9    10   11  12   13   14  15  16    17    IS   19  20   21  22  23  21   25  26  27  2S'29:30  31   32   33  j  M 

106  = 
105° 
10i= 
103= 
102° 
101° 
100  = 
!)9  = 

'       ,                  '      '       i      ■                         .                                     .                         ,            .      • 

^      '^      ^      \      '      '       '     \      '      \ 

i} 

1   1 

ft 

A  h  i\  l\  h  i\l\l\  I   /s  K  A 

\  /\  . 

r-^ 

h 

V  \  1  V  V  \/  V  \/ 1 1     \  \j\ 

Kl   1 1  l\l  \/\ 

\1  1    .»  V  ,        1  /  1/     1  ^ 

\  M / y  v\  \ 

iV  K  1 

j 

^       ^  K 

V '  \  hyi^ 

k  iH 

1 

^ 

/ 

98  = 

■ 

i       1 

MM    1 

V  i       1 

1    1    \y  Vv 

YiG.  95. — Temperature  curve  of  relapsing  broncho-pneumonia :  recovery. 

_H'isto)'y.—'Sla.]e.  nineteen  months  old ;  delicate.  Consolidation  on  sixth  day  in  left  lower  lobe 
behind:  twodavs  later  small  area  of  consolidation  in  right  lower  lobe  behind:  many  rales  both 
Bides  ;  eighteenth  day,  signs  of  consolidation  had  disappeared,  but  many  rales  persisted.  Acces- 
sion of  fe~ver  on  nineteenth  and  twentieth  days,  accompanied  by  extension  of  disease  as  shown 
by  new  rales,  but  no  evidences  of  consolidation  during  second  attack.  Slow  resolution  and  con- 
valescence. 

attack  being  shorter  and  milder  than  the  first.  Very  often  the  tempera- 
ture falls  to  normal  without  any  signs  of  resolution,  and  after  an  interval 
varying  from  two  or  three  days  to  a  week  there  is  recurrence  of  the  fever 


1     2     3     4     5     6     7  J 

107° 
106° 

105° 
104° 
103° 
102° 
101° 
100° 
99° 

i 

I      It      II 

\ 

JJUU 

V 

1/       1 

VI 

LiL  :^ 

1  iV 

V 

1 

Fig.  96. — Temperature  curve  of  broncho-pneumonia ;  fatal. 

History. — Male,  six  months  old :  markedly  rachitic  :  sudden  onset.  Si^ns  first  day  were  tine 
moist  rales  throughout  the  chest,  marked  prostration,  and  cyanosis;  on  third  day,_a  small  area 
of  consolidation  in  upper  lobe  of  left  lung  behind  ;  increasing  prostration,  cyanosis,  and  death. 
Autopsy.— Iso  pleurisy  ;  consolidation  at  left  apex  behind,  and  posterior  two  thirds  of  left  lower 
lobe ;  consolidation  of  right  apex  posteriorly,  lower  lobe  intensely  congested. 


ACUTE   BRONCHO-PNEUMONIA.  543 

and  other  constitutional  symptoms,  the  second  attack  frequently  proving 
fatal. 

A  frequent  course  in  fatal  cases  is  shown  in  Fig.  96.  The  duration  of 
the  disease,  instead  of  being  five  days  as  in  this  case,  is  often  only  three  or 
four.  The  temperature  at  first  fluctuates  widely,  then  rises  gradually 
until  death. 

Duration  of  the  fever. — The  following  figures  give  the  duration  of  the 
fever  in  231  cases.  The  majority  were  primary  ;  none  were  secondary  to 
diphtheria,  and  only  a  few  complicated  measles.  Of  the  169  cases  that 
were  fatal — 

There  died  during  the  first  six  days 25-0  per  cent. 

"         •'     between  the  seventh  and  twenty-first  days.  ..  .     55-5   " 

'•        "  "  "    twenty-first  and  sixtieth  days 19-5   "       " 

100-0  "      " 

Of  78  cases  which  recovered,  the  duration  of  the  fever  was — 

Less  than  seven  days 11-5  per  cent. 

From  seven  to  twenty-one  days 66-6   "       " 

From  twenty-one  to  ninety  days 21-9   "       " 

100-0   "       " 

Physical  Signs. — In  considering  the  signs  of  broncho-pneumonia,  it  is 
better  to  connect  them  with  the  different  conditions  in  the  luiig  than  to 
group  them  in  stages,  as  in  lobar  pneumonia. 

(a)  Without  consolidation. — It  can  not  too  often  be  repeated  that 
broncho-pneumonia  may  exist  without  signs  of  consolidation  at  any  period 
during  the  course  of  the  disease.  When  the  attack  is  primary,  the  ear- 
liest signs  are  due  to  congestion  of  the  lung,  associated  with  bronchitis 
of  the  fine  tubes,  which  is  usually  localized,  but  which  may  be  general. 
If  the  disease  has  followed  bronchitis  of  the  large  tubes,  its  signs  are 
added.  Congestion  of  the  lung  gives  feeble  breathing  over  the  affected 
area,  and  occasionally  slight  dulness  or  diminished  resonance.  With  this 
are  found  coarse  sonorous,  and  finer  sibilant  rales,  due  to  congestion  and 
swelling  of  the  mucous  membrane  of  the  larger  and  smaller  bronchi  re- 
spectively. These  signs  are  soon  replaced  by  very  fine  moist  rales,  which 
are  usually  localized  in  one  of  the  lower  lobes  behind  (Fig.  97).  These 
localized  fine  rales  are  the  first  distinctive  sign  of  broncho-pneumonia. 
Soon  a  change  in  the  respiratory  murmur  is  heard  in  the  affected  area, 
becoming  feebler  in  intensity  and  higher  in  pitch.  Elsewhere  in  the  chest 
there  may  be  coarse  rdles,  due  to  bronchitis  of  tlie  large  tubes.  In  such 
cases  the  areas  of  pneumonia  are  so  small  and  so  scattered  as  to  give  in 
themselves  no  additional  signs,  and  the  case  may  go  on  to  recovery  with- 
out presenting  anything  more  distinctive  than  the  signs  mentioned. 

{b)  With  areas  of  j^artial  consolidation. — In  the  lung  at  this  time 
there  are  small  areas  of  consolidation,  generally  superficial  and  separated 


PHYSICAL    SIGNS    OF    BKONCHO-PNEUMOXIA. 


Fig.  97. — First  stage.  Coarse  rales  over  both  lungs;  Kig.  98. — Second  stajre.  Coar.M.- aiul  tiur  r;ilfs  over 
localized    fine"  (subcrepitant)   rales   at    the   left  both  lungs  behind  ;    at  left  ba^e  an  area  of 

base.     No  change  in  breathing  sounds.  partial  consolidation,  with  broncho-vesicular 

breathing,  exaggerated  voice,  and  very  sharp 

rales. 


Fig.    99. — Third   stage.      A    larger   area   of  partial   Fig.  100.— Fourth  stage.     E.xtensive  disease  of  both 


consolidation,  and  in  the  centre  a  small  area  of 
complete  consolidation,  with  bronchial  breath- 
ing and  voice  and  slight  dulness.  Signs  over 
the  right  lung  similar'to  what  were  previously 
present  over  the  left. 


sides;  large  area  of  complete  consolitlation  on 
the  left,  with  dulness,  bronchial  breatiiing  and 
voice,  and  no  rales  ;  surrounding  this,  broncho- 
vesicular  breathing,  with  many  rales.  Signs 
in  the  right  lung  similar  to  those  previously 
present  over  the  left. 


Note. — The  disease  may  stop  at  any  one  of  these  stages  and  resolution  take  place. 


544 


ACUTE   BRONCHO-PXEUMONIA.  54,5 

by  healthy  or  congested  lobules.  Perc-ussion  in  these  cases  iisuall}'  gives 
negative  results,  but  sometimes  there  is  very  slight  dulness.  The  vocal 
fremitus  is  not  usually  altered.  The  fine  moist  rales  may  be  heard  over 
quite  a  large  area,  but  at  some  point,  usually  near  the  spine,  over  one  of 
the  lower  lobes,  they  are  sharper,  louder,  higher  pitched,  and  seem  close 
under  the  ear  (Fig.  98).  Eespiration  is  feebler  here  than  elsewhere,  and 
broncho-vesicular  in  quality,  approaching  bronchial  breathing  more  and 
more  as  the  consolidation  increases.  The  resonance  of  the  voice  and  cry 
is  exaggerated. 

(c)  ^Yith  areas  of  consolidation  more  or  less  complete. — On  percus- 
sion there  is  dulness,  but  surprisingly  little  in  comparison  with  the  other 
signs  of  consolidation  present.  It  is  due  to  the  fact  that  the  consolidated 
portion,  though  extensive,  is  superficial,  and  does  not  involve  the  lung  to 
any  great  depth,  and  also  that  there  are  in  the  consolidated  area  many 
alveoli  which  still  contain  air  (Plate  XIII).  On  palpation  there  is  usu- 
ally a  slight  increase  in  the  vocal  fremitus.  On  auscultation,  there  are 
still  present  the  evidences  of  bronchitis,  usually  only  behind,  but  some- 
times over  the  entire  chest.  Coarse  and  fine  rales  are  intermingled. 
Over  the  consolidated  parts  are  heard  bronchial  breathing  and  bronchial 
voice.  At  the  centre  of  these  areas  the  bronchial  breathing  is  pure  and 
rales  are  usually  absent,  but  at  the  margin  rales  are  present  and  the 
breathing  approaches  the  broncho-vesicular  type  (Fig.  99).  The  signs  of 
consolidation  are  rarely  sharply  circumscribed  as  they  are  in  lobar  pneu- 
monia, but  shade  off  gradually.  The  consolidated  area  is  at  first  suiall, 
usually  in  one  of  the  lower  lobes  near  the  spine,  but  may  gradually  extend 
until  nearly  the  whole  of  one  or  even  both  lungs  l^ehind  are  more  or  less 
•completely  solidified  (Fig.  100).  The  signs  are  found  as  far  forward  as 
the  axillary  line,  but  usually  stop  there.  Friction  sounds  may  be  heard 
over  the  consolidated  areas,  but  very  rarel_Y  except  where  signs  of  com- 
plete consolidation  are  present.  It  is  often  impossible  to  obtain  any  idea 
of  the  condition  of  an  infant's  lung  during  quiet,  superficial  respiration. 
Sometimes  over  a  part  which  is  completely  consolidated  there  is  heard 
only  very  feeble  breathing,  or  the  lung  may  be  almost  silent.  If.  liow- 
ever,  the  child  be  made  to  cry  or  to  take  a  deep  inspiration,  bolh  the  luun- 
chial  breathing  and  rales  are  distinctly  brought  out.  The  intensity  of 
the  consolidation  increases  as  the  ease  advances,  and  the  signs  become 
more  and  more  like  those  of  lobar  pneumonia.  During  resolution  there 
is  first  ;i  disappearance  of  the  signs  of  consolidnlion.  \\liich  itmy  be  (|uite 
rai)itl,  but  friction  sounds  and  rales  of  all  kinds  olteii  persisl  \'nv  iln'ce  or 
four  weeks  longer. 

The  following  statistics  are  of  some  interest,  as  showing  the  frequenc-y 
with  which  signs  of  consolidation  were  found,  and  tlie  day  when  tliey  were 
discovt'i'ed.  ^rheir  value  is  inci'eased  by  Hie  fart  that  the  childi-en  wei'e 
under  observation  in  an  institution  at  thr  time  ihev  were  taken  sick,  and 
that  in  all  the  fatal  cases — tliirtv-si.\  in  nundiei' — in  'vhicli  sijiiis  of  con- 


546  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

solidation  were  absent,  the  diagnosis  of  pneumonia  was  confirmed   by 
autopsy  : 

Consolidation  noted  on  or  before  the  fourth  day 47  cases. 

"  "      from  the  fifth  to  the  seventh  day  36 

"  "         "      the  eighth  to  the  twelfth  day 12 

"  "      after  the  twelfth  day 9 

No  signs  of  consolidation 62 

1G6 

In  general,  it  must  be  borne  in  mind  that  in  many  cases  signs  of  con- 
solidation are  never  present,  as  the  areas  of  pneumonia  are  small  and 
widely  scattered ;  that  where  there  is  consolidation  it  is  usually  incom- 
plete, because  there  are  small  areas  of  healthy  lung  tissue  between  the 
hepatized  portions ;  that  the  signs  of  consolidation  usually  shade  off 
gradually ;  and  that  both  sides  are  almost  invariably  involved,  although 
one  side  usually  to  a  greater  degree  than  the  other. 

(4)  The  protracted  form — Persistent  hronclio-iineumonia. — This  is 
seen  in  primary  cases,  especially  among  delicate  children,  and  it  is  not 
uncommon  in  pneumonia  complicating  pertussis.  The  onset  and  course 
of  the  disease  for  the  first  two  or  three  weeks  do  not  differ  from  an  ordi- 
nary attack  of  moderate  severity,  but  at  the  end  of  this  period  there  is  seen 
no  tendency  in  the  process  to  subside.  The  fever  continues,  but  it  is  not 
high,  and  by  physical  examination  it  is  found  that  the  areas  of  consolida- 
tion are  gradually  increasing  day  by  day,  until  sometimes  the  greater  part 
of  both  lungs  behind  are  involved.  The  air  vesicles  become  so  distended 
with  cells  that  the  signs  of  consolidation  are  more  complete  than  in  ordi- 
nary broncho-pneumonia.  There  is  marked  dulness,  sometimes  almost 
flatness  ;  bronchial  breathing  is  exaggerated  in  intensity,  until  it  resem- 
bles cavernous  breathing,  and  it  may  be  impossible  to  distinguish  between 
them.  However,  the  fact  that  it  is  heard  over  so  large  an  area,  that  it 
shades  off  gradually,  and  that  it  is  accompanied  by  friction  sounds,  usually 
make  a  distinction  possible. 

The  temperature  in  these  protracted  cases  for  the  first  two  or  three 
weeks  is  from  100°  to  105°  F.;  but  after  this  time  it  is  generally  lower — 
from  100°  to  102°  or  103°  F.  The  course  is  not  at  all  regular,  but  marked 
by  frequent  exacerbations  and  remissions.  The  general  symptoms  are 
those  of  progressive  asthenia.  There  is  continued  wasting,  angemia,  and 
steadily  increasing  prostration.  The  appetite  is  lost,  often  there  is  an 
aversion  to  food,  and  vomiting  is  easily  excited  if  food  or  stimulants  are 
forced.  The  stools  show  that  even  what  food  is  taken  is  very  imperfectly 
digested  and  assimilated.  The  skin  becomes  dry  and  loses  its  elasticity; 
bed-sores  may  form;  fine  punctate  hEemorrhages  are  seen  over  the  ab- 
domen, sometimes  over  the  chest  and  extremities.  The  latter  is  always  a 
very  bad  symptom,  and  I  have  never  seen  recovery  where  it  was  present. 

The  chart  in  Fig.  101  is  typical  of  the  course  of  one  of  these  in'otracted 


ACUTE   BRONCHO-PNEUMONIA. 


547 


cases  terminating  fatally.     The  temperature  shows  four  distinct  exacer- 
bations. 

Death  takes  place  from  slow  asthenia,  usually  after  five  or  six  weeks, 
but  the  attack  may  be  prolonged  for  eight  or  ten  weeks.     The  general 


106 
105° 
104° 
103° 
108° 

lor 

100! 
99= 

1 

2 

3 

4 

5 

6 

7|8 

9 

10 

1112 

13 

14 

15  18 

17 

18 

1U'20!21 

22 

23 

24 

25  20 

27 

28  29 

30  31 

32 

33 

34 

3bl 

36 

3? 

38 

39l40 

41,42143 

|44j-15i40l47!48-i3'50!51I 

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t 

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jl 

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/ 

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j 

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\ 

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\ 

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if 

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Fig.  101. — Temperature  curve  of  persistent  broncho-pneumonia,  terminating  fatally. 

History. — Male,  two  and  a  half  years  old ;  healthy ;  sudden  onset ;  for  two  weeks  the  only 
signs  were  very  fine  moist  rales  throughout  both  lungs,  front  and  back.  The  rales  in  front  in 
great  part  gradually  cleared  up  ;  those  behind  persisted,  but  it  was  not  until  the  thirty-fourth  day 
that  positive  signs  of  consolidation  were  discovered  in  the  left  lower  lobe  behind;  these  signs 
gradually  extended,  and,  before  death,  were  present  over  nearly  the  whole  left  lung  behind  and 
over  the  right  lower  lobe.  There  were  also  friction  sounds  over  both  lungs.  Autopsy. — Old  and 
recent  pleurisy  with  general  adhesions;  left  lower  lobe  completely  solid,  patches  of  consolida- 
tion in  left  upper  lobe.  Right  lower  lobe  about  one  half  consolidated,  with  patches  elsewhere. 
Bronchial  glands  large,  but  not  cheesy.  No  evidence  of  tuberculosis  upon  either  gross  or  micro- 
scopical examination  (see  Fig.  92). 


symptoms,  the  temperature,  and  the  wasting  strikingly  resemble  cases  of 
tuberculosis,  and.  such  is  the  diagnosis  often  made. 

Although  the  majority  of  the  cases  in  which  the  fever  lasts  over  four 
weeks  run  the  fatal  course  just  described,  such  apparently  hopeless  cases 
occasionally  recover.  The  temperature  gradually  falls  lower  and  lower, 
until  it  remains  at  the  normal  point.  For  some  time  after  this,  often  two 
or  three  weeks,  little  change  can  be  seen,  either  in  the  general  symptoms 
or  in  the  physical  signs.  G-radually  the  appetite  returns,  the  child  is 
brighter  and  begins  to  take  an  interest  in  its  surroundings,  the  cough 
abates,  and  little  by  little  the  signs  in  the  lungs  clear  up,  and  the  case 
may  go  on  to  complete  recovery.  Convalescence,  however,  is  always  slow, 
and  may  be  interrupted  by  relapses,  it  being  many  months  before  health 
is  fully  restored.  Although  the  signs  of  consolidation  disappear  in  a  few 
weeks,  rales  are  apt  to  persist  for  a  much  longer  time.  It  is  probable  in 
such  cases,  even  though  all  signs  of  disease  disappear  from  the  chest,  that 
the  lung  does  not  become  quite  normal,  and  relapses  and  second  attacks 
are  always  possible.  The  general  health  may  be  so  undermined  that  the 
child  never  regains  his  former  vigour  ;  yet  in  a  surprising  number  of 
these  cases  recovery  seems  to  be  complete. 

5.  Secondary  pneumonia. — (a)  Complicating  pertussis. — It  is  not 
often  that  pneumonia  develops  during  liie  first  two  weeks  of  this  disease. 
The  most  frequent  time  is  from  the  third  to  the  fifth  week,  when  the 
patient  has  become  exhausted  from  the  previous  severity  of  the  per- 
tussis. In  two  thirds  of  my  cases  the  develo])ment  of  the  pneumonia  was 
gradual,  following  bronchitis  of  the  larger  tubes.  The  temperature 
chart  shown  in  FIm"-  103  well  illustrates  this  course. 


548 


DISEASES   OF   THE   RESPIRATORY   SYSTEM. 


"When  the  onset  is  sudden,  the  symptoms  do  not  differ  essentially  from 
those  of  primary  jDneumonia.  The  temperature  of  pertussis-pneumonia  is 
usually  low,  in  a  very  large  number  of  cases  not  rising  above  103-5°  F., 
and  ranging  most  of  the  time  from  101°  to  103°  F.  These  cases  are  very 
apt  to  be  prolonged,  the  fever  often  lasting  for  three  or  four  and  some- 


107^ 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

1  1  2 

3     4  15  16  17 

8  1  9  1 10  :  11 

12 

13 

li   15  1 16 

1     i 

''   1 

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\ 

,   / 

\ 

r 

!                 A     /■ 

---J 

^V 

r' 

1 

A               \     r^      ^    ^ 

'A   J\h 

98° 

^--^/^ 

Fig.  102. — Temperature  curve  of  fatal  broncho-pneumonia,  complicating  pertussis. 

History. — Male,  six  months  old  ;  delicate ;  pertussis  for  three  weeks.     Early  signs  of  bron- 
chitLs  of  large  tubes  only  ;  on  the  eleventh  day  signs  of  conf'olidation  in  right  upper  lobe.     In- 
creasing prostration,  cyanosis,  and  death.   Autopsy. — Large  areas  of  consolidation  in  right  middle 
^  and  upper  lobe,  small  scattered  spots  throughout  left  lung. 


times  even  for  six  weeks.  The  physical  signs  of  consolidation  may  per- 
sist for  a  long  time  after  the  temperature  has  become  normal,  and  yet 
the  case  may  recover  entirely.  I  have  seen  one  case  in  which  complete 
recovery  occurred  after  the  signs  of  consolidation  had  persisted  for  six 
months,  and  another  in  Avhicli  they  had  persisted  for  over  eight  months. 
Very  often  the  signs  continue  during  the  entire  attack  of  pertussis. 
Cerebral  symptoms  are  common,  especially  toward  the  close  of  the  disease. 
Of  fifty-four  fatal  cases  twenty-five  had  convulsions,  and  in  twenty-two 
this  was  the  mode  of  death.  Only  one  case  which  developed  convulsions 
recovered. 

{b)  Complicating  measles. — In  a  small  number  of  cases  the  pneumonia 
begins  simultaneously  with  the  invasion  of  measles,  but  generally  not  until 
the  eruption  appears.  Instead  of  gradually  falling  to  normal  with  the 
fading  of  the  eruption,  the  temperature  continues  high.  Any  of  the 
clinical  types  of  primary  pneumonia  may  occur  in  measles,  the  acute  con- 
gestive variety  which  is  fatal  in  two  or  three  days,  being  especially  com- 
mon. In  its  course  and  duration  the  pneumonia  of  measles  resembles 
the  seyere  form  of  primary  pneumonia.  The  broncho-pneumonia  of  scar- 
let fever  differs  in  no  way  from  that  of  measles. 

(c)  Complicating  diphtheria. — In  many  cases  this  does  not  give  a  dis- 
tinct clinical  picture  of  its  own,  its  symptoms  being  mingled  with  those  of 
diphtheritic  bronchitis,  with  which  it  is  frequently  associated.  In  others  the 
forms  resemble  those  seen  in  measles.  The  majority  of  cases  occur  as  a 
complication  of  diphtheria  of  the  larynx,  although  it  is  not  infrequent  in 
the  septic  cases  in  which  only  the  upper  air  passages  are  involved.  Pneu- 
monia  developing  after  laryngitis  is  usually  seen  within  two  days  from 


ACUTE   BRONCiiO-PNEUMONIA.  549 

the  beginning  of  laryngeal  symptoms,  and  runs  a  very  rapid  course.  In 
rare  cases  it  may  develop  as  late  as  the  middle  or  end  of  the  second 
week.  When  it  complicates  diphtheritic  bronchitis,  pneumonia  is  recog- 
nised bv  the  high  temperature,  rapid  breathing,  and  increased  prostra- 
tion, much  more  certainly  than  by  the  physical  signs,  which  are  always 
obscured  by  the  laryngeal  sounds.  Percussion  may  aid  in  the  diagnosis 
of  consolidation  where  the  signs  on  auscultation  are  doubtful  In  the 
early  cases,  death  usually  occurs  before  the.  disease  has  advanced  far 
enough  to  give  the  physical  signs  of  consolidation,  but  in  the  late  pneu- 
monia, which  develops  more  slowly,  these  may  be  present. 

(d)  Complicating  influenza. — Without  doubt  many  cases  regarded  as 
primary  are  really  secondary  to  influenza,  particularly  when  that  disease 
is  prevailing,  for  very  often  the  pneumonia  of  influenza  difl:ers  in  no 
essential  points  from  the  primary  form.  There  are,  however,  two  types 
which  are  quite  characteristic.  In  the  first,  high  temperature  and  pros- 
tration exist  for  several  days  before  there  are  any  physical  signs  of  pul- 
monary disease,  and  often  before  there  are  any  symptoms  pointing  defi- 
nitely to  the  lungs.  Pneumonia  may  then  develop  and  run  its  usual 
course.  The  second  variety  are  the  cases  of  short  duration  often  lasting 
but  three  or  four  days,  and  sometimes  only  two,  but  with  excessively  high 
temperature  and  very  severe  general  symptoms. 

(e)  Complicating  ileo-colitis. — This  is  usually  a  somewhat  subacute 
form  of  pneumonia,  which  is  scarcely  recognisable  except  by  the  phys- 
ical signs.  It  is  seen  in  the  protracted  cases  of  ileo-colitis,  usually  of  the 
ulcerative  variety,  and  occurs  late  in  its  course.  The  temperature  is  not 
high.  Cough,  pain,  and  dyspnoea  are  slight  or  entirely  wanting.  Accel- 
erated respiration  is  frequently  the  only  symptom  suggestive  of  pulmo- 
nary disease.  By  physical  examination  there  are  found  the  usual  signs, 
generally  involving  both  lungs  posteriorly.  Very  often  pneumonia  is 
not  suspected  during  life,  the  constitutional  symptoms  being  sufficiently 
explained  by  the  intestinal  lesions,  although  the  autopsy  discloses  the  fact 
that  death  was  due  to  pneumonia. 

Complications. — Those  relating  to  the  lungs  have  been  described  with 
the  lesions.  Pleurisy  will  be  separately  considered.  Emphysema  can 
rarely,  and  abscess  and  gangrene  never,  be  recognised  by  the  physical 
signs. 

Purulent  meningitis  may  complicate  acute  broncho-pneumonia.  It 
was  met  with  twice  in  one  hundred  and  seventy  autopsies.  It  is  in  all 
respects  similar  to  that  occurring  with  lobar  pneumonia.  Meningeal 
haemorrhage  was  seen  only  once,  and  was  the  cause  of  death  in  a  patient 
eleven  months  old,  who  a  few  days  before  was  seized  with  convulsions,  fol- 
lowed by  a  gradually  increasing  stupor,  which  continued  until  death. 
The  heemorrhage  covered  the  entire  convexity  of  the  brain.  Endocar- 
ditis is  extremely  rare ;   it  was  not  observed  in  any  of  my  cases.     Acute 


550  DISEASES   OP  THE   RESPIRATORY  SYSTEM. 

pericarditis  was  seen  but  twice,  in  both  cases  complicating  pneumonia  of 
the  left  side.  Complications  referable  to  the  digestive  tract  are  quite 
common.  Herpetic  stomatitis  is  frequent,  and  occasionally  the  ulcerative 
variety  is  seen.  Thrush  often  occurs  in  the  protracted  cases  among 
very  young  infants.  Gastro-enteritis  is  not  very  common,  considering 
the  frequency  of  vomiting  and  diarrhoea,  these  depending  usually  upon 
functional  derangement.  In  only  three  of  my  cases  was  there  nephritis. 
In  all  it  was  of  the  acute  exudative  variety,  and  in  only  one  case  was  it 
severe  enough  to  affect  the  prognosis. 

Old  lesions  of  tuberculosis — cheesy  nodules  in  the  lungs  and  some- 
times in  the  pleura — are  not  infrequently  met  with  in  patients  dying  of 
acute  pneumonia  of  a  non-tuberculous  character. 

Diagnosis. — An  acute  onset  with  continuous  high  fever,  rapid  respira- 
tion, and  cough,  should  always  lead  one  to  suspect  pneumonia.  When, 
to  these  symptoms  are  added  prostration  and  cyanosis,  the  diagnosis  of 
pneumonia  is  almost  certain.  Cases  of  the  acute  congestive  type  are 
the  ones  most  frequently  unrecognised,  and  in  many  of  these  cases  a  posi- 
tive diagnosis  is  im.possible  during  life.  Many  atypical  cases  of  pneumo- 
nia are  seen,  particularly  in  young  infants.  An  unusual  temperature 
course  is  perhaps  the  symptom  most  likely  to  lead  to  a  mistake.  While 
this,  as  a  rule,  is  high  and  remittent,  it  is  sometimes  not  so,  and  may  be 
but  little  above  normal.  Rapid  respiration  is  almost  always  present,  but 
cough  may  be  very  slight,  especially  in  infants.  In  very  young  infants,, 
the  diagnosis  often  rests  upon  the  prostration,  cyanosis,  and  rapid  respi- 
ration, the  other  acute  inflammatory  symptoms  being  absent.  Only  the 
physical  signs  of  the  disease  can  positively  settle  the  question  of  diagnosis. 

When  pneumonia  follows  bronchitis  of  the  large  tubes,  whether  the 
bronchitis  is  primary  or  complicates  one  of  the  infectious  diseases,  the 
extension  of  the  disease  to  the  lungs  is  usually  marked  by  three  symptoms 
— a  steadily  rising  temperature,  more  frequent  respiration,  and  increasing 
prostration.  It  may  be  twelve  or  twenty-four  hours  before  the  change  is 
indicated  by  the  physical  signs. 

The  diagnosis  of  broncho-pneumonia  from  congenital  atelectasis  has 
to  be  considered  only  during  the  first  three  or  four  months  of  life,  it  being 
rare  for  atelectasis  to  give  symptoms  after  this  time.  In  early  infancy  the 
danger  of  confusing  the  two  is  increased  by  the  fact  that  atelectasis  and 
broncho-pneumonia  may  be  associated.  If  the  infant  has  been  strong  and 
well  for  the  first  two  months,  congenital  atelectasis  can  be  excluded.  It  is 
likely  to  be  found  in  delicate  infants,  where  there  is  a  history  of  difficulty 
in  resuscitation  at  birth  and  feeble  cry  during  the  early  days  of  life.  The- 
temperature  is  low,  often  subnormal,  the  cyanosis  is  out  of  proportion  to^ 
the  other  symptoms,  and  the  physical  signs  are  doubtful  or  absent. 

At  the  outset,  pneumonia  can  not  be  positively  diagnosticated  from 
severe  bronchitis.    Such  a  bronchitis  often  begins  with  severe  pulmonary 


ACUTE    BRONCHO-PNEUMONIA.  551 

symptoms  aud  a  temperature  of  103°  or  104:°  F. ;  but  this  high  tempera- 
ture is  of  short  duration,  usually  falling  after  twenty-four  or  forty-eight 
hours  to  100°  or  101°  F.  The  prostration  is  much  less,  and  all  the  symp- 
toms, possibly  excepting  the  cough,  less  severe.  The  only  physical  signs 
are  coarse  rales,  which  are  heard  throughout  the  chest. 

The  same  rules  apply  to  bronchitis  of  the  smaller  tubes.  The  rales  are 
heard  both  in  front  and  behind,  and  usually  over  both  sides.  If  with  such 
rales  the  temperature  continues  to  rise  for  three  days  in  succession  above 
103°  F.,  it  may  be  assumed  that  pneumonia  is  present,  provided  there 
is  no  other  disease  which  might  explain  the  temperature.  If,  instead 
of  being  generalized,  the  signs  of  bronchitis  are  limited  to  a  single  lung, 
or  to  one  lung  posteriorly,  the  existence  of  broncho-pneumonia  may  be 
regarded  as  certain.  Localized  bronchitis,  then,  is  always  to  be  inter- 
preted as  broncho-pneumonia,  provided  tuberculosis  can  be  excluded.  In 
doubtful  cases  the  chances  largely  favour  broncho-pneumonia  rather  than 
bronchitis.  Attention  is  again  called  to  the  fact  already  mentioned, 
that  there  are  a  large  number  of  cases  of  pneumonia  without  signs  of 
consolidation. 

The  differential  diagnosis  of  broncho-  from  lobar  pneumonia  will  be 
considered  in  connection  with  the  latter  disease.  On  account  of  the  remit- 
tent temperature,  broncho-pneumonia  may  be  confounded  with  malarial 
fever;  if  with  the  latter  there  is  some  bronchitis,  or  if  accompanying  the 
onset  of  a  severe  malarial  paroxysm  there  is  pulmonary  congestion — two  not 
infrequent  combinations — the  difficulties  are  increased.  A  positive  diag- 
nosis is  often  impossible  except  by  careful  observations  of  the  temperature 
for  one  or  two  days.  The  points  of  differentiation  are,  that  the  tempera- 
ture of  pneumonia,  though  often  remittent,  is  very  rarely  intermittent,  and 
that  it  is  not  affected  by  quinine.  In  addition,  the  characteristic  features 
of  malaria — enlargement  of  the  spleen,  the  plasmodium  in  the  blood,  and 
a  history  of  exposure — must,  of  course,  be  taken  into  account. 

Both  the  acute  aud  the  persistent  forms  of  simple  broncho-pneumonia 
may  be  confounded  with  the  tuberculous  form ;  the  points  of  distinctiou 
are  considered  in  the  chajster  on  Tuberculosis. 

Prognosis. — Broncho-pneumonia  is  always  a  serious  disease,  and  in  an 
infant  dangerous  to  life.  The  prognosis  depends  upon  the  age,  surround- 
ings, and  previous  condition  of  the  patient,  upon  the  nature  of  the  in- 
fection, whether  the  disease  is  primary  or  secondary,  and,  if  the  latter, 
upon  the  character  of  the  primary  disease.  In  private  practice  the  mor- 
tality from  broncho-pneumonia  is  from  10  to  30  per  cent,  depending  upon 
the  conditions  mentioned.  One  whose  knowledge  of  broncho-pneumonia 
is  derived  from  observations  in  private  practice  can,  however,  form  but 
little  idea  of  tlie  frequency  and  severity  of  this  disease  in  hospitals  and 
asylums  for  infants  and  young  children,  particularly  when  it  occurs  with 
epidemics  of  measles,  diphtheria,  and  pertussis.     The  statistics  in  the  fol- 


552 


DISEASES   OF   THE   RESPIRATOEY  SYSTEM. 


lowing  table  are  taken  from  the  records  of  two  institutions  with  which  I 
am  connected,  and  fairly  represent  the  results  seen  in  such  places  in  chil- 
dren under  three  years : 


Forms  of  Pneumonia. 


Cases. 


Deaths. 


Primary  broncho-pneumonia 

Following  bronchitis  of  the  large  tubes. 
iSecondary  to  measles 

"  "  pertussis 

"  "  scarlet  fever 

"  "  diphtheria 

"  "  ileo-colitis 

"  '•  epidemic  influenza 

"  "  varicella 

"  "  erysipelas 


194 

29 

89 

66 

7 

47 

19 

6 

2 


Totals. 


461 


Percentage 
mortality. 


49-4 
65-5 
62-9 

81-8 
100-0 
100-0 
94-7 
16-6 
100-0 
100-0 

65-5 


The  mortality  varies  directly  with  the  age  of  the  patient,  being  the 
highest  during  the  first  year,  and  diminishing  steadily  thereafter,  as  shown 
by  the  following  table  giving  the  result  in  three  hundred  and  forty-five 
cases : 


Age. 

Cases. 

Percentage 
mortality. 

During  the  first  year 

202 

102 

33 

6 

3 

66 

'■        "    second  vear 

55 

'*         "    third  A'ear 

33 

"         "    fourth  vear                 

16 

"         "    fifth  year     .  .        

In  this  table  are  included  no  cases  secondary  to  measles,  scarlet  fever, 
or  diphtheria. 

Probably  the  best  of  all  guides  to  the  nature  and  virulence  of  the  in- 
fection is  the  temperature.  An  excessively  high  temperature  indicates  a 
virulent  t3^pe  of  infection.  Some  idea  of  this  may  be  gained  from  these 
figures,  giving  the  highest  temperature  and  the  mortality  in  two  hundred 
and  thirty-one  cases,  not  including  cases  with  measles  or  dijihtheria : 


Highest  Temperature. 

Cases. 

Deaths. 

Percentage 
mortality. 

106'  F.  or  over 

55 
94 
53 
22 

7 

47 
56 
26 
13 
5 

85-5 

105'  or  105-5' 

60-0 

104'  or  104-5' 

49-0 

102"'  to  103-5' 

60-0 

99-5'  to  101-5' 

71-0 

The  high  mortality  of  the  cases  with  unusually  low  temperature  is  due 
to  the  fact  that  they  nearly  always  were  seen  in  infants  with  very  feeble 


ACL'TE   BROXCHO-PXEUMONIA.  553 

vitality.  Cases  with  a  steadily  high  temperature — between  102  -5°  and 
104°  F. — usually  do  better  than  those  with  wide  fluctuations,  such  as  100"^ 
to  105 -5°  F.  The  probable  explanation  of  this  is,  that  the  former  are 
due  to  the  pneumococcus,  while  the  latter  are  apt  to  be  cases  of  mixed 
infection,  or  due  to  the  streptococcus.  As  a  rule,  the  danger  from  the  dis- 
ease increases  steadily  with  every  degree  of  temperature  above  104 -5°  F. 
An  important  factor  in  the  prognosis  is  the  previous  condition  of  the 
patient.  The  association  with  rickets  is  unfavourable,  both  on  account  of 
the  feeble  muscular  power  of  these  children  and  their  thoracic  deformities. 
Any  condition  which  diminishes  the  general  vitality  increases  the  danger 
from  broncho-pneumonia.  As  a  rule,  second  attacks  are  more  serious 
than  the  primary  ones,  especially  if  the  interval  between  them  is  short. 

In  making  the  prognosis  in  any  given  case,  the  symptoms  to  be  con- 
sidered are  the  height  and  course  of  the  temperature,  the  presence  or 
absence  of  nervous  symptoms,  the  condition  of  the  organs  of  digestion,, 
the  i^resence  of  cyanosis  and  the  extent  of  the  disease  as  shown  by  the 
physical  signs. 

Xervous  symptoms  early  in  the  disease  do  not  affect  the  prognosis. 
Three  cases  in  which  convulsions  occurred  at  the  onset  recovered,  but 
of  thirty-seven  cases  in  which  convulsions  occurred  at  a  late  period  during- 
the  course  of  the  disease,  all  but  one  proved  fatal. 

So  long  as  the  food  is  well  taken  and  retained  and  the  stools  show 
that  it  is  being  assimilated,  no  case  is  hopeless,  no  matter  how  severe  the 
other  symptoms  may  be ;  but  the  existence  of  vomiting,  diarrha?a,  or 
severe  indigestion  makes  the  issue  doubtful,  even  though  the  other  symp- 
toms are  very  favourable.  These  conditions  are  especially  important  in 
protracted  cases,  where  death  is  usually  due  to  slow  asthenia. 

Treatment. — The  most  important  part  of  prophylaxis  is  to  give  careful 
and  early  attention  to  every  attack  of  bronchitis  in  an  infant,  for  every 
such  attack  should  be  regarded  as  a  possible  precursor  of  pneumonia.  It 
is  striking  that  one  sees  broncho-iDneumonia  so  seldom  in  private  practice 
among  the  better  classes,  even  though  bronchitis  is  very  frequent ;  while 
among  hospital  and  dispensary  patients,  where  bronchitis  is  very  often 
neglected,  broncho-pneumonia  is  constantly  seen.  The  question  of  isolat- 
ing cases  of  pneumonia  is  one  which  is  lately  becoming  more  and  more 
important.  While  it  may  not  often  be  the  case  that  primary  pneumonia 
is  due  to  contagion,  there  seems  to  be  little  doubt  that  this  is  at  times  true 
of  the  pneumonia  secondary  to  measles  and  diphtheria.  Twice  in  one  insti- 
tution have  I  seen  regular  epidemics  of  broncho-pneumonia  occur  with 
outbreaks  of  measles — in  some  of  the  wards  nearly  every  case  of  measles 
developing  pneumonia.  In  another  institution,  during  one  entire  season 
(1888-'89),  almost  every  case  of  diphtheria  transferred  to  a  certain  isola- 
tion pavilion  developed  pneumonia,  and  died  from  that  complication. 
Cases  of  measles  and  diphtheria  which  are  complicated  by  pneumonia 


554  DISEASES  OF   THE  RESPIRATORY  SYSTEM. 

should,  if  possible,  be  carefully  isolated  from  others,  and  wards  in  which 
they  are  treated  should  be  thoroughly  disinfected  before  they  are  used 
for  simple  cases. 

The  hygienic  treatment  of  pneumonia  is  important,  and  usually  it 
receives  too  little  attention.  The  child  should  be  kept  in  a  large,  well- 
ventilated  room,  preferably  one  with  an  open  fire;  if  possible,  he  should 
be  changed  from  one  room  to  another  two  or  three  times  a  day,  to  allow 
thorough  airing.  iSTothing  is  more  important  for  an  infant  sick  with 
acute  pulmonary  disease  than  plenty  of  oxygen.  Older  children  should 
be  kept  in  bed.  Infants  for  a  considerable  part  of  the  time  ma}^  be  held 
in  the  nurse's  arms.  A  frequent  change  of  position  in  all  cases  is  essen- 
tial; no  child  should  be  allowed  to  lie  for  hours  directly  on  the  back. 
The  general  rules  for  feeding  all  sick  children  (page  222)  should  be  fol- 
lowed here.  As  a  rule,  neither  stimulants  nor  medicine  should  be  admin- 
istered in  the  food. 

The  same  local  treatment  may  be  emplo^'ed  as  in  cases  of  bronchitis 
(page  513).  Counter-irritation  may  be  maintained  by  the  use  of  the 
mustard  paste,  and  the  oiled-silk  jacket  should  be  worn  throughout  the 
attack,  except  in  cases  attended  by  very  high  temperature,  when  it  is 
better  omitted.  Poultices  of  flaxseed  may  be  employed  occasionally,  but 
never  continuously. 

Emetics. — What  was  said  of  expectorant  mixtures  and  emetics  in  the 
treatment  of  bronchitis  applies  here  with  even  greater  force. 

Stimulants. — Alcoholic  stimulants  are  needed  in  all  secondary  cases, 
and  in  a  large  proportion  of  those  which  are  primary.  Xo  doubt  they 
have  been  greatly  abused,  and,  when  pushed  in  the  early  stage,  often  do 
much  harm;  but  in  most  of  the  severe  cases  the}'  are  indispensable. 
They  are  usually  needed  from  the  outset,  where  the  pneumonia  is  sec- 
ondary to  measles,  diphtheria,  scarlet  fever,  or  other  infectious  diseases. 
They  are  called  for  when  the  pulse  is  weak,  compressible,  rapid,  and 
irregular.  Whisky  or  brandy  is  usually  to  be  preferred,  although  the 
taste  of  the  patient  often  has  to  be  consulted,  and  when  these  are  re- 
fused, some  wines,  like  sherry  or  tokay,  may  be  readily  taken.  (For 
methods  of  administration  see  page  49.)  The  dose  is  to  be  regulated  by 
the  condition  of  the  patient.  From  one-half  to  one  ounce  daily  may  be 
given  to  an  infant  of  one  year.  It  is  rarely  advisable  to  go  above  this 
quantity  except  for  a  few  hours  at  a  time  at  criticial  periods ;  then  two  or 
three  times  as  much  may  be  used.  Contrary  to  the  statement  of  many 
writers,  these  stimulants  are  usually  well  borne,  even  by  young  children. 
Stimulants  are  most  needed  when  the  temperature  is  low,  or  falls  sud- 
denly, as  at  the  crisis  of  the  disease.  When  the  temperature  is  high, 
smaller  amounts  are  generally  required. 

In  many  cases  strychnine  is  even  more  valuable  than  alcohol.  Usu- 
ally they  should  be  combined,  as  the  indications  are  the  same.  Where 
the  dose  is  to  be  repeated  every  three  hours,  g-J-Q  of  a  grain  is  as  much  as 


ACUTE   BRONCHO-PNEUMONIA.  555 

it  is  wise  to  give  to  an  infant  a  year  old.  This  may  be  kept  up  for  days, 
and  for  a  shorter  time  hirger  doses  may  be  given,  the  effect  always  being 
carefully  watched.  For  older  children  digitalis  may  be  used,  but  I  have 
rarely  seen  much  benefit  from  it  in  infants.  In  attacks  of  heart  failure 
associated  with  pulmonary  congestion,  nitroglycerin  should  be  given,  to 
a  child  of  one  year  gr.  y^  every  hour. 

Eespiratory  stimulants  are  needed  in  most  cases,  even  more  than  are 
cardiac  stimulants,  but  we  have  none  which  can  be  wholly  depended  upon. 
For  a  short  time,  atropine  gr.  4^,  cafEein  gr.  -J,  or  strychnine  gr.  -^^-ff, 
may  sustain  a  child  with  sudden  failure  of  respiration,  but  in  the  slow 
respiratory  failure  that  results  from  exhaustion  their  effect  is  but  tem- 
porary. The  doses  mentioned  are  for  an  infant  of  one  year.  The  drugs 
may  be  used  successive!}^  or  together;  for  immediate  effect  they  should 
be  given  hypodermically.  Oxygen  may  be  classed  with  the  respiratory 
stimulants.  It  may  be  given  continuously,  but  always  mixed  with  atmos- 
pheric air.  To  the  rubber  tube  coming  from  the  cylinder  a  glass  funnel 
may  be  attached  and  held  one  inch  from  the  child's  face.  Gentle  friction 
of  the  chest  wall,  without  disturbing  the  patient,  is  sometimes  useful  in 
stimulating  the  respiratory  muscles,  especially  in  protracted  cases. 

Antipyretics. — It  must  be  remembered  that  the  normal  range  of  tem- 
perature in  broncho-pneumonia  is  from  101°  to  10-1  *5°  F.  This  tempera- 
ture is  not  in  itself  exhausting,  and  the  chances  of  recovery  are  not,  I 
think,  improved  by  systematic  efforts  at  reducing  it  so  long  as  it  re- 
mains within  these  limits.  Too  much  can  not  be  said  in  condemnation 
of  the  practice  of  giving  such  drugs  as  phenacetine,  antipyrine,  and  anti- 
febrine  in  full  doses  for  the  reduction  of  temperature.  In  small  doses 
they  are  often  useful  to  allay  nervous  irritability,  restlessness,  and  pro- 
mote sleep.  Quinine  can  not  be  considered  an  antipyretic  in  pneumonia 
except  in  cases  complicated  by  malaria.  Otherwise  it  does  little  if  any 
good,  and  often  great  harm,  by  disturbing  the  stomach. 

Antipyretic  measures  are  indicated  in  cases  of  hyperpyrexia,  which  we 
may  define  as  105°  F.  or  over,  or  when  extreme  nervous  symptoms  exist, 
even  though  the  thermometer  may  not  register  the  degree  mentioned. 
Under  these  circumstances,  the  most  certain,  the  most  within  our  control, 
and  hence  the  safest  antipyretic,  is  cold.  It  may  be  used  by  the  evapo- 
ration bath,  the  cold  pack  (pages  47,  48),  sponging,  cold  compresses,  or 
an  ice-bag  applied  to  the  chest. 

The  most  convenient  and  efficient  methods  of  using  cold  arc  the  bath 
and  the  cold  pack — the  bath  for  infants,  and  the  pack  for  older  children. 
The  peripheral  circulation  should  be  closely  watched,  and  maintained  by 
friction  of  the  body  during  the  bath,  and  the  application  of  heat  to  the  ex- 
tremities immediately  after  it.  In  most  cases  the  bath  should  be  preceded 
by  stimulants.  The  effects  are  often  very  striking;  when  there  have  been 
a  flushed  face,  hot  dry  skin,  extreme  restlessness,  and  muscular  twitch- 
ings,  all  these  symptoms  may  subside  rapidly  and  a  quiet  sleep  follow. 


556  DISEASES  OF   THE   RESPIRATORY  SYSTEM. 

The  bath  should  be  repeated  as  soon  as  these  symptoms  return,  whether 
the  thermometer  has  risen  to  its  former  height  or  not.  Xot  all  children 
bear  cold  well,  and  in  its  use  and  frecjuency  of  repetition  one  must  be 
guided  by  its  effect  upon  the  child's  general  condition  as  well  as  upon  the 
temperature.  "When  with  hyperpyrexia  we  have  general  cyanosis,  cold 
surface,  feeble  pulse,  shallow  respiration,  and  stupor,  cold  is  contraindi- 
eated  and  a  hot  mustard  bath  should  be  used. 

Inhalations. — These  are  of  more  value  in  relieving  cough  and  in  pro- 
moting bronchial  secretion  than  any  other  means  we  possess.  The  same 
substances  are  to  be  used,  and  in  the  same  way  as  mentioned  in  the  arti- 
cle on  Bronchitis. 

The  nervous  symptoms,  restlessness,  loss  of  sleep,  etc.,  are  often  best 
controlled  by  cold  or  tepid  sponging;  in  other  cases  b}^  small  doses  of 
phenacetine — i.  e.,  one  grain  every  three  hours  to  a  child  of  six  months. 
Oj)ium  is  to  be  avoided  unless  there  is  severe  pain,  which  is  very  rare;, 
or,  when  the  incessant  cough  is  not  relieved  by  inhalations.  Codeine  may 
be  given  in  doses  of  gr.  ^,  or  heroin  gr.  j^-q,  every  three  or  four  hours 
to  a  child  of  six  months. 

Sudden  attacks  of  general  collapse  with  cyanosis  are  frec^uent  in  se- 
vere cases  of  broncho-pneumonia.  They  may  come  on  at  any  period  in 
the  disease.  When  occurring  in  the  early  stage,  if  promptl}'  and  energet- 
icall}'  treated,  recovery  may  take  place,  but  when  they  come  on  in  the  late 
stages  they  are  usually  fatal.  They  may  be  due  to  acute  congestion  or 
oedema  of  the  lung  not  previously  involved.  The  most  efficient  treatment 
is  to  put  the  child  into  a  hot  mustard  bath  (page  54),  to  use  strychnine 
and  nitroglycerin  hypodermically,  and  to  give  oxygen  continuously.  For 
a  few  hours  alcohol  should  be  given  freely.  Xitrite  of  amyl  is  some- 
times more  efficient  than  nitroglycerin,  because  of  its  almost  instanta- 
neous effect.  I  must  confess  to  have  seen  very  little  benefit  from  the  use 
of  camphor,  although  many  excellent  observers  esteem  it  very  highly. 

Treatment  of  protracted  cases. — Where  the  fever  continues  for  five 
or  six  weeks,  with  no  disposition  on  the  part  of  the  disease  to  subside, 
about  all  that  can  be  done  is  to  continue  the  sustaining  treatment  adopted 
in  the  earlier  part  of  the  disease — careful  feeding,  judicious  stimulation, 
and  proper  hygienic  means.  Many  of  these  cases  will  recover  if  the  pa- 
tient's strength  holds  out;  but,  unfortunately,  in  the  majority  the  con- 
tinuance of  the  pneumonic  process  is  in  itself  evidence  of  the  weakened 
vitality  of  the  patient,  and,  though  he  may  live  a  long  time,  most  of  the 
attacks  ultimately  prove  fatal. 

Where  the  fever  has  disappeared,  and  there  is  only  a  persistence  of 
the  physical  signs  and  the  general  cachexia,  the  cases  are  more  hopeful. 
Here,  a  change  of  air  is  more  important  than  all  other  means  of  treat- 
ment. If  in  the  winter  or  spring  the  child  can  be  removed  to  a  warm,  dry 
climate  where  it  can  be  kept  in  the  open  air,  or  if,  in  the  summer,  he  can 


ACUTE  BRONCHO-PNEUMONIA.  557 

be  taken  to  the  mountains,  innnecliate  improvement  is  often  seen,  fol- 
lowed by  rapid  recovery.  This  experience  we  see  repeated  every  year 
with  hospital  patients  when  they  are  transferred  from  the  city  to  the 
country  in  May  or  June.  M^ith  the  change  of  air  a  general  tonic  plan  of 
treatment  should  be  followed,  cod-liver  oil,  arsenic,  iron,  and  quinine 
being  used,  according  to  the  indications  in  each  particular  case. 

One  should  never  declare  one  of  these  cases  of  protracted  pneumonia 
to  be  hopeless,  nor  should  he  be  too  ready  to  assume  that  tuberculosis 
is  present  because  the  child  is  wasted  and  anaemic,  and  the  physical  signs 
have  persisted.  In  private  practice  the  cases  of  simple  protracted  pneu- 
monia outnumber  the  tuberculous  ones,  three  to  one. 

Summary. — In  the  treatment  of  broncho-pneumonia  it  should  be 
borne  in  mind  that,  while  very  little  can  be  done  for  the  disease,  very 
much  can  be  done  for  the  patient.  The  hygienic  measures  generally 
grouped  under  the  term  "  careful  nursing  "'  are  of  great  importance,  and 
many  of  the  mild  cases  need  no  other  treatment.  One  should  watch  the 
digestive  organs  closely,  keep  the  bowels  freely  open,  and  not  allow  the 
abdomen  to  become  distended  with  gas,  since  this  often  seriously  inter- 
feres with  the  action  of  the  diaphragm.  In  severe  cases,  the  patient 
may  be  in  great  danger  in  the  early  stage  from  two  causes :  first,  from 
the  intensity  of  the  general  infection,  which  is  best  combatted  by  the 
use  of  alcohol  and  strychnia ;  and,  secondly,  from  the  mechanical  embar- 
rassment of  the  heart  and  respiration,  in  consequence  of  the  sudden  inter- 
ference with  the  function  of  the  lungs,  partly  from  inflammation,  but 
chiefly  from  congestion ;  this  is  best  relieved  by  counter-irritation  to  the 
chest  and  heat  to  the  extremities.  During  the  later  stage  the  principal 
danger  is  from  exhaustion ;  this  forbids  the  use  of  all  depressing  meas- 
ures, and  necessitates  the  most  careful  attention  to  the  nutrition  of 
the  patient  throughout  the  disease.  All  unnecessary  medication  is  to  be 
avoided,  particularly  the  use  of  expectorant  mixtures,  on  account  of  the 
disturbance  of  the  stomach.  Opium  is  to  be  used  very  sparingly,  and  in 
most  cases  it  should  be  Avithheld  altogether.  Tlie  cough  is  best  relieved 
by  inhalations  of  creosote,  and  the  nervous  symptoms  by  phenacetine  or 
baths.  For  local  use,  the  oiled-silk  jacket  is  better  than  poultices,  but 
neither  is  to  be  used  if  the  temperature  is  very  high.  Counter-irritation  by 
mustard  should  be  continued  throughout  the  attack,  when  there  is  much 
bronchitis.  Where  antipyretics  are  required,  cold  is  safer  and  more  effi- 
cient than  the  use  of  drugs.  Of  the  cardiac  stimulants,  alcohol  and 
strychnia  are  most  to  be  depended  upon.  Care  should  be  taken  in  all 
cases  to  maintain  a  good  peripheral  circulation.  In  sudden  general  col- 
lapse, the  most  valuable  measures  are  hot  nmstard  baths,  strychnia  hypo- 
dermically,  alcohol  freely  by  the  moutli.  and  tlic  inhalation  of  oxygen. 
In  protracted  cases,  and  in  those  with  delayed  resolution,  change  of  air 
is  more  important  than  all  other  means  combined, 
37 


558 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


CHAPTEE    V. 

DISEASES  OF   THE  LUNGS.— {Continued.) 

LOBAR   PNEUMONIA. 

Synonyms :  Fibrinous  pneumonia,  croupous  pneumonia,  pneumonic  fever. 

With  our  present  knowledge,  lobar  pneumonia  may  be  best  defined  as 
an  infectious  disease,  caused  by  the  micrococcus  lanceolatus  (pneumo- 
coceus)  and  accompanied  by  a  local  lesion  in  the  lungs.  While  in  most 
cases  the  general  s3miptoms  correspond  with  the  extent  and  severity  of 
the  local  lesion,  they  may  be  out  of  all  proportion  to  each  other. 

Etiology. — Age. — Lobar  pneumonia  may  occur  at  any  age.  I  have 
recently  seen  a  case  in  an  infant  of  three  months  which  followed  the  typi- 
cal course.  It  may  be  seen  even  in  the  newly  born,  but  it  is  not  until 
after  the  second  year  that  it  begins  to  be  frequent.  After  the  third  year 
nearly  all  the  cases  of  primary  pneumonia  are  of  this  variety.* 

Of  160  personal  cases,  and  340  collected  from  various  sources,  the  ages 
were  as  follows : 


Age. 

Cases. 

Per  cent. 

During  the  first  year 

76 
309 
104 

11 

15 

From  the  second  to  the  sixth  year 

"        "    seventh  to  the  eleventh  year 

63 
21 

"       "    twelfth  to  the  fourteenth  year 

2 

Totals 

500 

100 

The  greatest  susceptibility  appears  to  be  from  the  second  to  the  sixth 
year,  and  during  this  period  it  is  most  frequent  from  the  third  to  the  fifth 
year. 

Sex. — Of  my  own  cases,  60  per  cent  were  males,  and  the  same  pro- 
portion was  noted  in  544  collected  cases.  This  predominance  of  males 
has  been  everywhere  observed,  but  is  as  yet  unexplained. 

Season. — In  my  series  of  cases,  the  seasons  were  divided  as  follows  : 


Cases. 

Per  cent. 

In  the  three  winter  months 

48 

62 

6 

20 

35 

"        "      sprinar       '         

46 

"        "      summer    "         

4 

"        "      autumn     "       

15 

Totals 

136 

100 

*  For  the  relative  frequency  of  broncho-  and  lobar  pneumonia  during  infancy,  see 
the  table  on  p.  535. 


LOBAR    PNEUMONIA. 


559 


Lobar  pneumonia,  in  children  therefore,  as  in  adults,  occurs  most  fre- 
quently during  the  spring  months.  April  shows  the  largest  number  of 
any  single  month. 

Previous  condition. — In  my  hospital  cases,  83  per  cent  of  the  children 
were  previously  in  good  condition,  and  only  18  per  cent  were  delicate, 
rachitic,  or  syphilitic.  This  observation  has  been  borne  out  by  my  ex- 
perience in  private  practice — viz.,  that  as  a  rule  lobar  pneumonia  affects 
children  who  were  previously  healthy. 

Previous  disease. — Previous  attacks  of  pneumonia  are  observed  in  but 
a  small  proportion  of  cases.  It  was  noted  only  five  times  in  160  cases. 
In  the  vast  majority  of  cases  lobar  pneumonia  is  a  primary  disease, 
although  it  occasionally  occurs  as  a  complication  of  pertussis,  measles, 
typhoid  or  scarlet  fever,  and  even  diphtheria — chiefly,  however,  in  chil- 
dren over  three  years  old. 

Epidemics  of  lobar  pneumonia  I  have  never  witnessed,  although 
on  several  occasions  I  have  seen  two  children  in  a  family  attacked  either 
simultaneously  or  in  rapid  succession.  Exhaustion,  fatigue,  and  exposure 
are  to  be  ranked  as  associated  exciting  causes. 

In  addition  to  other  causes,  there  is  required  for  the  production  of  the 
disease  the  presence  and  growth  of  the  pneumococcus. 

Lesions. — The  seat  of  the  disease. — In  950  cases  in  children  under 
fourteen  years,  this  was  as  follows : 


Seat  of  Disease. 

Personal 
cases. 

Collected 
cases. 

Totals. 

Right  lung,  upper  lobe  only 

"         "■      middle  "      "     

39 

8 

26 

13 

137 
4 

143 
64 

176 

12 

"          "      lower      "      "     

168 

"         "      n:iore  than  one  lobe 

t*fr*r 

Totals,  right  lung 

86 

347 

433 

Left  lung,  upper  lobe  only 

25 

49 

9 

68 

214 

29 

93 

"        "      lower     "      "    

263 

"        "     more  than  one  lobe 

38 

Totals,  left  lung 

83 

311 

394 

Both  lungs,  upper  lobes 

3 
9 

13 
38 
60 

13 

"        "       lower     "     

41 

"        "       elsewhere 

69 

Totals,  both  lungs 

12 

111 

123 

The  right  lung  was  thus  affected  in  45-5  per  cent ;  the  left  lung  in 
41-5  per  cent;  both  lungs  in  13  per  cent.  In  the  order  of  frequency,  the 
disease  involves,  first,  the  left  base  ;  second,  the  right  apex ;  third,  the 
right  base;  fourth,  the  left  apex.  The  disease  affects,  as  a  rule,  a  single 
lobe,  and  often  only  a  circumscribed  portion  of  a  lobe,  stopping  sharply 
at  the  interlobar  fissure. 


560  DISEASES   OF  THE   RESPIRATORY  SYSTEM. 

Lobar  pneumonia  among  children  is  so  rarely  fatal  that  the  oppor- 
tunities for  a  study  of  the  peculiarities  of  the  lesion  have  been  somewhat 
limited.  I  have  myself  made  eleven  autopsies,  and  have  among  my  hos- 
pital records  reports  of  nine  others,  making  twenty  cases  in  all.  The 
anatomical  changes  resemble  those  seen  in  the  adult  lung.  There  is  an 
exudation  into  the  alveoli  and  smaller  bronchi  of  fibrin,  serum,  leucocytes, 
and  red  blood-cells  (Fig.  87).  There  is  usually  in  addition  an  in- 
flammation of  the  mucous  membrane  of  the  larger  bronchi  and  of  the 
pleura.  The  frequency  and  severity  of  the  pleurisy  is  a  peculiarity  of  the 
lesion  in  children. 

In  the  first  stage,  that  of  congestion^  the  portion  of  lung  involved  is 
dark-coloured,  heavy,  and  oedematous,  and  shows  under  the  microscope  a 
serous  and  cellular  exudation  into  the  air  vesicles,  with  swelling  of  the 
epithelial  cells  lining  the  alveoli. 

In  the  second  stage,  that  of  red  liepatizatmi,  there  is  usually  some  ex- 
udation upon  the  pulmonary  pleura,  generally  a  thin  layer  of  fibrin,  giving 
it  a  dull,  granular  look.  The  lung  itself  is  of  a  uniform  dark-red  colour. 
It  is  solid,  and  cuts  like  liver.  It  looks  as  if  it  had  been  inflated  to  its 
utmost  extent  and  then  injected  with  a  material  which  had  solidified.  The 
consolidated  area  is  sharply  defined.  Under  the  microscope  the  air  vesi- 
cles are  seen  to  be  distended  with  an  exudation  whi'ch  is  chiefly  fibrin^ 
but  with  some  leucocytes,  red  blood-cells,  and  desquamated  epithelial  cells. 
The  cells  are  chiefly  leucocytes,  and  are  usually  more  abundant  than  in 
the  pneumonia  of  adults. 

In  the  third  stage,  that  of  gray  hepatization,  the  lung  is  more  moist, 
and  the  inflammatory  products  are  partly  decolourized.  This  change  takes 
place  irregularly  throughout  the  lung,  giving  it  a  mottled  appearance. 

The  fourth  stage,  that  of  resolution,  follows  gray  hepatization,  and 
consists  in  the  degeneration  and  liquefaction  of  the  products  of  inflam- 
mation, which  are  ultimately  carried  away  by  the  lymphatics,  or  pushed 
out  into  the  bronchi  and  removed  by  coughing. 

The  duration  of  the  stage  of  congestion  is  from  a  few  hours  to  sev- 
eral days;  that  of  the  stage  of  red  hepatization  from  two  days  to  two  or 
three  weeks.  This  is  the  condition  in  which  the  lung  is  most  often  seen 
at  autopsy.  The  stage  of  gray  hepatization  is  commonly  shorter.  Eeso- 
lution  usually  begins  when  the  temperature  falls  to  normal,  but  occa- 
sionally it  may  be  delayed  for  several  days.  It  is  generally  complete 
in  about  a  week. 

Variations  in  the  lesions. — (1.)  Instead  of  clearing  up  at  the  usual 
time,  the  hmg  may  remain  consolidated  for  several  weeks,  and  then  re- 
solve. (2.)  The  stage  of  gray  hepatization  may  be  followed  by  a  great 
exudation  of  pus  cells,  which  may  everywhere  infiltrate  the  affected  lung; 
or  these  may  be  circumscribed  so  as  to  form  a  single  large  abscess  or  many- 
small  ones.   (3.)  There  may  be  small  areas  of  gangrene.  All  these  condi- 


LOBAR  PNEUMONIA.  561 

tions  are  very  rare  in  children.  Purulent  infiltration  and  delayed  resolu- 
tion were  noted  in  none  of  my  cases,  and  gangrene  but  once.  (4.)  There 
may  be  excessive  j^leurisy,  or  pleuro-pneunionia.  This  was  found  in  one- 
half  of  my  autopsies.    These  cases  will  be  separately  considered  elsewhere. 

Lesions  in  other  organs. — With  pneumonia  of  the  left  side,  if  compli- 
cated by  pleurisy,  there  may  also  be  pericarditis.  This  is  seen  even  in 
infants.  The  pericardial  inflammation  closely  resembles  that  of  the 
pleura.  There  is  a  very  abundant  exudation  of  fibrin  and  pus,  coating 
both  surfaces  of  the  pericardium.  Acute  meningitis  was  met  with  twice 
in  my  cases.  The  form  was  an  acute  purulent  meningitis,  with  a  very 
abundant  exudation  of  greenish-yellow  lymph,  chiefly  at  the  convexity. 
In  one  of  my  cases  peritonitis  was  also  present.  As  the  pneumococcus  is 
found  in  all  these  inflammations,  they  may  be  regarded  as  examples  of  a 
more  generalized  infection  than  usually  occurs.  In  most  of  these  the 
other  processes  are  secondary  to  that  in  the  lungs,  but  sometimes  they 
begin  simultaneously  with,  or  may  even  precede,  the  pulmonary  lesion. 
In  a  very  small  proportion  of  cases  the  ^Dneumoeoceus  is  found  in  the 
blood,  spleen,  the  kidney,  and  liver — i.  e.,  a  general  pneumococcus  septi- 
cgemia. 

The  heart  is  generally  found  in  diastole,  with  the  cavities,  especially 
those  of  the  right  side,  distended  with  soft  clots.  There  may  be  foimd 
ante-mortem  thrombi,  which  may  extend  into  the  pulmonary  artery  or 
the  aorta. 

Symptoms. — (1.)  The  typical  course. — A  child  three  or  four  years  of  age, 
after  a  few  hours  of  slight  indisposition,  is  suddenly  taken  with  vomiting, 
followed  by  a  rajDid  rise  in  temperature.  He  is  dull  and  heavy,  complains 
of  headache  and  general  weakness,  refuses  food,  and  is  easily  persuaded  to 
remain  in  bed.  He  has  the  appearance  of  being  quite  ill,  even  after  a  few 
hours.  Occasionally  sharji  pain  in  the  side  is  complained  of.  The  skin  is 
dry;  there  are  marked  thirst,  restlessness,  and  the  other  symptoms  which 
accompany  fever.  The  temperature  is  found  to  be  104°  F.,  or  even  higher ; 
the  respirations  40  to  50  a  minute ;  the  pulse  full,  strong,  and  120  to  130. 
On  the  second  day  the  patient  is  no  better.  The  temperature  remains 
high ;  the  tongue  is  coated ;  the  anorexia  continues ;  the  pain  is  more 
severe ;  cough  is  present  and  may  be  quite  frequent. 

After  the  second  or  third  day  the  patient  is  usually  more  comfortable, 
and  sleeps  better,  but  may  be  disturbed  by  the  cough.  At  times  there  is 
restlessness,  and  at  night  there  may  even  be  slight  delirium.  The  respi- 
ration continues  rapid  and  the  temperature  high.  These  general  symp- 
toms show  very  little  change  until  the  sixth  or  seventh  day,  when,  after  a 
long  sleep,  which  has  been  more  natural  than  before,  the  patient  wakes, 
decidedly  improved  as  to  all  his  symptoms.  There  is  less  fever,  and  the 
temperature  continues  to  fall  rapidly  until  it  touches  the  normal  line,  or 
it  may  even  go  below  this.  As  the  fever  subsides  the  pulse  drops  to  90  or 
100,  and  the  respirations  to  25  or  30  a  minute.    The  appetite  soon  returns. 


562  DISEASES   OP  THE  RESPIRATORY  SYSTEM. 

and  convalescence  is  usually  rapid.  In  a  week  the  jDatient  is  ont  of  bed, 
and  in  a  month  from  the  beginning  of  the  illness  he  is  out  of  doors ;  but 
it  may  be  another  month  before  he  can  be  considered  to  have  entirely  re- 
covered. This  is  the  course  seen  in  fully  two-thirds  of  all  the  cases  of 
lobar  pneumonia  at  this  age. 

(3.)  Pneumonia  of  short  duration. — Instead  of  running  the  usual 
course  of  from  five  to  eight  days,  cases  are  seen  in  which  the  duration  is 
only  three  or  four  days,  although  the  physical  signs  indicate  that  the 
process  in  the  lung  passes  through  the  usual  stages.  These  differ  from 
the  ordinary  type  chiefly  in  their  duration.    They  are  always  mild. 

(3.)  Abortive  pneumonia. — This  form  of  the  disease  is  rarely  seen  in 
hospitals,  but  it  is  not  infrequent  in  private  practice  where  the  physician 
is  summoned  at  the  earliest  signs  of  illness.  The  onset  is  precisely  like 
that  of  ordinary  pneumonia,  and  may  even  be  as  severe  as  the  average 
case.  The  physical  examination  of  the  chest  gives  all  the  signs  of  the 
first  stage  of  the  disease,  but  on  the  second  or  third  day  the  physician  is 
greatly  surprised  to  find  that  the  temperature  has  fallen  to  normal,  and 
that  all  the  physical  signs  have  disajDpeared.  The  process  in  such  cases 
does  not  seem  to  go  beyond  the  first  stage  of  congestion ;  there  is  no  evi- 
dence of  hejDatization  of  the  lung.  The  course  is  often  such  as  to  lead 
the  physician  to  the  opinion  that  he  has  made  a  mistake  in  his  diagnosis. 
There  seems,  however,  to  be  no  doubt  that  these  are  cases  of  genuine 
pneumonia.  D'Espine  found  the  pneumococcus  in  the  sputum  of  such 
a  case.  This  type  of  pneumonia  corresponds  with  abortive  types  of  other 
infectious  diseases  so  frequenth^  met  with  in  children.  The  temperature 
curve  in  such  a  case  is  shown  in  Fig.  106,  page  565.  The  diagnosis  of 
these  cases  is  always  attended  with  some  uncertaint3^  There  can  be  no 
doubt  that  very  many  of  the  unexplained  high  temperatures  of  brief  dura- 
tion which  are  seen  in  children  are  from  this  cause.  Exactly  why  the 
disease  terminates  in  this  way  is  not  known.  It  may  be  because  the  re- 
sistance of  the  patient  is  greater  than  usual,  or  the  virulence  of  the  pneu- 
mococcus is  less. 

(4.)  The  prolonged  course. — Although  usually  lasting  about  a  week, 
it  is  not  rare  for  pneumonia  to  continue  ten,  twelve,  or  even  fifteen  days. 
This  prolonged  course  is  usually  due  to  the  fact  that  the  disease  spreads 
from  one  part  of  the  lung  to  another,  or  even  to  the  opposite  lung,  in- 
volving in  succession  two,  three,  or  more  lobes.  This  is  sometimes 
known  as  "  creeping "  pneumonia ;  it  is  always  severe  and  the  out- 
look is  generally  unfavourable.  A  prolonged  temperature  with  pneu- 
monia of  a  single  lobe  should  always  suggest  complications,  usually 
pleurisy. 

(5.)  Cerebral  pneumonia. — This  term  was  first  applied  by  Eilliet 
and  Barthez  to  cases  of  pneumonia  in  which  the  cerebral  symptoms  pre- 
dominate.    They  will  be  considered  later. 


LOBAR   PNEUMONIA.  563 

Onset. — Prodromal  symptoms  of  more  than  a  few  hours'  duration  are 
quite  rare.  The  onset  of  lobar  pneumonia  is  almost  invariably  sudden, 
Avith  well-marked  symptoms — vomiting,  diarrhoea,  chill,  or  convulsions. 
Vomiting  is  altogether  the  most  frequently  seen.  It  was  the  mode  of 
onset  in  about  one  half  my  cases.  In  summer  particularly,  there  may  be 
vomiting  and  diarrhoea.  A  distinct  chill  is  rare  in  a  child  under  five 
years  of  age,  and  is  not  very  common  even  in  older  children.  Convul- 
sions are  not  very  infrequent,  being  seen  in  about  five  per  cent  of  the 
cases.  Their  occurrence  depends  upon  the  suddenness  of  the  invasion 
and  the  susceptibility  of  the  patient. 

Cough. — This  is  present  in  most  of  the  cases  throughout  the  disease, 
but  often  is  not  marked  for  the  first  day  or  two.  It  ia  seldom  a  distress- 
ing symptom.  A  disposition  to  suppress  the  cough  on  account  of  pain  is 
very  frequently  noticed. 

Expectoration. — This  is  rarely  seen  in  childhood,  and  practically  never 
under  five  years  of  age.  Children  of  ten  or  twelve  may  have  the  same 
expectoration  as  adults — white  and  viscid,  or  brownish-red  early  in  the 
disease,  yellow  and  abundant  toward  its  close. 

Pcdn. — Headache  and  general  muscular  pains  in  the  back  and  extremi- 
ties are  frequent  during  the  invasion.  The  characteristic  pain,  however, 
is  pleuritic.  It  is  not  necessarily  felt  in  the  region  of  the  affected  lung, 
and  often  not  in  the  chest  at  all.  It  is  frequently  referred  to  the  loin,  the 
epigastrium,  or  to  any  region  to  which  the  intercostal  nerves  are  distrib- 
uted. In  a  recent  case,  in  a  boy  of  seven  years,  for  the  first  twelve  hours 
there  was  intense  localized  pain  in  the  right  iliac  fossa,  associated  with 
such  extreme  tenderness  as  to  lead  to  the  suspicion  that  the  case  was  one 
of  appendicitis.  The  pain  may  last  throughout  the  disease,  and  occasion- 
ally it  is  a  most  distressing  symptom  ;  but  usually  it  is  only  moderate,  and 
rather  more  severe  early  than  late  in  the  disease. 

Prostration. — This  is  one  of  the  characteristic  features  of  pneumonia. 
The  patient  is  generally  willing  to  go  to  bed  on  the  first  day  of  the  attack, 
and  shows  little  desire  to  leave  it  while  the  disease  continues.  "  Walking 
cases  "  are  not  common  in  children. 

Respiration. — This  is  always  accelerated,  and  generally  out  of  propor- 
tion to  the  pulse.  The  normal  ratio  of  the  respiration  to  the  pulse  is  one 
to  four ;  in  pneumonia,  frequently  one  to  two.  The  respiration  is  not 
laboured  and  not  quite  panting,  although  this  term  is  sometimes  used 
to  describe  it.  It  is  jerky.  There  is  a  short  inspiration,  then  a  momen- 
tary pause,  followed  by  a  quick  expiration,  which  is  accompanied  by  a  short 
moan.  This  expiratory  moan  is  very  characteristic.  The  rapidity  of  res- 
piration is  usually  in  proportion  to  the  amount  of  lung  involved,  but  it  is 
also  modified  by  the  temperature,  as  the  respirations  often  drop  from  60 
to  30  in  the  course  of  a  few  hours  at  the  crisis. 

Pulse. — In  the  early  part  of    the  disease  this  is  frequent,  full,  and 


564 


DISEASES   OP   THE  EESPIRATORY  SYSTEM. 


strong,  from  110  to  140  a  minute.  Later  it  may  be  weak,  small,  com- 
pressible, and  sometimes  irregular.  It  is  relatively  more  rapid  in  the 
child  than  in  the  adult.  The  frequency  of  the  pulse  is  of  less  impor- 
tance than  its  character. 

Temperature. — The  typical  temperature  curve  of  lobar  pneumonia 
(Fig.  103)  is  characterized  by  an  abrupt  rise  usually  to  104°  or  105°  F., 
and  by  daily  fluctuations  generally  within  the  limits  of  two  or  three  de- 


101° 
103° 
102° 
101° 
100° 
99° 

1 

2 

3 

i  1  5 

6 

7 

a 

.^ 

M 

/ 

\ 

l 

— 

V 

^./l 

98° 

^ 

1 

Fig.  103. — Typical  temperature  curve  of  lobar  pneumonia. 

History. — Male,  three  years  old;  in  fair  condition;  sudden  onset;  signs  of  consolidation-— 
bronchial  respiration  and  voice,  and  duluess — over  left  lower  lobe  behind,  not  distinct  until 
the  morning  of  the  fifth  day.    On  the  seventh  day  the  lung  was  resolving. 

grees  until  the  crisis,  at  Avhich  time  the  temperature  falls  to  normal,  usu- 
ally in  the  course  of  twenty-four  hours.  After  this  time  it  does  not  go 
above  the  normal  line.  Such  a  curve  is  seen  in  the  majority  of  cases  over 
three  years  of  age. 

In  cases  under  three  years  of  age  it  is  not  uncommon  for  the  tempera- 
ture to  he  of  a  more  or  less  remittent  type  (Fig.  104). 


107° 

1 

2 

3 

i 

5 

6 

7 

8 

9 

10 

11   12 

13 

11 

15 

16 

17 

18 

19 

20 

10C° 
105° 
lOi" 
103° 
102° 
101° 
100° 
99° 

A 

/ 

/ 

\f 

i 

/\ 

\ 

r 

/ 

\ 

/ 

AW 

r 

\ 

f 

' 

1 

\     \\ 

\j 

/ 

\ 

. 

I 

1 

1 

98° 
97° 

\ 

J^ 

,  ^ 

-^ 

♦ 

V 

Fig.  104. — Lobar  pneumonia  with  remittent  temperature. 

History. — Female,  eighteen  months  old  ;  in  fair  condition:  sudden  onset;  repeated  exami- 
nations of  chest  made,  but  no  abnormal  signs  until  the  ninth  day,  when  there  were  very  rude 
respiration  and  slight  dulness  at  the  right  apex,  in  front;  on  the  twelfth  day  all  the  signs  of 
consolidation  at  the  same  point,  no  rales ;  four  days  after  the  crisis  the  lungs  were  clear. 

These  wide  fluctuations  often  lead  to  great  difficulty  in  diagnosis,  par- 
ticularly if  the  physical  signs  appear  late,  as  they  not  infrequently  do.  It 
is  possible  that  some  of  them  are  to  be  explained  by  mixed  infection. 

The  following  chart  (Fig.  105)  illustrates  three  features  which  are 
often  seen  in  pneumonia  :  (1)  A  temperature  which  early  in  the  disease  is 
steadily  high  and  as  the  day  of  crisis  approaches  becomes  remittent;  (2) 
a  secondary  rise  after  being  normal  for  twenty-four  hours,  which  was  due 


LOBAR  PNEUMONIA. 


565 


in  this  instance  to  an  extension  of  the  disease  to  a  new  part  of  the  lung; 
(3)  a  fall  to  a  point  considerably  below  normal  at  the  time  of  the  crisis. 
In  this  case  the  temperature  fell  in  the  course  of  eighteen  hours  from 


107° 

1 

2 

3 

I 

5 

c 

7 

8 

9 

10 

11 

I2I13 

11 

15 

16 

17 

IS 

19 

20 

108° 
105° 
101° 
103° 
102° 
101° 
100° 
99° 

il 

/I 

A 

1  ^ 

A 

j- 

/ 

t 

V 

f 

s 

\ 

1 

/ 

V 

V 

s 

1 

98° 
97° 
96° 
flS° 
91° 

A 

N 

A 

r- 

^ 

ft 

^ 

J 

/ 

V 

1 

Fig.  105. — ^Lobar  pneumonia  witli  subnormal  temperature  after  the  crisis. 

Uisfori/. — Female,  nineteen  months  old ;  fairly  healthy  ;  sudden  onset ;  symptoms  typical 
but  physical  signs  delayed;  consolidation  in  left  mammary  region  on  the  eighth  day ;  on  the 
ninth  in  right  lung  middle  lobe ;  on  the  eleventh  day  a  pseudo-critical  drop,  followed  after 
twenty-four  hours  of  apyrexia  by  a  further  rise,  which  was  accompanied  by  signs  of  extension 
■of  the  disease  in  the  right  lung.     Eesolution  rapid  after  crisis. 

105°  to  95°  F.,  and  later  still  lower;  it  was  two  days  before  it  finally  re- 
mained at  the  normal  point.  A  fall  to  96  -5°  or  9T°  F.  at  the  time  of 
•crisis  is  not  uncommon. 

In  the  foregoing  cases  the  fever  terminated  by  crisis.  In  Fig.  106  is 
.shown  one  ending  by  lysis.  This  is  a  mode  of  termination  much  more 
frequent  in  young  children  than  in  those  who  are  older.    Thus,  in  ninety- 


106=' 
105° 
104° 
103' 
102  = 
101° 
100  = 
99-' 

1 

2 

3 

1 

5 

6 

7 

8 

9 

10   11 

12 

13 

14 

15 

16 

17 

/^ 

i 

\l 

v\ 

/ 

/ 

\/ 

/ 

- 

-^ 

/ 

V 

A 

J 

\ 

1 

\. 

L 

J 

\-< 

^r 

l^ 

98  = 

^ 

'  i  1 

1 

'<- 

^" 

Fig.  106.— Abortive  pneumonia  in  left  lung,  followed  by  typical  pneumonia  in  right  lung, 

teruiinating  by  lysis. 

History. — Male,  seventeen  months  old  ;  healthy  ;  sudden  onset :  on  the  second  day  dissemi- 
nated fine  rales  in  botli  lungs  behind,  and  over  left  lower  very  feeble  respiration,  high-intched 
— i.  e.,  some  bronchitis,  with  congestion  (?)  of  left  base.  On' the  third,  fourtii,  and  tiftli  days, 
general  symptoms  gone  and  signs  nearly  disappeared.  On  the  si.\th  day  all  symptoms  of  pneu- 
monia, and  on  the  seventh  distinct  consolidation  of  right  base,  rest  of  chest  clear.  Subsequent 
course  typical ;  resolution  rapid  and  complete. 


tliree  of  my  own  cases,  nearly  all  of  which  were  under  three  years  of  age, 
the  fever  ended  by  crisis  in  forty-nine,  and  by  lysis  in  forty-four ;  while 
in  five  hundred  and  twenty-two  collected  cases,  the  majority  of  which 
were  in  older  children,  three  hundred  and  ninety-six  ended  Ijy  crisis,  and 
one  hundred  and  twentv-six  bv  Ivsis. 


566  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

The  following  table  shows  the  day  of  crisis  in  five  hundred  and  sixty- 
seven  eases  of  lobar  jjneumonia  in  children  who  recovered  : 

The  Day  of  Crisis. 

Second  day 3  cases,     i     Eleventh  daj' 18  cases. 

Third      " 22      "         I     Twelfth      "" 7      " 

Thirteenth  day 8      " 

Fourteenth  '•   7      " 

Fifteenth      "    1  case. 

Eighteenth   "    3  cases. 

Twenty-first  duy 1  case. 

Twenty-sixth  '•    1     " 

567 


Fourth  '•    43 

Fifth  '•    88 

Sixth  ••    83 

Seventh  "    133 

Eighth  '•    73 

Ninth  "    55 

Tenth  "    32 


From  this  table  it  will  be  seen  that  the  most  frequent  critical  day  is 
the  seventh,  and  that  in  66  per  cent  of  the  cases  it  was  from  the  fifth  to 
the  eighth  day.  The  causes  of  a  post-critical  rise  in  the  temperature  are 
chiefly  two — extension  of  the  disease  to  a  new  area,  or  the  development 
of  pleurisy,  which  is  apt  to  be  purulent.  Less  frequently  it  is  due  to- 
meningitis,  pericarditis,  gastro-enteritis,  or  malaria.  In  fatal  cases  the 
temperature  is  generally  high  until  the  end.  In  general,  it  may  be  said 
that  the  temperature  is  considerably  higher  in  children  than  in  adults ; 
in  the  majority  of  cases  it  reaches  105°  F.,  the  usual  range  being  from 
102°  to  105°  F.  In  fifteen  of  one  hundred  and  thirty-seven  cases,  or  11 
per  cent,  it  reached  106°  F.  or  over. 

Gastro-enteric  symptoms. — These  are  more  common  in  infants  than  in 
older  children.  At  the  onset  there  is  frequently  vomiting,  sometimes 
also  diarrhoea.  A  continuance  of  the  vomiting  is  rare,  and  is  generally 
due  to  improper  feeding  or  medication.  It  may  be  a  very  serious  com- 
plication. Diarrhoea  is  also  rare,  except  at  the  onset  and  in  summer  cases. 
It  is  sometimes  seen  at  the  time  of  crisis.  Throughout  the  disease  there 
are  anorexia,  coated  tongue,  and  the  usual  symptoms  of  high  fever. 

Nervous  symptoms. — Cerebral  symptoms  are  frequent  and  very  often- 
misleading.  In  seven  of  my  cases  the  pneumonia  was  ushered  in  by  convul- 
sions. These  differ  in  no  respect  from  convulsions  from  other  causes,  and 
may  be  repeated  two  or  three  times  in  the  course  of  the  first  twenty-four 
hours.  They  are  sometimes  followed  by  drowsiness  or  stupor,  sometimes- 
by  active  delirium.  Cerebral  symptoms  may  predominate  for  several  days. 
There  may  be  opisthotonus,  dilated  or  contracted  pupils,  irregular  pulse,, 
retracted  abdomen,  and,  in  fact,  almost  every  symptom  of  meningitis. 
Occasionally  the  decubitus  eri  cMen  de  fusil,  or  gun-hammer  position,  is 
assumed.  These  are  often  described  as  cases  of  cerebral  pneumonia,  and 
in  many  of  them  pneumonia  is  not  suspected  until  the  fourth  or  fifth  day 
of  the  disease,  sometimes  not  until  the  crisis  occurs,  when  the  rapid  dis- 
appearance of  all  these  nervous  symptoms  indicates  their  origin.     Early 


LOBAR   PNEUMONIA.  567 

convulsions  are  not  generally  followed  by  an  especially  severe  type  of  the 
disease,  only  one  of  seven  cases  beginning  in  this  way  proving  fatal.  On 
the  other  hand,  cases  with  late  convulsions  are  usually  fatal.  In  two  of 
the  three  cases  in  which  I  have  noted  them,  the  convulsions  ushered  in 
an  attack  of  meningitis. 

Delirium  is  much  more  frec[uent  than  convulsions,  and  is  seen  in 
nearly  one  fourth  of  the  cases.  Generally  it  is  slight,  and  noticed  only 
at  night  or  when  the  temperature  is  very  high.  It  is  usually  mild,  but 
may  be  low  and  muttering,  like  that  of  typhoid,  or  wild  and  active,  like 
that  of  cerebro-spinal  meningitis.  It  is  most  pronounced  at  the  height 
of  the  disease.  Other  nervous  symptoms  belonging  to  the  typhoid  state, 
such  as  incontinence  of  urine  or  faeces,  muscular  twitchings,  and  tremor 
of  the  tongue  or  protrusion,  are  occasionally  seen,  but  only  in  the  worst 
forms  of  the  disease. 

There  is  no  relation  between  the  seat  of  the  disease  in  the  lungs  and 
the  occurrence  of  cerebral  symptoms.  They  are  more  frequent  in  chil- 
dren under  five  years  than  in  those  who  are  older,  and  depend  upon  the 
suddenness  of  the  invasion,  the  intensity  of  the  infection,  and  the  sus- 
ceptibility of  the  child.  Late  in  the  disease  they  may  indicate  exhaus- 
tion, toxemia,  or  complicating  meningitis.  They  are  frequently  asso- 
ciated with  very  high  temperature  and  extensive  disease.  The  usual 
nervous  symptoms — restlessness,  headache,  sleeplessness,  etc. — are 
nearly  always  proportionate  to  the  height  of  the  temperature. 

Urine. — Throughout  the  febrile  period  of  the  disease  the  urine  is- 
scanty,  high-coloured,  with  a  high  specific  gravity,  and  usually  loaded 
with  urates.  In  a  small  number  of  cases  a  trace  of  albumin  may  be 
found,  and  occasionally  a  few  hyaline  casts.  Evidences  of  serious  renal 
disease  I  have  seldom  found  in  lobar  pneumonia,  and  in  the  experience 
of  all  observers  it  is  extremely  rare  in  early  life. 

Shin. — The  face,  in  pneumonia,  is  usually  flushed,  sometimes  on 
both  sides  and  sometimes  only  on  one;  in  other  cases  it  is  pale,  but  not 
indicative  of  pain.  Cyanosis  is  rare  except  toward  the  close  of  the  dis- 
ease and  is  usually  a  sign  of  respiratory  failure.  Herpes  of  the  lips  or 
face  is  quite  frequent. 

Blood. — The  leucocyte  count  is  of  considerable  value  both  from  a 
diagnostic  and  a  prognostic  standpoint.  For  a  discussion  of  this  subject 
see  page  814, 

Physical  Signs. — The  earliest  signs  in  pneumonia  are  due  to  the  acute 
congestion  of  the  affected  lung  or  lobe,  in  consequence  of  which  less  air 
enters  this  portion  and  more  air  the  rest  of  the  lungs.  Percussion  gives 
diminished  resonance  or  slight  dulness  over  the  affected  area,  and  exag- 
gerated resonance  over  the  remainder  of  this  lung  and  over  the  opposite 
lung.  Auscultation  over  the  affected  lobe  gives  feeble  respiratory  mur- 
mur, rather  high  in  pitch;  sometimes  there  may  be  absence  of  all  breath- 


568  DISEASES  OF   THE  RESPIRATORY  SYSTEM. 

sounds  so  complete  as  to  suggest  fluid.  The  normal  respiratory  murmur 
over  the  healthy  portions  of  the  lungs  is  intensified.  In  children  this  ex- 
aggerated hreathing  is  not  infrequently  mistaken  for  bronchial  breath- 
ing, and  the  physician  may  be  led  into  the  error  of  locating  the  pneu- 
monia upon  the  wrong  side.  Exaggerated  breathing  does  not  differ 
from  normal  breathing  except  in  intensity,  and  is  heard  only  on  in- 
spiration. Bronchial  breathing  is  higher  in  pitch,  and  is  heard  with 
nearly  equal  intensity,  both  on  expiration  and  inspiration.  If  the  chest 
is  frequently  auscultated,  crepitant  rales  (Figs.  107  and  108)  may  usu- 
ally be  heard  at  some  period  at  the  end  of  full  inspiration,  but  often  they 
are  present  but  for  a  few  hours,  and  they  may  be  missed  altogether. 

In  the  second  stage,  that  of  consolidation  (Fig.  109),  no  air  enters  the 
affected  part  of  the  lung.  Upon  palpation  there  is  found  here  exaggerated 
vocal  fremitus,  and  on  percussion  there  is  marked  dulness,  but  very  rarely 
flatness.  Over  the  rest  of  this  lung  there  is  exaggerated,  sometimes  even 
tympanitic,  resonance  ;  this  is  especially  frequent  at  the  apex  of  the  lung 
in  front,  when  there  is  consolidation  at  the  base  behind.  Under  these 
•conditions  cracked-pot  resonance  may  sometimes  be  obtained.  Over  the 
healthy  lung  there  is  exaggerated  resonance.  On  auscultation  over  the 
consolidated  portion  there  are  bronchial  breathing  and  bronchial  voice, 
the  area  over  which  they  are  heard  being  sharply  defined.  Eales  are  usu- 
ally absent,  but  there  may  be  pleuritic  friction  sounds. 

In  the  stage  of  resolution  there  is  a  gradual  disappearance  of  the 
signs  of  consolidation.  The  pure  bronchial  is  replaced  by  broncho-vesic- 
ular breathing,  the  vesicular  element  gradually  predominating.  Moist 
rdles  of  all  varieties  are  heard.  Usually  the  most  persistent  signs  are 
slight  dulness  or  diminished  resonance,  with  a  respiratory  murmur  which 
is  feebler  than  normal  and  a  little  higher  in  pitch ;  sometimes  there  are 
also  dry  friction  sounds.     These  signs  may  persist  for  two  or  three  weeks. 

Exceptional  physical  signs. — While  in  the  majority  of  cases  the  signs 
of  consolidation  are  distinct  on  or  before  the  fourth  day,  in  not  a  few  they 
may  be  delayed  much  longer.  Of  eighty-two  cases  in  which  the  day  was 
noted  on  which  consolidation  was  found,  it  was  not  until  the  fifth  day  or 
later  in  one  fourth  the  number.  In  six  of  them,  although  carefully  and 
repeatedly  examined,  no  consolidation  was  found  until  the  seventh  day  or 
later  and  in  one  case  not  until  the  twelfth  day.  It  has  been  customary 
to  look  upon  these  cases  of  delayed  or  concealed  physical  signs  as  cases 
of  central  pneumonia.  That  pneumonia  may  exist  in  the  centre  of  a 
lung  for  a  number  of  days  is,  to  my  mind,  extremely  improbable.  At 
autopsy,  superficial  pneumonia  I  have  very  frequently  seen,  but  central 
pneumonia  never.  There  are  two  regions  in  which  pneumonia  may  exist 
and  yet  not  be  accessible  by  our  means  of  physical  examination,  viz.,  at 
the  apex  of  the  lung  in  the  part  covered  by  the  shoulder,  and  along  the 
posterior  border  of  the  lung  where  it  lies  against  the  vertebrse.     In  either 


PHYSICAL    SIGN'S    OF   LOBAR    PXEU:\IOXIA. 


Fig.  107. — First  stage.     Congestion  of  left  lower  Fig.  108. — In  the  centre  of  the  area,  a  small  spot  of 
lobe,  with  crepitant  rales.     Feeble  breathing  pui-e  bronchial  breathing  and  voice ;  surround- 

of  a  rude  character,  with  slight  dulness.  ing  this  an  occasional  crepitant  rale,  with  bron- 

cho-vesicular breathing  and  slight  dulness. 


Fig.  109. — Second  stage.  Ctomplete  consolidation  of  left  lower  lobe.  Pure  bronchial  breathing  and 
bronchial  voice;  marked  dulness;  increased  vocal  fremitus,  and  at  the  lower  part  a  few  friction 
sounds. 

Note. — During:  resolution  the  signs  take  the  inverse  order :  those  of  Fig.  109  give  place 
to  those  of  Fig.  108,  and  these  in  turn  to  those  of  Fig.  107.  In  addition,  many  coarse  rales 
may  be  heard. 

569 


570  DISEASES   OP   THE  RESPIRATORY  SYSTEM. 

of  these  situations  iDiieumonia  may  be  present  witliout  our  being  able  to 
find  it.  It  is  quite  common  in  cases  with  late  physical  signs  that  the  first 
distinctive  evidences  of  disease  are  found  high  in  the  axilla,  or  beneath 
the  clavicle  in  front,  and  these  regions  should  be  closely  watched  in 
doubtful  cases.  Sometimes  the  delay  is  best  explained  by  assuming  that 
constitutional  symptoms  due  to  a  pneumococcus  infection,  may  be  present 
for  several  days  before  the  development  of  the  local  lesion  in  the  lung. 

Complications. — The  occurrence  of  dry  pleurisy  over  the  consolidated 
portion  of  the  lung  is  so  constant  that  it  can  hardly  be  considered  a  com- 
plication. A  slight  serous  exudation  of  two  or  three  ounces  is  not  un- 
common, but  more  than  this  is  very  rare  in  young  children.  In  the  most 
sere  re  cases  of  pleurisy  there  is  an  excessive  exudation  of  fibrin  and  pus. 
This  occiTrred  in  eight  per  cent  of  my  cases.  This  variety  is  known  clin- 
ically as  pleuro-pneumonia,  and  will  be  considered  separately.  Pericar- 
ditis is  rare ;  it  was  seen  only  twice  in  the  series  of  cases  reported,  being 
associated  with  pleuro-pneumonia  of  the  left  side.  It  rarely  gives  rise  to 
any  new  symptoms.  Endocarditis  was  not  seen  in  my  cases,  though  it 
occasionally  occurs.  Meningitis  is  rare,  and  generally  develops  late  in 
the  disease.  It  is  nearly  always  ushered  in  by  repeated  attacks  of  vomit- 
ing or  convulsions.  Its  course  is  short  and  progressive.  Peritonitis 
causes  few  new  symptoms  except  abdominal  distention,  pain,  and  tender- 
ness. 

Course  and  Termination. — In  the  great  majority  of  cases  lobar  pneu- 
monia terminates  either  in  perfect  recovery  or  in  death.  A¥hen  ending 
in  recovery,  resolution  commonly  begins  immediately  upon  the  cessation 
of  the  fever,  and  is  complete  in  about  a  week.  Delayed  resolution  is  not 
common  in  children;  chronic  pneumonia  and  tuberculosis  are  rare 
sequelae,  but  empyema  is  very  common.  Its  symptoms  sometimes  de- 
velop immediately  after  the  pneumonia,  the  temperature  continuing 
Mgh ;  or  there  may  be  an  interval  of  a  few  days  before  the  development 
of  the  pleural  symptoms.  Some  pleuritic  adhesions  probably  remain  in 
every  case  in  which  there  has  been  much  dry  pleurisy,  and  when  severe 
and  extensive,  these  may  be  the  cause  of  subsequent  symptoms,  like  any 
other  dry  pleurisy. 

Death  from  uncomplicated  pneumonia  may  be  due  to  exhaustion,  or 
to  heart  failure,  with  or  without  failure  of  the  respiration.  The  signs  of 
heart  failure  sometimes  develop  quite  rapidly  in  cases  which  are  appar- 
ently doing  well.  The  symptoms  are :  coldness  of  the  hands  and  feet, 
then  of  the  legs  and  arms ;  a  rapid,  compressible,  and  sometimes  irregu- 
lar pulse ;  muscular  weakness  and  pallor,  but  usually  no  cyanosis.  The 
symptoms  of  respiratory  failure  are :  very  rapid  superficial  respirations, 
sometimes  100  a  minute ;  blueness  of  the  lips  and  finger  nails ;  often  a 
leaden  hue  of  the  whole  body ;  there  are  loud  tracheal  rales,  and  reces- 
sion of  all  the  soft  parts  of  the  chest  on  inspiration. 


LOBAR    PNEUMONIA. 


571 


Death  may  result  early  in  the  disease,  where  the  pneumonia  has  spread 
rapidly,  involving  both  lungs.  The  earliest  deaths  I  have  seen  were  on 
the  fourth  day,  and  were  due  to  a  failure  of  the  heart  and  respiration. 
In  most  of  the  uncomplicated  fatal  cases,  death  results  from  heart  failure 
at  about  the  time  of  the  crisis.  In  the  complicated  cases  death  usually 
occurs  in  the  second  week.  I  once  knew  fatal  meningitis  to  develop  at 
the  end  of  the  fourth  week. 

Diagnosis. — The  most  characteristic  differences  between  broncho-  and 
lobar  pneumonia  are  shown  in  the  following  table  : 


BRONCHO-P^sTEUMONIA. 

1.  More  than  half  the  cases  secondary. 

2.  Under  three,  chiefly  under  two  years. 

•  3.  Occurs  more  frequently  in  delicate 
and  debilitated  childi-en. 

4.  Bacteria — in  pi-imary  cases,  usually 
the  pneuraococcus ;  in  secondary  cases, 
usually  mixed  infection. 

5.  Products  of  inflammation  chiefly  cel- 
lular ;  process  often  diffuse. 

6.  Onset  often  gradual,  sometimes  in- 
sidious, especially  when  secondary. 

7.  No  typical  course ;  fever  often  lasts 
three  or  four  weeks  ;  rarely  terminates  by 
crisis. 

8.  Involves  both  lungs  as  a  rule,  most 
frequently  lower  lobes  posteriorly. 

9.  Signs  of  bronchitis  mingled  with 
those  of  consolidation  ;  rales  in  other  parts 
of  the  same  lung,  or  in  the  opposite  lung, 
throughout  the  disease. 

10.  Consolidation  later — fourth  to  sev- 
enth day :  there  may  be  none ;  apt  to  be 
incomplete ;  shades  off  gradually. 

11.  Resolution  slow,  one  week  to  two 
months ;  often  incomplete  :  strong  tend- 
ency to  become  chronic. 

13.  Relapses  and  second  attacks  fre- 
■quent. 

13.  Sequelie  :  Empyema,  chronic  inter- 
•stitial  pneumonia,  sometimes  tubercu- 
losis. 

14.  Prognosis  always  serious  from  the 
•age  and  the  circumstances  under  which 
disease  occurs. 

15.  Hospital  mortality  50  per  cent  of 
primary  cases,  05  per  cent  of  all  cases. 


LOBAR    PNEUMONIA. 

1.  Almost  always  primary. 

2.  Most    common   between    three   and 
eight  years. 

3.  More     often    in    those    previously 
healthy. 

4.  The   pneumococcus. 


5.  Chiefly  fibrin;  process  circumscribed. 

6.  Onset  sudden,  with  well-marked 
symptoms. 

7.  Typical  course;  crisis  usually  from 
fifth  to  eighth  day. 

8.  Usually  one  lobe  or  a  part  of  a  lobe ; 
left  base  most  frequently,  right  apex  next. 

9.  Rales  only  early,  and  during  reso- 
lution ;  frequently  no  signs  in  opposite 
lung. 

10.  Consolidation  earlier ;  second  or 
third  day.  Consolidation  complete;  area 
usually  sharply  defined. 

11.  Resolution  rapid,  usually  complete 
within  a  week. 

12.  Both  are  rare. 

13.  No  sequelae  except  empyema. 


14.  Prognosis  good ;  rarely  fatal  ex- 
cept from  complications — empyema,  men- 
ingitis, pericarditis. 

15.  Mortality  4  per  cent  of  all  cases. 


572  DISEASES   OF   THE   RESPIRATORY  SYSTEM. 

In  the  majority  of  cases  the  symptoms  are  plain  and  the  physical 
signs  so  typical  that  it  is  difficult  to  overlook  pneumonia  if  any  degree 
of  care  is  used  in  the  examination  of  the  patient.  The  characteristic 
features  are  the  sudden  onset,  with  vomiting,  convulsions,  or  chill ;  pros- 
tration ;  rapid  respiration,  with  the  expiratory  moan ;  a  temperature  of 
102°  to  105°  F. ;  cough  and  thoi'acic  pain  ;  and  the  physical  signs  of  a 
rapidly  developing,  circumscribed  consolidation  in  one  lobe  Or  a  portion  of 
a  lobe.  The  difficulties  in  diagnosis  are  due  to  the  great  variation  that  is 
seen  in  the  general  symptoms,  and  to  the  late  apjiearance  of  the  physical 
signs.  The  error  usually  made  is  to  mistake  pneumonia  for  some  other 
disease,  rather  than  to  mistake  some  other  disease  for  pneumonia.  On 
account  of  its  frequency  in  children,  pneumonia  should  always  be  ex- 
cluded before  accepting  any  other  explanation  of  a  continuously  high 
temperature.  It  is  surprising  to  find  how  often  obscure  and  indefinite 
symptoms  accompanied  by  high  fever,  are  due  to  pneumonia.  The  rule 
should  be  followed,  in  all  cases  of  acute  illness,  of  making  a  thorough 
examination  of  the  chest  daily  until  the  diagnosis  is  clear.  If  to  high 
temperature  rapid  respiration  is  added,  one  should  always  suspect  the 
lungs,  no  matter  what  the  other  symptoms  may  be.  It  not  infrequently 
happens  that  the  general  symptoms  are  quite  characteristic  and  yet  the 
physical  signs  appear  late.  In  such  cases  pneumonia  should  always  be 
looked  for  high  in  the  axilla  or  just  beneath  the  clavicle,  since  it  is  par- 
ticularly in  the  cases  of  apex  pneumonia  that  this  obscurity  is  likely  to 
exist.  If  frequent  and  thorough  examinations  of  the  chest  are  made,  very 
few  cases  will  be  overlooked. 

In  their  onset,  scarlet  fever, tonsillitis,  and  gastro-enteritis  may  all  re- 
semble pneumonia.  Scarlet  fever  is  recognised  by  the  sore  throat  and  the 
characteristic  eruption  on  the  second  day;  tonsillitis,  by  the  local  symp- 
toms. In  infancy,  pneumonia  often  begins  with  vomiting  and  sometimes 
there  is  also  diarrhoea,  which  may  lead  one  to  mistake  the  disease  for 
gastro-enteritis.  The  constitutional  symptoms  of  influenza  often  closely 
resemble  those  of  pneumonia ;  the  diagnosis  is  frequently  in  doubt  for  sev- 
eral days  until  definite  physical  signs  of  pneumonia  make  their  appear- 
ance. Malaria  is  distinguished  from  lobar  pneumonia  by  the  points  men- 
tioned in  the  diagnosis  of  broncho-pneumonia  (page  551).  From  all  other 
general  diseases,  pneumonia  is  to  be  differentiated  by  the  physical  signs. 

Pneumonia  with  marked  cerebral  symptoms  sometimes  resembles  cere- 
bro-spinal  meningitis.  In  both  we  may  have  the  abrupt  onset,  convul- 
sions, delirium  or  stupor,  opisthotonus,  and  prostration.  In  pneumonia 
the  temperature  is  usually  higher  than  in  meningitis  ;  the  pulse  is  never 
slow  and  intermittent ;  the  respiration  is  rapid,  instead  of  slow  and  irreg- 
ular; and  the  stupor  is  usually  less  profound;  and  there  are  no  localized 
paralyses.  In  meningitis  there  is  a  steady  increase  in  the  severity  of  the 
nervous  symptoms  for  the  first  three  or  four  days;  in  pneumonia  they 


LOBAR  PNEUMONIA.  573 

are  as  a  rule  most  marked  during  the  first  twenty-four  or  fortj'-eight 
hours,  and  then  gradually  diminish,  always  subsiding  completely  at  the 
crisis.  While  most  of  the  individual  symptoms  belonging  to  meningitis 
may  be  present,  they  are  usually  less  severe  and  less  persistent  in  pneu- 
monia. 

The  question  sometimes  arises,  in  a  case  of  pneumonia,  whether  the 
cerebral  symptoms  are  functional,  or  whether  meningitis  also  exists. 
If  the  nervous  symptoms  are  present  from  the  beginning,  there  is  prob- 
ably no  meningitis.  If  they  develop  suddenly  during  the  course  or  to- 
ward the  close  of  the  disease,  meningitis  should  be  suspected. 

Lobar  pneumonia  is  to  be  differentiated  from  a  pleuritic  effusion. 
The  most  common  mistake  which  I  have  seen  made  is  to  confound  em- 
pyema with  unresolved  pneumonia.  The  latter  is  very  infrequent,  so 
that  the  probabilities  are  always  strongly  in  favour  of  the  diagnosis  of 
empyema.  In  pneumonia  rarely,  if  ever,  is  the  whole  lung  affected. 
There  is  increased  local  fremitus,  dulness,  bronchial  voice  and  breath- 
ing, and  occasional  rales  of  friction  sounds.  In  empyema  the  whole  lung 
is  often  affected,  there  is  displacement  of  the  heart,  flatness  on  percus- 
sion, diminished  or  absent  vocal  fremitus,  and  although  bronchial  voice 
and  breathing  are  present,  they  are  usually  distant  and  feeble.  There 
are  no  rales  or  friction  sounds.  In  doubtful  cases  an  exploratory  punc- 
ture should  always  be  made.  Serous  effusions  give  the  same  physical 
signs  as  empyema,  but  are  relatively  rare. 

Prognosis. — There  is  probably  no  disease  in  which  the  patient  appears 
so  ill,  and  yet  so  often  recovers  completely,  as  in  lobar  pneumonia  in  a 
child  over  three  years  old.  Of  1,295  collected  cases,  chiefly  from  hos- 
pital practice,  there  were  but  39  deaths,  a  mortality  of  three  per  cent. 
In  187  cases  of  my  own  there  were  21  deaths,  a  mortality  of  eleven 
per  cent.  Only  one  of  the  fatal  cases  was  over  two  3^ears  old.  The  dif- 
ference between  the  mortality  among  my  cases  and  the  general  mortality 
given,  is  due  to  the  fact  that  a  large  proportion  of  the  first  group  were 
observed  in  children  under  two  years,  while  of  the  collected  cases  the 
vast  majority  were  in  older  children.  Combining  the  above  figures,  we 
have  a  total  of  1,482  cases  with  60  deaths,  a  mortality  of  four  per  cent. 
In  nearly  all  my  cases  death  was  due  either  to  complications  or  to  very 
extensive  disease,  as  when  both  lungs  were  involved,  or  nearly  the  whole 
of  one  lung.  In  only  one  case  was  an  uncomplicated  pneumonia  of  a 
single  lobe  fatal. 

The  prognosis  depends  upon  the  age  of  the  patient,  the  presence  or 
absence  of  complications,  and  the  extent  of  the  disease.  These  factors 
are  to  be  taken  into  consideration  rather  than  any  special  symptoms. 
Early  convulsions  do  not  materially  affect  the  prognosis.  Of  seven  such 
cases  only  one  was  fatal.  Late  convulsions  are  always  very  unfavourable, 
indicating  either  exhaustion,  toxaemia,  or  the  development  of  meningitis. 
38 


574  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

The  occurrence  of  vomiting  or  diarrhoea  late  in  the  disease  is  also  un- 
favourable,  especially  in  infants. 

A  temperature  range  between  102°  and  105°  F.  is  the  rule,  and  within 
these  limits  the  fever  does  not  aifect  the  prognosis.  Even  very  high 
temperature  does  not  increase  the  danger  from  the  disease  as  much  as 
would  be  expected.  Of  fifteen  cases  in  which  the  temperature  reached 
106°  F.  or  over,  all  but  three  recovered;  while  of  six  cases  in  which  it  was 
106-5°  or  over,  only  one  died.  The  highest  recorded  temperature  in 
my  cases — 107  -5°  F. — was  in  a  patient  who  recovered.  A  transient  rise, 
even  though  the  temperature  may  go  very  high^  is  not  often  serious. 
Much  more  serious  is  a  fever  which  remains  steadily  above  105°  F.,  as  in 
most  cases  this  accompanies  either  very  extensive  disease  or  pleuro- 
pneumonia. The  continuance  of  the  fever  after  the  tenth  day  is  a  bad 
symptom,  for,  although  the  crisis  may  be  postponed  until  the  twelfth 
day  and  occur  normally,  such  a  prolonged  temperature  is  apt  to  be  an 
indication  of  a  new  focus  of  disease  or  the  development  of  complications. 
In  a  severe  attack,  the  extension  of  the  disease  to  a  new  lobe  after  the 
fifth  day  is  always  unfavourable.  If  resolution  does  not  begin  soon 
after  the  temperature  becomes  normal  a  relapse  should  then  be  ap- 
prehended, or  the  development  of  empyema,  or  some  other  complica- 
tion. 

Treatment. — In  the  treatment  of  lobar  jmeumonia  in  children,  several 
cardinal  facts  are  to  be  kept  in  mind.  It  is  a  self-limited  disease,  having 
a  strong  tendency  to  recovery  in  the  great  majority  of  cases  regardless 
of  the  treatment  adopted.  The  fatal  cases  are  almost  always  in  children 
under  three  years  of  age ;  the  rare  deaths  in  older  ones  are  usually  due 
to  complications.  I  believe  that  there  is  no  means  of  treatment  by  which 
we  can  abort  pneumonia  or  shorten  its  course.  It  follows,  therefore,  that 
the  indications  are,  so  far  as  possible,  to  make  the  patient  comfortable 
during  his  illness,  to  prevent  complications,  and  to  treat  the  individual 
symptoms  as  they  arise. 

In  perhaps  the  majority  of  cases,  hygienic  treatment  is  all  that  is 
required.  The  patient  should  be  kept  in  bed,  no  matter  how  mild  the 
attack ;  he  should  be  lightly  covered,  disturbed  just  as  little  as  possible, 
and  allowed  plenty  of  fresh  air  in  the  room.  Food  should  be  given  at 
regular  intervals,  never  oftener  than  every  two  hours,  and  usually  only 
every  four  hours.  It  should  not  be  forced  when  the  patient  is  suffering 
only  from  thirst.  These  measures,  careful  nursing,  an  occasional  dose 
of  codeine  (gr.  ^Iq  to  a  child  of  three  years)  when  the  patient  is  very 
restless,  fretful,  or  sleepless,  and  cold  sponging  when  the  temperature 
makes  him  uncomfortable,  are  usually  all  that  is  necessar}',  except  to  keep 
a  sharp  lookout  for  complications. 

Special  symptoms  may  require  treatment.  When  not  severe,  the 
nervous  symptoms  may  be  controlled  by  codeine  alone  or  in  combination 


PLEURO-PNEUMONIA.  575 

with  phenacetine  or  bromides.  Sometimes  sponging  with  tepid  water  is 
better  than  drugs.  Severe  nervous  symptoms,  such  as  delirium,  stupor, 
great  restlessness  with  impending  convulsions,  when  associated  with 
high  temperature,  call  for  ice  to  the  head,  cold  sponging,  or  the  cold 
pack  or  bath.  Pain,  if  moderate,  may  be  relieved  by  counter-irritation 
by  a  mustard  paste  or  by  a  hot  poultice;  if  severe,  morphine  should 
be  used  in  addition.  The  cough  is  rarely  severe  enough  to  require  treat- 
ment. When  it  is  so  severe  as  to  prevent  sleep,  small  doses  of  Dover's 
powder  or  codeine  should  be  given.  Antipyretic  measures  are  not  neces- 
sarily called  for  even  if  the  temperature  is  very  high.  Some  nervous  chil- 
dren are  less  disturbed  by  the  temperature  than  by  the  means  used  to 
reduce  it.  Under  such  conditions  the  temperature  should  be  closely 
watched,  but  not  necessarily  interfered  with  unless  other  symptoms  de- 
velop. The  nervous  symptoms  are  a  better  guide  than  the  thermometer 
to  the  use  of  antipyretics.  Cold  I  believe  to  be  for  most  cases  the  safest 
and  most  certain  antipyretic  we  possess.  It  may  be  used  as  a  cold 
sponge  bath  or  the  cold  pack  (pages  47,  48).  There  is  no  objection  to 
the  bath  except  the  prejudice  of  the  laity.  While  cold  is  applied  to  the 
trunk  the  extremities  should  be  closely  watched,  and  heat  applied  if 
necessary.  The  duration  of  the  pack  or  bath,  and  the  frequency  of  their 
use,  will  depend  upon  the  individual  case.  In  the  majority  of  cases 
stimulants  are  not  required.  They  are  called  for  when  the  pulse  is 
weak,  compressible,  and  rapid,  when  the  face  is  pale  and  the  extrem- 
ities are  cold.  The  same  stimulants  are  to  be  employed,  and  in  the 
same  way,  as  in  broncho-pneumonia  (page  554),  Cardiac  stimulants 
are  usually  required  in  larger  quantity  at  the  time  of  and  just  after 
the  crisis.  Eespiratory  stimulants  are  indicated  as  in  broncho-pneu- 
monia. 

Pleuro-pneumonia. — Under  this  term  are  included  cases  of  pneu- 
monia with  an  excessive  amount  of  pleurisy,  the  two  processes  uniting 
to  produce  a  single  clinical  type  of  disease. 

In  nearly  all  cases  of  lobar  pneumonia  there  is  a  certain  amount  of 
inflammation  of  the  pulmonary  pleura,  and  also  in  those  cases  of  bron- 
cho-pneumonia which  are  accompanied  by  any  marked  degree  of  con- 
solidation. In  both  of  these  the  pleurisy  is  usually  coextensive  with  the 
consolidation.  But  in  certain  cases,  in  both  forms  of  pneumonia,  the 
amount  of  pleurisy  is  excessive,  and  this  so  modifies  the  symptoms  and 
course  of  the  disease  as  to  require  for  them  a  separate  considera- 
tion. In  some  it  appears  that  the  inflammatory  process  begins  almost 
simultaneously  in  the  lung  and  in  the  pleura;  while  in  others  the 
pleurisy  follows  the  pneumonia.  These  cases  are,  I  believe,  almost  in- 
variably due  to  the  pneumococcus,  although  in  some  there  is  a  mixed 
infection. 

In  398  hospital  cases  of  pneumonia  lliere  were  27,  or  6  -8  per  cent, 


576  DISEASES  OP   THE   RESPIRATORY  SYSTEM. 

which  could  be  classed  as  pleuro-pneumonia,  the  diagnosis  being  con- 
firmed either  by  autopsy  or  operation.  Of  190  fatal  cases,  12-5  per  cent 
were  pleuro-pneumonia.  Most  of  these  hospital  patients  were  under  three 
years  of  age,  and  the  disease  is,  I  think,  more  frequent  at  this  period  than 
in  older  children. 

Lesions. — Of  these  37  cases,  17  were  classed  as  broncho-pneumonia  and 
10  as  lobar  pneumonia.  The  left  lung  was  more  frequently  affected  than 
the  right  in  the  proportion  of  three  to  two.  In  most  of  the  cases  the 
pleura  covering  the  entire  lung  was  involved,  even  though  the  pneumonia 
affected  but  a  single  lobe,  or  only  a  part  of  a  lobe.  In  nearly  half  the  cases 
both  lungs  were  involved,  but  one  to  a  very  much  less  extent  than  the 
other.  In  a  small  number  of  cases  the  pleurisy  was  limited  to  the  pos- 
terior surface  of  the  lung,  stopping  at  the  axillary  line. 

In  pleuro-pneumonia  both  the  visceral  and  the  parietal  pleura  are 
coated  with  a  layer  of  yellowish-green  fibrin,  in  thick,  shaggy  masses,  by 
which  the  lung  is  adherent  to  the  chest  wall,  the  diaphragm,  and  the 
pericardium  (Plate  XIV).  The  exudation  varies  between  one  eighth 
and  one  half  an  inch  in  thickness.  It  can  often  be  stripped  from  the 
lung  or  scraped  from  the  chest  wall  by  the  handful.  In  its  meshes  small 
pockets  may  form,  which  contain  only  a  few  drops,  or  sometimes  a 
drachm  of  pus,  or  less  frequently  serum.  This  is  the  condition  in  which 
the  lung  is  usually  found  where  death  has  occurred  at  the  height  of  the 
disease.  If  the  process  has  lasted  longer,  larger  collections  of  pus  may  be 
present.  The  lung  itself  shows  the  usual  changes  of  pneumonia,  and  if 
there  has  been  any  considerable  accumulation  of  fluid,  there  are  in  addi- 
tion the  evidences  of  compression. 

With  pleuro-pneumonia  of  the  left  side,  the  pericardium  is  occa- 
sionally involved.  This  was  seen  in  two  of  my  cases,  the  lesions  closely 
resembling  those  of  the  pleura.  In  two  cases  there  was  also  meningitis, 
and  in  one  peritonitis,  the  exudation  in  all  cases  having  the  same  charac- 
teristics. 

An  inflammation  of  the  intensity  described  is  very  often  fatal  in  the 
acute  stage,  if  the  patient  is  a  child  under  two  years  old.  Occasionally 
at  this  age,  and  very  frequently  in  older  children,  we  see  the  later  stages 
of  the  process.  The  most  frequent  course  is  for  more  and  more  pus  to  be 
poured  out  from  the  inflamed  pleura  until  the  chest  is  filled,  the  case 
becoming  thus  one  of  empyema.  Sometimes  the  fluid  is  serous  instead  of 
purulent,  but  this  is  very  rare  in  infancy.  Under  other  circumstances  the 
exudation  is  partly  absorbed,  but  the  greater  part  becomes  organized  so  as 
to  form  a  thick  jacket  of  fibrous  tissue  which  binds  the  lobe  or  lung  to 
the  chest  wall,  and  interferes  seriously  with  its  subsequent  full  expansion. 
Chronic  interstitial  pneumonia  may  follow. 

Symptoms. — There  is  little  which  distinguishes  a  case  of  pleuro-pneu- 
monia except  the  severity  of  all  the  constitutional  symptoms ;  the  tem- 


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PLEURO-PNEUMONIA.  577 

perature  is  often  higher,  the  prostration  greater,  and  the  patient  in  every 
way  impresses  one  as  being  more  seriously  ill  than  with  ordinary  pneu- 
monia. Sometimes  the  thoracic  pain  is  more  severe  and  more  constant 
than  is  usual  in  pneumonia.  The  diagnosis,  however,  is  to  be  made  by 
the  physical  signs. 

In  the  early  stage  the  pleuritic  friction  sounds  are  unusually  promi- 
nent ;  after  two  or  three  days  the  signs  of  consolidation  come  out  clearly 
in  most  cases,  but  still  accompanied  by  loud  friction  sounds.  After  the 
fibrinous  exudation  is  very  abundant,  the  signs  are  often  obscure  and  con- 
fusing, and  there  may  be  at  no  time  well-defined  signs  of  consolidation. 
There  is  usually  a  mingling  of  the  signs  of  consolidation  with  those  of 
effusion.  There  is  marked  dulness,  and  sometimes  flatness.  The  vocal 
fremitus  is  apt  to  be  diminished,  and  it  may  be  absent.  Bronchial  voice 
and  breathing  are  heard,  but  they  are  not  distinct  as  in  consolidation ; 
they  are,  however,  feeble  and  distant,  as  over  fluid.  There  are  usually 
coarse,  moist,  crackling  pleuritic  sounds,  but  these  may  be  absent.  The 
signs  may  be  found  over  one  entire  lung,  or  they  may  be  limited  to 
the  posterior  region,  and  even  to  a  single  lobe.  They  resemble  those 
present  over  fluid,  with  one  exception — viz.,  the  heart  is  not  displaced. 
If  an  exploratory  puncture  is  made,  nothing  is  found ;  occasionally  the 
exploring  needle  happens  to  strike  one  of  the  small  pockets  of  pus 
in  the  meshes  of  the  fibrin,  and  a  few  drops  of  clear  pus  are  withdrawn. 
If  an  incision  is  made  under  the  supposition  that  the  case  is  one  of  em- 
pyema, no  more  pus  may  be  found,  the  surgeon  coming  upon  the  pul- 
monary adhesions  as  soon  as  the  chest  is  opened.  There  is  scarcely  any 
condition  in  the  chest  giving  signs  more  puzzling  than  those  just  enu- 
merated. They  are,  however,  easily  explained  by  the  pathological  con- 
ditions present. 

Prognosis. — The  prognosis  in  pleuro-pneumonia  is  much  worse  than 
in  simple  pneumonia.  In  infants  the  outlook  is  very  bad,  the  majority  of 
cases  dying  during  the  acute  stage,  usually  in  the  second  week.  Very 
young  children  may  be  overwhelmed  with  the  extent  and  the  intensity  of 
the  inflammation,  and  die  in  four  or  five  days.  In  children  over  two  years 
old  the  most  frequent  result  is  for  the  case  to  go  on  to  empyema,  which 
with  proper  treatment  usually  terminates  in  recovery.  Where  there  is 
organization  of  the  fibrin  with  the  production  of  extensive  adhesions,  the 
ultimate  result  is  often  not  so  favourable  as  when  empyema  develops. 
Convalescence  is  usually  slow,  and  the  patients  are  liable  to  exacerbations  of 
pleurisy;  they  may  suffer  for  years  from  the  partial  cripjiling  of  one  lung. 

Diagnosis. — This  is  to  be  made  only  by  the  physical  signs.  A  differ- 
ential diagnosis  from  fluid  in  the  chest  can  in  some  cases  be  made  only 
by  an  exploratory  puncture. 

Treatment. — Cases  of  pleuro-pneumonia  require  no  special  treatment. 
In  general  they  are  to  be  managed  like  the  ordinary  cases  of  pneumonia 


578  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

of  the  severe  type.  In  some,  the  excessive  pain  may  call  for  more  active 
counter-irritation  and  a  freer  use  of  opium  than  in  other  forms  of  pneu- 
monia, and  the  greater  prostration  may  require  that  stimulants  be  given 
earlier  and  in  larger  quantities. 

HYPOSTATIC  PNEUMONIA. 

This  can  not  often  be  recognised  clinically,  but  it  is  very  frequently 
seen  upon  the  post-mortem  table.  It  is  present  in  some  degree  in  al- 
most every  case  where  an  infant  has  died  of  chronic  disease.  It  is  par- 
ticularly frequent  in  those  who  have  died  of  marasmus.  It  is  sometimes 
described  as  "  strip  pneumonia,"  on  account  of  its  position.  It  invari- 
ably occupies  a  strip  along  the  posterior  border  of  both  lungs,  and  usu- 
ally of  both  the  uper  and  lower  lobes.  This  is  from  one  to  two  inches 
wide,  of  a  uniform  dark-red  colour,  and  is  sharply  outlined.  The  pleura 
is  not  involved,  and  the  remainder  of  the  lung  may  be  normal,  congested, 
or  slightly  emphysematous.  On  section,  it  is  seen  that  the  pneumonic 
area  is  quite  superficial,  rarely  involving  the  lung  to  a  greater  depth 
than  half  an  inch.  Under  the  microscope  there  is  found  a  distention  of 
the  small  blood-vessels  in  the  affected  area,  and  the  air  vesicles  are  filled 
with  many  red  blood  cells,  epithelial  cells,  and  a  few  leucocytes.  Be- 
tween the  areas  of  consolidation  are  groups  of  air  vesicles  which  are 
normal,  congested,  or  collapsed.  It  is  a  lobular  rather  than  a  broncho- 
pneumonia. The  lesions  in  this  form  of  pneumonia  are  probably  the 
result  of  venous  stasis,  owing  to  the  child's  recumbent  position. 

At  autopsy  the  condition  may  be  confounded  with  atelectasis ;  this, 
however,  is  almost  invariably  more  marked  in  the  interior  of  the  lung, 
while  pneumonia  is  always  more  marked  upon  the  surface.  The  two  con- 
ditions are  sometimes  associated.  Little  significance  is  to  be  attached 
to  the  finding  of  hypostatic  pneumonia  at  autopsy,  and  it  alone  should 
never  be  regarded  as  a  sufficient  cause  of  death,  although  it  is  perhaps 
the  only  lesion  present.  During  life  it  may  give  rise  to  fine  moist  rales, 
which  are  heard  along  the  spine,  usually  upon  both  sides;  but  there  is 
neither  dulness  nor  bronchial  breathing. 

The  treatment  is  that  of  the  primary  disease. 

CHRONIC  BRONCHO-PNEUMONIA— CHRONIC  INTERSTITIAL 
PNEUMONIA— BRONCHIECTASIS. 

Chronic  broncho-pneumonia  is  an  inflammation  of  the  connective- 
tissue  framework  of  the  lung,  involving  the  stroma,  the  alveolar  septa, 
the  walls  of  the  bronchi,  and  the  pleura.  It  is  usually  accompanied  by 
cylindrical  dilatation  of  the  bronchi — bronchiectasis. 

Etiology. — In  children,  as  in  adults,  this  process  is  most  frequently 
associated  with  pulmonary  tuberculosis ;  but  in  early  life  it  is  not  an  in- 


PLATE    XV. 


-    B 


Chroxic  Broncho-Pneumoxia. 

In  the  greater  part  of  the  specimen  the  disease  is  limited  to  the  vicinity  of  the 
small  bronchi,  A  A  A,  each  of  which  is  surrounded  by  a  zone  of  new  connective 
tissue,  the  result  of  the  inflammatory  process,  the  intervening  lung  tissue,  B  B,  being 
normal.  In  the  lower  left-hand  portion,  the  disease  is  more  diffuse:  the  air  vesicles, 
C,  between  the  areas  of  new  connective  tissue  are  greatly  compressed,  and  in  some 
places  entirely  obliterated.  (After  Delafield.) 


CHRONIC  BRONCHO-PNEUMONIA.  579 

frequent  condition  apart  from  tuberculosis.  The  non-tuberculous  cases, 
as  a  rule,  are  preceded  by  an  attack  of  acute  broncho-pneumonia,  some- 
times by  several  such  attacks,  separated  by  longer  or  shorter  intervals. 

Lesions. — The  part  of  the  lung  affected  may  be  an  entire  lobe,  but 
usually  it  is  a  portion  of  one  lobe,  or  there  are  areas  in  more  than  one 
lobe.  There  are  dense  connective-tissue  adhesions  binding  the  diseased 
part  to  the  chest  wall,  to  the  diaphragm  and  to  the  pericardium,  often 
so  firmly  that  the  lung  is  torn  on  removal.  The  affected  lung  is  smaller 
than  in  health;  it  is  hard,  tough,  and  fibrous.  Surrounding  the  fibrous 
portions  are  emphysematous  areas.  On  section,  the  process  is  seen  to 
be  somewhat  irregularly  distributed  through  the  lung,  the  lesion  being 
usually  most  marked  in  the  vicinity  of  the  smaller  bronchi,  and  some- 
times seen  only  there,  the  intervening  lung  being  nearly  normal  (Plate 
XV).  In  some  portions,  where  the  process  is  most  advanced,  almost 
all  trace  of  lung  tissue  has  disappeared,  the  part  resembling  a  solid 
fibrous  tumour,  through  which  run  the  bronchial  tubes,  usually  much 
dilated.  In  places  this  dilatation  may  be  sufficient  to  form  cavities  of 
considerable  size.  The  bronchial  glands  are  often  enlarged  to  the  size 
of  a  hazelnut,  and  they  may  be  tuberculous. 

Upon  examination  with  the  microscope,  the  pleura  is  found  greatly 
thickened,  with  bands  of  new  fibrous  tissue  passing  from  it  into  the  lung. 
The  walls  of  the  small  bronchi  are  in  most  places  thicker  than  normal, 
but  elsewhere  they  have  undergone  cylindrical  dilatation,  and  are  filled 
with  pus.  The  walls  of  the  alveoli  show  a  marked  proliferation  of  the 
connective-tissue  elements,  and  the  alveoli  are  filled  with  organized  in- 
flammatory products,  so  that  they  are  nearly  or  quite  obliterated.  The 
stroma  is  much  increased  in  amount  throughout  the  affected  lung. 

Symptoms. — In  most  of  the  cases  there  is  a  history  of  an  attack  of 
acute  broncho-pneumonia,  from  which  the  child  made  a  slow  convales- 
cence, remaining  pale,  anaemic,  and  sometimes  wasted  for  several  months. 
Improvement  then  took  place  in  the  general  sj'mptoms,  the  appetite  and 
strength  returned,  and  in  many  cases,  the  lost  weight  was  nearly  or  quite 
regained.  However,  neither  the  pulmonary  symptoms  nor  the  physical 
signs  entirely  disappeared.  There  remained  a  dry,  hard  cough,  which  at 
times  was  severe.  Pains  in  the  chest  were  occasionally  complained  of, 
and  perhaps  shortness  of  breath  on  exertion  was  noticed. 

Examination  shows  a  persistence  of  the  dulness  on  percussion,  with 
a  rude  or  broncho-vesicular  respiratory  murmur  of  very  feeble  intensity. 
Little  change  may  take  place  in  these  signs  for  months;  then  an  acute 
attack  of  bronchitis  or  broncho-pneumonia  may  occur.  If  the  latter,  the 
same  lung  is  affected,  and  a  fresh  consolidation  is  added  to  the  previous 
disease.  This  attack  may  not  be  very  severe,  but  it  drags  on  for  several 
weeks,  with  slight  fever  and  little  or  no  change  in  the  physical  signs. 
Partial  resolution  may  then  take  place,  but  the  lung  is  left  much  more 


580  DISEASES  OF  THE  RESPIiiATORY  SYSTEM. 

seriousl}"  crippled  than  before.  In  many  cases  there  is  a  history  of 
several  such  attacks^,  each  one  leaving  the  lung  a  little  worse  than  it 
found  it. 

The  characteristic  physical  signs  of  chronic  broncho-pneumonia  are 
not  usually  present  until  the  process  has  continued  for  many  months, 
sometimes  for  several  years.  They  may  be  over  part  of  a  lobe,  or  over  an 
entire  lobe,  or  even  the  greater  part  of  one  lung.  On  inspection,  there 
is  seen  in  a  well-marked  case,  a  retraction  of  the  chest,  which  is  espe- 
cially noticeable  when  the  disease  is  situated  at  the  apex  of  the  lung. 
The  vocal  fremitus  is  usually  increased,  but  it  may  not  be  abnormal. 
There  is  marked  dulness,  often  flatness,  over  the  affected  area,  with 
exaggerated  resonance  over  the  rest  of  the  lung.  The  area  of  flat- 
ness is  not  sharply  circumscribed,  but  shades  off  gradually.  The  most 
striking  thing  on  auscultation  is  the  very  feeble  res^Diratory  murmur;  in 
many  cases  the  lung  is  almost  silent.  In  other  cases  the  respiration  is 
distinctly  bronchial  in  character,  and,  if  marked  bronchiectasis  exists, 
it  may  be  cavernous.  Eales  and  friction  sounds  are  usually  absent  ex- 
cept during  an  acute  exacerbation  of  the  symptoms,  when  they  may  be 
heard  as  in  any  attack  of  broncho-pneumonia.  There  is  no  displace- 
ment of  the  heart. 

The  course  of  these  cases  is  always  uncertain.  When  once  present 
the  lesions  are  permanent,  and  there  is  always  a  tendency  to  increase 
rapidly  or  slowly,  according  to  the  child's  vigour  of  constitution,  its  sur- 
roundings, and,  most  of  all,  the  frequency  with  which  exacerbations  occur. 
If  the  disease  is  extensive  the  general  health  is  so  undermined  that  the  pa- 
tient succumbs  either  to  some  intercurrent  disease  or  to  an  acute  attack 
of  pneumonia;  if  limited  in  area,  the  process  may  be  arrested  and  the 
patient  recover,  always,  however,  to  be  more  or  less  embarrassed  because 
of  the  crippling  of  a  part  of  one  lung.  Not  a  small  number  of  these  chil- 
dren ultimately  die  of  tuberculosis,  and  in  such  cases  it  is  always  a  diffi- 
cult matter  to  decide  whether  tuberculosis  was  present  from  the  begin- 
ing,  or  whether  there  was  subsequent  infection.  The  classical  symptoms 
which  are  presented  by  adults  with  bronchiectasis  are  rarely  seen  in 
young  children. 

Prognosis. — From  what  has  already  been  said,  it  will  be  evident  that 
the  prognosis  in  these  cases  is  always  doubtful  as  to  the  ultimate  result. 
It  depends  on  the  extent  of  the  disease,  the  patient's  age  and  constitu- 
tion, and  on  our  ability  to  prevent  by  treatment,  climatic  and  otherwise, 
the  occurrence  of  acute  exacerbations.  Under  the  most  favourable  con- 
ditions, a  few  patients  may  recover  completely  so  far  as  symptoms  are 
concerned;  but  the  majority  at  best  remain  delicate  during  childhood,  or 
even  throughout  life. 

Diagnosis. — The  most  important  thing  is  to  distinguish  between  the 
simple  and  the  tuberculous  cases,  and  this,  it  must  be  confessed,  is  in  the 


GANGRENE   OF   THE   LUNG.  581 

majority  impossible.  I  have  repeatedly  seen  a  process  proved  at  autopsy 
to  be  simple,  which  all  who  had  observed  the  case  had  unhesitatingly  pro- 
nounced to  be  tuberculous,  and  quite  as  often  the  opposite  has  been  true. 
If  the  family  history  is  good,  if  the  patient  lives  in  the  country,  if  his 
symptoms  begin  with  a  well-defined  acute  attack  of  pneumonia,  if  the 
seat  of  disease  is  the  base  of  one  lung,  and  if  the  examination  of  the 
sputum  is  negative,  the  process  is  probably  simple.  If  the  family  history 
is  doubtful  or  is  positively  tuberculous,  if  the  patient  lives  in  the  city,  and 
especially  if  he  is  an  inmate  of  an  institution  or  if  his  home  is  among 
the  tenements,  if  the  initial  symptoms  are  indefinite,  if  the  seat  of  dis- 
ease is  the  axilla,  the  mammary  region,  or  the  apex  in  front,  the  process 
is  probably  tuberculous.  The  discovery  of  tubercle  bacilli  in  the  sputum 
is,  of  course,  conclusive.  Even  the  course  of  the  disease  may  not  settle 
the  diagnosis,  unless  there  develop  in  the  bones  or  in  other  viscera,  lesions 
undoubtedly  tuberculous. 

Treatment. — Nothing  has  any  essential  influence  upon  the  disease 
except  change  of  climate.  This  should  be  the  same  as  for  tuberculous 
cases.  The  treatment  of  the  patient  has  for  its  object  the  maintenance 
of  the  general  nutrition  at  its  highest  point,  by  careful  feeding,  judicious 
exercise,  and  by  most  of  the  measures  enumerated  in  the  chapter  on  Mal- 
nutrition. Cod-liver  oil  should  be  given  throughout  every  winter  season. 
The  cough  may  be  treated  as  in  cases  of  chronic  bronchitis. 

GANGRENE   OF   THE    LUNG. 

Pulmonary  gangrene  is  quite  rare  in  children,  although  it  is  probably 
more  common  than  in  adults.  It  is  most  frequently  associated  with 
pneumonia.  It  is  usually  circumscribed,  and  in  the  majority  of  cases  it  is 
latent. 

Etiology. — Children  of  all  ages  may  be  affected  ;  all  of  my  own  cases 
have  been  under  three  years  old,  the  youngest  being  an  infant  of  four 
months.  It  occurs  for  the  most  part  in  children  who  are  ill-conditioned, 
feeble,  or  cachectic,  and  often  follows  one  of  the  infectious  diseases,  par- 
ticularly measles.  In  such  cases  it  may  be  associated  with  gangrene  of  the 
mouth  or  of  the  vulva.  It  is  seen  in  general  pyasmia,  and  has  followed 
caries  of  the  petrous  bone.  Of  the  local  causes,  altogether  the  most  fre- 
quent is  broncho-pneumonia.  Of  nine  cases  which  have  come  under 
my  personal  observation,  six  complicated  acute  broncho-pneumonia  and 
one  lobar  pneumonia.  It  has  been  present  in  three  per  cent  of  my  autop- 
sies upon  cases  of  pneumonia.  It  may  accompany  pulmonary  tubercu- 
losis, bronchiectasis,  and  pulmonary  apoplexy,  or  it  may  be  due  to  a  for- 
eign body  in  one  of  the  bronchi.  The  immediate  cause  of  the  necrotic 
process  is  interference  with  the  circulation  in  a  part  of  the  lung,  which 
is  usually  due  to  thrombosis  or  embolism  of  some  of  tlie  brandies  of  the 
pulmonary  artery.     To  this  there  is  added  the  entrance  of  putrefactive 


582  DISEASES   OP   THE   RESPIRATORY   SYSTEM. 

bacteria.  In  some  cases  the  jDrocess  may  begin  as  a  septic  thrombosis,  this 
infection  originating  in  some  process  in  a  distant  part  of  the  body. 

Lesions. — According  to  general  experience,  the  lower  lobes  are  more 
frequently  affected  than  the  upper,  and  this  is  borne  out  by  my  own  cases. 
The  surface  of  the  lung,  rather  than  the  central  portions,  are  most  often 
involved. 

Two  forms  of  gangrene  may  be  seen  :  the  diffuse  form,  which  affects  a 
whole  lobe,  or  even  a  whole  lung ;  and  the  circumscribed  form,  which 
occurs  in '  a  number  of  small  scattered  areas,  usually  from  half  an  inch  to 
two  inches  in  diameter.  The  latter  is  the  variety  usually  seen  in  children. 
In  the  diffuse  form  the  lung  is  of  a  dirty  green  or  brown  colour,  moist, 
and  emits  a  gangrenous  odour.  In  the  circumscribed  form,  when  occur- 
ring in  pneumonia,  the  parts  affected  are  of  a  gray  or  green  colour,  usually 
wedge-shaped,  with  the  base  at  the  surface  of  the  lung.  In  the  early  stage 
they  are  not  softened,  and  have  no  gangrenous  odour ;  later,  both  these 
conditions  may  be  present,  and  masses  of  necrotic  lung  tissue  may  be 
found  in  a  cavity  with  ragged  walls,  partly  filled  with  fetid  pus.  Careful 
dissection  will  reveal,  in  many  cases,  the  presence  of  thrombi  in  the  ves- 
sels leading  to  the  gangrenous  parts.  The  later  stages  of  the  process  are 
very  rarely  seen.  However,  in  some  cases  the  gangrenous  masses  may  be 
coughed  up  and  the  cavity  closed  by  cicatrization.  This  is  more  likely  to 
happen  where  there  is  but  one  area,  as  when  the  process  is  due  to  the 
presence  of  a  foreign  body.  Sometimes  rupture  into  the  pleura  takes 
place,  and  empyema  or  pneumothorax  follows. 

Two  unique  cases  of  necrosis  of  the  lung  have  come  to  my  notice ; 
they  were  in  all  respects  similar.  The  surface  of  the  lung  was  of  a  uni- 
form dark  reddish-brown,  and  seemed  to  be  slightly  softened.  On  section, 
a  large  part  of  the  lower  lobe  was  of  a  dark-red  colour  and  of  a  semifluid 
consistency,  the  pulmonary  tissue  being  so  completely  disintegrated  that  it 
could  be  washed  away  with  a  stream  of  water.  There  was  no  gangrenous 
odour.  No  thrombosis  was  found  in  these  cases,  and  no  explanation  of 
their  origin  was  discovered  even  by  microscopical  examination.  There  was 
some  broncho-pneumonia  present.  Both  cases  occuried  in  infants  suf- 
ering  from  marasmus.  These  are  perhaps  to  be  classed,  as  examples  of 
diffuse  gangrene,  although  they  differed  very  markedly  from  the  form 
usually  seen. 

Symptoms. — There  are  but  two  distinctive  symptoms  of  pulmonary 
gangrene  :  the  gangrenous  odour  of  the  breath,  and  the  expectoration  of 
masses  of  necrotic  lung  tissue.  In  the  cases  associated  with  acute  pneu- 
monia, which  include  the  majority  of  those  seen,  death  nearly  always 
takes  place  before  there  is  any  separation  of  the  sloughs,  and  even  before 
very  active  decomposition  in  the  necrotic  areas  has  occurred.  Both  the 
peculiar  symptoms  are  therefore  wanting,  and  the  diagnosis  is  made  only 
at  the  autopsy.     This  has  been  true  of  all  the  cases  which  have  come 


PULMONARY   COLLAPSE.  583 

under  my  own  observation.  But  these  patients,  with  one  exception,  were 
infants.  In  older  children,  particularly  in  cases  secondary  to  the  en- 
trance of  a  foreign  body,  the  characteristic  symptoms  are  more  fre- 
quently seen,  and  there  may  be  a  third  symptom — lijemorrhage.  This 
is  present  in  about  one  fourth  of  the  cases  (Rilliet  and  Barthez),  and 
may  be  fatal.  The  general  symptoms  associated  with  gangrene  are  those 
of  profound  depression,  and  often  all  the  signs  of  the  typhoid  condition 
are  present. 

From  what  has  already  been  said,  it  will  be  evident  that  the  diagnosis 
is  very  difficult  in  children,  and  that  most  cases  of  gangrene  of  the  lung 
are  overlooked.  When  the  characteristic  odour  of  the  breath  is  present, 
conditions  in  the  mouth  from  which  it  might  arise  must  first  be  ex- 
cluded. The  physical  signs  differ  in  no  respect  from  those  of  ordinary 
cases  of  pneumonia.  The  termination  is  almost  always  in  death.  This 
is  due  not  only  to  the  condition  itself,  but  to  the  circumstances  in  which 
it  is  seen. 

Treatment. — The  general  treatment  is  supporting  and  stimulating,  as 
in  all  very  severe  cases  of  pneumonia.  For  the  local  process  but  little  can 
be  done,  except  the  inhalation  of  antiseptics,  of  which  creosote  and  tur- 
pentine are  undoubtedly  the  best. 

ACQUIRED   ATELECTASIS— PULMONARY   COLLAPSE. 

These  terms  are  applied  to  a  state  of  the  lung  resembling  the  foetal 
condition,  but  which  occurs  in  a  lung  which  has  once  been  expanded. 
Two  varieties  are  met  with  :  collapse  from  compression  and  collapse  from 
obstruction. 

Collapse  from  Compression. — The  principal  cause  of  this  form  is  pleu- 
ritic effusion.  It  may  also  be  produced  by  pneumothorax,  enlargement 
of  the  heart,  pericardial  effusion,  deformities  of  the  chest  from  rickets 
or  Pott's  disease,  and  tumours  of  the  mediastinum  or  thoracic  wall.  In 
these  conditions,  on  account  of  the  external  pressure,  the  air  vesicles  are 
not  filled,  although  the  bronchi  are  pervious.  The  elasticity  of  the  vesi- 
cles tends  to  expel  the  air  which  they  contain.  This  form  of  collapse 
may  be  complete  or  partial,  according  to  the  cause.  After  it  has  existed 
for  a  considerable  time,  changes  may  take  place  in  the  lung  which  ren- 
der expansion  difficult  or  impossible.  Unless,  however,  there  are  thick 
pleuritic  adhesions,  expansion  often  takes  place  readily  after  many  weeks 
and  even  months,  as  in  most  cases  it  is  the  condition  of  the  pleura,  rather 
than  of  the  lung  itself,  which  interferes  with  it.  In  recent  cases  only 
moderate  force  is  required  at  autopsy  to  produce  expansion  ;  in  old  cases 
it  is  more  difficult  and  may  be  impossible.  The  symptoms  and  signs  are 
those  of  the  original  disease. 

Treatment  is  available  chiefly  in  that  form  which  follows  pleuritic 
effusion,  and  will  be  considered  in  the  chapter  on  Empyema. 


584  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Collapse  from  Obstruction. — This  is  due  to  two  factors  :  blocking  of 
either  the  large  or  small  bronchial  tubes,  and  feeble  insjDiratory  force. 
The  importance  of  collapse  from  obstruction  as  a  factor  in  the  acute  dis- 
eases of  the  lung  in  infancy  has,  I  think,  been  very  much  exaggerated. 
It  is  well  known  that  whenever  a  large  or  small  bronchus  is  completely 
obstructed  by  a  foreign  body  so  that  the  entrance  of  air  is  prevented,  the 
portion  of  the  lung  to  which  the  bronchus  is  distributed  gradually  becomes 
collapsed.  If  it  is  one  of  the  primary  bronchi  which  is  occluded,  a  whole 
lung  may  be  collapsed ;  if  one  of  the  lobar  divisions,  an  entire  lobe ;  if 
one  of  the  smaller  divisions,  a  small  area,  usually  somewhat  wedge-shaped. 
The  collapse  does  not  take  place  immediately,  but  the  contents  of  the  air 
vesicles  are  gradually  absorbed  by  the  blood,  requiring  perhaps  twenty- 
four  hours,  or  even  longer.  According  to  Lichtheim,  the  oxygen  is  first 
absorbed,  then  the  carbon  dioxide,  and  finally  the  nitrogen.  The  collapsed 
portion  of  the  lung  is  smaller  than  the  inflated  portions,  and  consequently 
is  slightly  depressed  below  the  surface.  It  is  of  a  dark-red  colour,  very 
vascular,  and  to  the  naked  eye  resembles  a  pneumonic  area,  which  it 
may  subsequently  become. 

It  has  been  the  fashion  since  the  writings  of  Gairdner  to  explain 
the  development  of  broncho-pneumonia  from  bronchitis  of  the  smaller 
tubes,  through  the  intervention  of  pulmonary  collapse.  It  has  been 
assumed  that  the  obstruction  of  the  small  bronchi  from  swelling  of 
their  walls  and  the  accumulation  of  secretion,  produced  the  same  re- 
sult as  the  plugging  of  a  bronchus  by  a  foreign  body.  Without  going 
into  a  full  discussion  of  the  subject,  I  will  only  say  that  from  personal 
observations  upon  nearly  one  thousand  autopsies  upon  infants,  in  which 
are  included  a  very  large  number  of  the  acute  pulmonary  diseases  of 
all  varieties,  I  have  found  very  little  support  for  this  theory.  In  acute 
bronchitis  of  the  smaller  tubes  the  lumen  is  narrowed,  but  not  often 
to  such  a  degree  as  entirely  to  prevent  the  entrance  of  air.  This  con- 
dition of  stenosis  results,  as  a  rule,  in  the  production  of  emphysema, 
not  atelectasis.  Such,  at  least,  has  been  the  condition  in  the  cases 
in  which  I  have  had  an  opportunity  to  make  autopsies  in  the  ear- 
liest stage  of  broncho-pneumonia,  when  it  has  developed  from  a  gener- 
alized bronchitis  of  the  fine  tubes.  It  is  certainly  true  that  there  are 
very  often  groups  of  collapsed  air  vesicles  found  surrounding  those  which 
are  the  seat  of  pneumonia,  but  these  are  neither  an  essential  nor  a  very 
important  part  of  the  lesion.  Anything  approaching  collapse  of  a 
large  part  of  the  lung,  or  even  of  a  lobe,  I  have  never  seen,  either  in 
pertussis  or  in  acute  bronchitis,  nor  do  I  believe  that  it  occurs  in  the 
way  mentioned. 

There  is  occasionally  seen,  usually  in  very  delicate  infants  or  in  those 
who  are  markedly  rachitic,  a  form  of  collapse  which  comes  on  very 
gradually.     It  is  accompanied  by  bronchitis  affecting  the  tubes  in  the 


EMPHYSEMA.  535 

dependent  part  of  the  lung.  Its  seat  is  the  lower  lobes  posteriorly, 
sometimes  also  the  posterior  border  of  the  upper  lobes.  In  general 
appearance  it  may  resemble  the  congenital  form  of  atelectasis.  Under  the 
microscope  there  is  almost  invariably  found  accompanying  the  collapse, 
lobular  pneumonia  and  bronchitis  of  the  tubes  in  the  affected  regions. 

The  symptoms  are  much  the  same  as  in  persistent  congenital  atelec- 
tasis. In  marked  cases  the  resjiiration  is  rapid,  and  there  may  be  in- 
spiratory dyspnoea  with  deep  recession  of  the  chest  walls,  especially 
if  there  is  rickets.  There  is  also  cyanosis  of  variable  intensity,  which 
may  be  constant  or  intermittent.  There  are  usually  jaresent  a  short 
cough,  feeble  cry,  and  poor  circulation  with  cold  extremities.  The  tem- 
perature is  not  elevated,  but  frequently  is  subnormal.  The  physical  signs 
are  very  uncertain.  There  may  be  slight  dulness  and  very  feeble  respira- 
tory murmur  over  the  affected  areas,  occasionally  accompanied  by  moist 
rdles.  The  course  and  termination  are  the  same  as  those  seen  in  some 
of  the  cases  of  congenital  atelectasis.  The  essential  point  of  difference 
is,  that  in  the  acquired  cases  the  patients  are  often  strong  at  birth,  crying 
and  breathing  well,  giving  no  signs  of  anything  wrong  in  the  lungs  until 
the  general  nutrition  has  suffered  from  some  other  cause.  The  symptoms 
come  on  gradually. 

The  following  is  a  fairly  typical  case  :  A  female  infant  thirteen  months 
old  had  been  under  observation  in  the  Nursery  and  Child's  Hospital  for 
several  months  before  death.  During  this  period  she  suffered  a  great  part 
of  the  time  from  mild  bronchitis.  The  child  was  extremely  rachitic,  and 
the  chest  showed  deep  lateral  furrows.  The  respiration  was  always  accel- 
erated, and  on  inspiration  the  lateral  recession  of  the  chest  was  at  times 
extreme.  There  was  occasionally  seen  slight  cyanosis,  and  during  the  last 
few  weeks  it  was  constant.  Death  occurred  quite  suddenly.  At  autopsy 
there  was  found  very  marked  vesicular  emphysema  of  both  lungs  in 
front.  Nearly  the  whole  of  both  lower  lobes  were  in  a  condition  of  col- 
lapse, and  of  a  uniform  grayish-purple  colour.  The  posterior  portion  of 
the  upper  lobes  was  similarly  affected,  but  to  a  less  degree.  With  mod- 
erate force  all  of  the  collapsed  areas  could  be  completely  inflated.  Bron- 
chitis was  present,  but  the  pleura  was  normal. 

The  treatment  of  these  cases  is  the  same  as  that  outlined  in  the  chapter 
upon  Congenital  Atelectasis  (page  75). 

EMPHYSEMA. 

Pulmonary  emphysema  consists  primarily  in  overdistentiou  of  the  air 
vesicles.  It  may  result  in  their  rupture  and  the  escape  of  air  into  the 
interlobular  connective  tissue  of  the  lung.  In  infancy  and  childhood  em- 
physema is  usually  associated  with  acute  processes. 

Etiology.— Cases  of  emphysema  are  divided  into  two  groups  which  are 
due  to  quite  different  causes.    In  one  group  it  is  compensatory,  and  consists 


586  DISEASES  OF   THE   RESPIRATORY   SYSTEM. 

in  overdistention  of  the  air  vesicles  in  certain  parts  of  the  lungs  because 
the  full  expansion  of  other  parts  is  prevented  either  because  they  are  con- 
solidated, as  in  pneumonia  or  tuberculosis,  bound  down  by  adhesions 
from  old  pleurisy,  or  subjected  to  external  pressure,  as  from  chest  de- 
formities due  to  Pott's  disease  or  rickets.  In  these  conditions  it  is  prob- 
able that  the  emphysema  is  produced  during  inspiration.  It  may  also  be 
produced  by  the  artificial  inflation  of  the  lungs  of  the  newly  born. 

In  the  second  group  of  cases  emphysema  is  produced  by  obstructive 
expiratory  dyspnoea  or  cough.  It  is  seen  in  all  forms  of  laryngeal  stenosis, 
in  acute  bronchitis  and  broncho-pneumonia,  in  asthma,  pertussis,  and 
occasionally  it  is  produced  by  any  condition  which  requires  deep  inspira- 
tion and  holding  the  breath.  A  case  has  been  reported  to  me  which 
occurred  in  a  little  boy,  who,  while  playing  that  he  was  a  steam  engine, 
would  hold  his  breath  for  a  long  time  and  then  issue  short,  forcible  ex- 
piratory pufls.  In  bronchitis  the  obstruction  may  be  caused  by  swelling 
of  the  mucous  membrane  or  by  an  accumulation  of  secretion.  In  this 
group  of  cases  air  enters  the  lung,  but  as  it  can  not  readily  escape,  the  air 
vesicles  are  distended,  sometimes  to  such  a  degree  that  their  resiliency  is 
almost  entirely  lost. 

Lesions. — The  most  common  form  in  early  life  is  acute  vesicular 
emphysema,  which  occurs  when  the  force  distending  the  air  cells  is  only 
moderate.  In  this  form  there  is  dilatation  of  the  vesicles  with  very  slight 
structural  changes,  there  being  usually  rupture  of  a  few  alveolar  septa 
only  (Fig.  90).  Although  the  dilatation  may  be  quite  marked,  the  emphy- 
sema is  not  permanent.  The  parts  most  affected  are  the  upper  lobes,  par- 
ticularly the  anterior  borders.  In  appearance  the  emphysematous  lung  is 
pale,  sometimes  almost  white.  The  areas  are  prominent,  and  do  not  col- 
lapse upon  opening  the  chest.  With  a  lens,  or  even  with  the  naked  eye, 
the  individual  air  vesicles  can  often  be  distinguished  as  minute  pearly 
bodies,  at  times  resembling  miliary  tubercles.  When  the  disease  is 
secondary  to  acute  bronchitis  or  laryngeal  stenosis  it  may  affect  nearly  the 
whole  of  both  lungs. 

With  a  greater  distending  force  rupture  of  many  of  the  air  vesicles 
results,  and  this  may  give  rise  to  interstitial  or  interlobular  emphysema. 
At  times  blebs  are  formed,  varying  in  size  from  a  pin's  head  to  a  cherry. 
These  are  usually  seen  at  the  anterior  border  or  at  the  root  of  the  lung  on 
its  inner  surface.  Again,  the  air  finds  its  way  between  the  lobules,  dis- 
secting them  apart  in  all  directions  throughout  the  lung.  Sometimes  a 
large  part  of  the  surface  of  both  lungs  is  seamed  with  irregular  deep 
crevasses  containing  air,  the  largest  being  an  inch  or  more  in  length  and 
nearly  one  fourth  of  an  inch  wide.  The  most  severe  cases  occur  in  per- 
tussis. On  two  or  three  occasions  I  have  seen  this  form  of  emphysema, 
once  to  an  extreme  degree,  where  children  had  died  from  diseases  uncon- 
nected with  the  respiratory  tract,  and  where  no  history  could  be  obtained 


PLEURISY.  587 

which  threw  any  light  upon  the  etiology  of  the  emphysema.  Eupture  of 
the  blebs  which  form  at  the  root  of  the  lung  may  lead  to  emphysema  of 
the  mediastinum,  or  even  of  the  subcutaneous  connective  tissue  of  the  body. 
This  is  occasionally  seen  in  whooping-cough  and  in  laryngeal  stenosis. 
The  primary  or  substantive  form  of  emphysema  seen  in  adult  life  rarely 
if  ever  occurs  in  childhood. 

Symptoms. — Emphysema  occurring  in  acute  pulmonary  diseases  gives 
rise  to  no  peculiar  symptoms  and  to  no  physical  signs  except  exao-- 
gerated  resonance  upon  percussion.  If  the  patients  recover  from  the 
original  disease,  the  emphysema  undoubtedly  disappears  completely  in 
the  course  of  a  few  weeks  or  months.  Acute  interlobular  emphysema 
can  not  be  diagnosticated  during  life.  The  lesion  is  of  such  a  nature 
that  complete  recovery  is  impossible,  although  improvement  often  takes 
place. 

The  treatment  of  emphysema  is  that  of  the  disease  with  which  it  is 
associated. 


CHAPTER   VI. 
PLEURISY. 

All  the  common  forms  of  inflammation  of  the  pleura  are  seen  in 
childhood.  In  the  great  majority  of  cases  they  are  secondary  to  disease 
of  the  lung  itself.  Serous  effusions  are  much  less  frequent  than  in 
adults,  and  under  three  years  they  are  extremely  rare.  Purulent  effu- 
sion (empyema)  is,  however,  much  more  often  seen  than  in  adult  life, 
and  it  is  the  most  important  variety  of  pleurisy  with  which  the  physi- 
cian has  to  deal. 

Whether  inflammation  of  the  pleura  ever  occurs  as  a  strictly  primary 
disease  is  still  a  mooted  point.  Cases  are  occasionally  observed  clinically 
in  which  both  the  serous  and  purulent  forms  of  the  disease  appear  to  be 
primary,  but  these  are  extremely  rare.  Acute  pleurisy  may,  however,  fol- 
low inflammation  of  the  lung  so  rapidly  that  it  is  not  easy  to  determine 
that  the  lung  was  first  affected.  In  infants,  extension  from  the  lung  is 
almost  the  sole  cause.  It  occurs  both  with  lobar  and  broncho-pneumonia, 
existing  to  some  degree  in  nearly  every  case  in  which  there  is  consolida- 
tion of  the  lung.  Next  in  frequency  to  simple  pneumonia  as  a  cause  of 
pleurisy  are  the  tuberculous  processes  of  the  lung.  Tuberculous  pleurisy 
without  tuberculosis  of  the  lungs  or  the  bronchial  glands  is  of  doubtful 
occurrence.  Acute  pleurisy  is  not  an  infrequent  complication  of  the 
infectious  diseases,  particularly  scarlet  and  typhoid  fevers,  measles,  and 
influenza.  In  most  of  these  cases  also  it  is  secondary  to  disease  of  the 
lung.     Pleurisy  in  older  children  occasionally  follows  cold  and  exposure, 


588  DISEASES   OF   THE   RESPIRATORY  SYSTEM. 

although  it  is  doubtful  whether  in  any  case  this  is  the  only  cause.     In 
them  also  it  may  occur  as  a  complication  of  rheumatism. 

The  most  important  cause  of  acute  pleurisy  being  extension  from 
pneumonia,  it  follows  that  it  is  most  frequent  in  the  cold  season,  that  it 
occurs  more  often  in  males  than  in  females,  and  between  the  ages  of  one 
and  five  years.  It  may,  however,  be  seen  at  all  ages,  and  may  even  occur 
in  intra-uterine  life.  The  youngest  case  in  which  I  have  found  extensive 
pleuritic  adhesions  as  an  evidence  of  previous  inflammation  was  in  an  in- 
fant of  three  months,  who  died  at  the  Eand all's  Island  Hospital.  In  this 
case  firm  connective  tissue  adhesions  were  found  over  the  whole  of  both 

lungs. 

DRY  PLEURISY. 

In  infants  and  young  children  this  usually  accompanies  pneumonia  or 
tuberculous  processes  in  the  lung.     In  older  children  it  may  be  primary. 

Lesions. — On  account  of  the  frequency  with  which  this  occurs  in 
pneumonia  we  have  an  opportunity  of  observing  it  in  all  stages.  In  the 
mildest  varieties  it  affects  only  the  pulmonary  pleura,  and  occurs  over  the 
pneumonic  areas.  The  pleura  is  injected,  has  lost  its  lustre,  and  appears 
dull  or  roughened.  This  is  due  to  an  exudation  of  fibrin  upon  its  surface. 
If  the  process  continues,  more  fibrin  is  poured  out,  and  there  are  in  addition 
swelling  and  a  proliferation  of  the  connective-tissue  cells,  and  an  exuda- 
tion of  leucocytes  from  the  blood-vessels.  The  pleura  is  then  coated  with 
a  layer  of  fibrin  of  variable  thickness,  in  which  are  entangled  pus  cells 
and  new  connective-tissue  cells.  The  layer  of  fibrin  varies  from  the  thick- 
ness of  tissue  paper  to  that  of  an  ordinary  book  cover.  In  recent  cases  it 
may  easily  be  stripped  off,  while  in  older  ones  it  becomes  organized  and  is 
firmly  adherent.  The  colour  of  the  exudate  varies  with  the  number  of 
pus  cells.  It  is  gray,  grayish-yellow,  or  yellowish-green,  according  as 
these  cells  are  few  or  numerous.  As  a  rule,  dry  pleurisy  is  localized,  but 
the  two  opposing  surfaces  are  affected.  Part  of  the  exudate  is  usually 
absorbed,  but  it  is  doubtful  if  complete  recovery  occurs,  there  being  left 
behind  some  adhesions  between  the  visceral  and  parietal  layers. 

In  some  cases  of  dry  pleurisy  there  is  an  excessive  exudation  of  pus 
cells.  These  cases  are  most  common  in  young  children,  and  usually  oc- 
cur with  pneumonia,  constituting  what  is  known  as  "  pleuro-pneumo- 
nia."  The  process  is  essentially  the  same  as  in  the  cases  just  mentioned, 
yet  the  gross  appearance  differs  very  much  from  that  of  ordinary  dry 
pleurisy.  The  lesions  have  already  been  described  under  the  head  of 
Pleuro-Pneumonia  (j^age  576). 

In  the  dry  form  of  tuberculous  pleurisy  there  may  be  only  an  exudation 
of  fibrin,  or  the  pleura  may  be  covered  with  gray  tubercles  and  yellow 
tuberculous  nodules.  These  are  not  only  seen  upon  the  pleura,  but  develop 
in  the  exudation.  In  this  form,  which  is  usually  chronic,  great  thickening 
of  the  pleura  may  take  place.     Both  the  serous  and  purulent  effusions 


PLEURISY  WITH  SEROUS  EFFUSION.  589 

occurring  in  conjunction  with  tuberculosis  are  likely  to  be  sacculated  be- 
cause of  the  previous  existence  of  adhesions. 

After  nearly  every  case  of  dry  pleurisy  there  probably  remains  some 
slight  thickening  of  the  pleura.  In  certain  cases  there  follows  a  chronic 
inflammation  of  the  pleura  with  the  production  of  new  connective  tissue, 
which  results  in  thickening  and  adhesions,  which  may  be  so  extensive  as 
to  entirely  obliterate  the  pleural  cavity.  Either  one  or  both  sides  may  be 
affected.     This  form  is  extremely  rare  in  childhood. 

Symptoms. — As  an  independent  clinical  disease,  acute  dry  pleurisy  has 
no  existence  in  infancy  or  early  childhood.  The  cases  which  are  occa- 
sionally so  diagnosticated  have  in  my  experience  invariably  proven  to  be 
broncho-pneumonia.  In  children  from  ten  to  fourteen  years  old,  dry 
pleurisy  may  occur  under  the  same  conditions  as  in  adults. 

The  symptoms  are  sharp,  localized  pain,  increased  by  full  inspiration, 
sometimes  tenderness  upon  pressure,  and  a  short,  teasing  cough.  The  pain 
is  not  always  felt  upon  the  affected  side,  and  it  may  be  referred  to  the  ab- 
domen. Upon  physical  examination,  dry  pleurisy  is  recognised  by  the  pres- 
ence of  a  pleuritic  friction  sound.  This  is  usually  of  a  moist,  crackling 
character,  generally  localized,  and  heard  both  on  inspiration  and  expira- 
tion. It  is  quite  superficial,  and  not  changed  by  coughing.  This  form 
of  pleurisy,  as  a  rule,  runs  a  course  of  a  few  days  or  a  week,  without  con- 
stitutional symptoms.  When  dry  pleurisy  occurs  as  a  comj^lication  of 
pneumonia  it  is  recognised  by  the  signs  just  mentioned ;  but  it  usually 
causes  no  new  symptoms  except  pain. 

Treatment. — The  treatment  consists  in  counter-irritation  by  mustard, 
iodine,  or  blisters,  according  to  the  severity  of  the  inflammation,  and  in 
the  use  of  opium.  Severe  pain  can  sometimes  be  relieved  by  firmly  en- 
circling the  chest  with  a  broad  band  of  adhesive  plaster. 

PLEURISY   WITH  SEROUS  EFFUSION. 

This  form  of  pleurisy  is* infrequent  in  children,  and  under  three  years 
it  is  very  rare.  It  may  occur  as  a  complication  of  pneumonia,  nephritis, 
acute  rheumatism,  scarlet  fever,  or  any  of  the  other  acute  infectious  dis- 
eases. It  may  be  tuberculous.  In  rare  cases  it  aj^pears  to  be  primary. 
Bacteria  are  occasionally  present  in  the  exudation,  even  in  cases  which  do 
not  become  purulent,  but  their  number  is  usually  small.  The  pneu mo- 
coccus,  the  streptococcus,  and  the  tubercle  bacillus  are  the  forms  most 
often  seen. 

Lesions. — The  early  changes  are  much  the  same  as  in  diy  pleurisy, 
but  in  addition  serum  is  poured  out  from  the  blood-vessels,  in  some  cases 
almost  from  the  beginning  of  the  inflammation.  This  may  be  small  in 
amount,  or  it  may  fill  the  pleural  cavity.  The  lesions  arc  similar  to  those 
seen  in  adults,  except  that  in  children  there  is  apt  to  be  hkh'c  lihrin.  'J'lic 
process  usually  terminates  in  absorjition  of  the  seruiii.  but.  as  in  (h-y 
39 


590  DISEASES   OF   THE  RESPIRATORY  SYSTEM. 

pleurisy,  more  or  less  extensive  adhesions  are  left  behind  from  the  fibri- 
nous exudation. 

Symptoms. — The  small  serous  effusions  of  one  or  two  ounces,  occurring- 
with  the  dry  pleurisy  that  complicates  pneumonia,  rarely  cause  either 
symptoms  or  physical  signs  by  which  they  can  be  recognised.  In  the 
present  connection  only  those  cases  will  be  discussed  in  which  the  amount 
of  effusion  is  considerable.  This  form  of  pleurisy  sometimes  follows  a 
well-defined  attack  of  pneumonia.  Other  cases  come  on  with  acute  febrile 
symptoms  somewhat  resembling  those  of  pneumonia,  but  with  all  the 
symptoms  less  severe,  except  the  pain.  After  an  illness  of  only  two  or 
three  days  the  chest  may  be  found  full  of  fluid.  In  a  third  class  the  dis- 
ease comes  on  insidiously,  with  little  or  no  fever,  and  often  with  no  dis- 
tinct pulmonary  symptoms  except  shortness  of  breath.  There  are  general 
weakness,  sometimes  loss  of  flesh,  aneemia,  and  moderate  prostration;  but 
usually  the  patients  are  not  sick  enough  to  go  to  bed.  The  symptoms 
of  pleurisy  with  effusion  vary  greatly.  When  it  occurs  as  a  complication  of 
some  acute  infectious  disease,  it  is  often  latent,  and  the  diagnosis  is  to  be 
made  only  by  the  physical  examination  of  the  chest. 

The  usual  course  of  the  disease  is  for  the  fluid  to  disappear  gradually 
by  absorption,  the  case  going  on  to  spontaneous  recover3\  Serious  symp- 
toms resulting  from  pressure  upon  the  heart  and  lungs  are  not  common, 
but  may  occur  when  the  fluid  accumulates  rapidly ;  hence  they  are  most 
likely  to  be  seen  early  in  the  attack.  There  may  be  great  dyspnoea,  some- 
times orthopncea,  cyanosis,  weak  pulse,  and  even  attacks  of  syncope. 
Death  may  occur  with  these  symptoms.  In  certain  cases  there  is  seen  no 
tendency  to  spontaneous  absorption,  and  the  exudation  may  remain  sta- 
tionary for  months.  There  may  then  be  fever,  usually  slight  but  some- 
times quite  regular,  with  a  decline  in  the  general  health,  pallor  and 
anaemia,  which  may  strongly  suggest  the  existence  of  pus,  although  this 
is  not  present.     Others  are  regarded  as  cases  of  tuberculosis. 

Physical  Signs. — The  signs  in  the  chest  are  Essentially  the  same  Avhether 
the  fluid  is  serous  or  purulent.  On  inspection,  there  is  diminished  move- 
ment of  the  affected  side,  sometimes  bulging  of  the  intercostal  spaces,  and 
if  the  effusion  is  large,  an  increase  in  the  measurement  of  the  affected  side 
of  the  chest.  The  apex  beat  of  the  heart  will  usually  be  considerably  dis- 
placed if  the  effusion  is  upon  the  left  side.  It  may  be  found  at  the  epi- 
gastrium, at  the  right  border  of  the  sternum,  or  even  in  the  right  mam- 
mary line.  In  disease  of  the  right  side  the  displacement  is  less,  and 
occurs  only  with  a  large  effusion.  It  may  then  be  found  in  or  near  the 
left  axillary  line.  On  palpation,  the  vocal  fremitus  is  usually  diminished 
or  absent,  but  it  may  be  but  little  changed.  Percussion  gives  marked  dul- 
ness  or  flatness.  In  a  large  effusion  this  is  over  the  entire  lung.  There 
is  also  a  sensation  of  increased  resistance  appreciable  by  the  percussing 
finger.     AYith  a  smaller  effusion  there  is  usually  flatness  over  the  lower 


PLEURISY  WITH  SEROUS  EFFUSION.  591 

part  of  the  chest  and  dulness  or  tympanitic  resonance  above ;  sometimes 
dulness  is  found  behind  and  tympanitic  resonance  at  the  apex  in  front. 
The  line  of  flatness  may  change  with  the  position  of  the  patient.  The 
signs  on  auscultation  are  variable,  and  probably  lead  to  more  frequent 
mistakes  in  diagnosis  than  in  any  other  pulmonary  affection.  Bronchial 
breathing  and  bronchial  voice  over  the  fluid  are  the  rule  in  children ;  they 
are  generally  more  distinct  the  greater  the  effusion.  Absence  of  both  voice 
and  breathing  is  sometimes  met  with,  but  it  is  exceptional.  The  bronchial 
breathing  over  fluid  usually  differs  from  that  over  consolidation,  in  that  it 
is  feebler  and  distant ;  in  some  cases,  however,  it  is  indistinguishable  from 
that  heard  over  consolidation.  Friction  sounds  may  be  heard  above  the 
level  of  the  fluid,  or  when  the  fluid  is  subsiding,  and  there  may  be  bron- 
chial rales. 

Diagnosis. — The  most  reliable  signs  for  diagnosis  are  displacement  of 
the  heart,  flatness  on  percussion,  absence  of  rdles  and  friction  sounds,  and 
(usually  distant)  bronchial  breathing.  In  an  infant,  flatness  should  always 
lead  one  to  suspect  fluid.  If  there  is  flatness  over  one  entire  lung,  the 
existence  of  fluid  is  almost  certain.  Between  serous  and  purulent  effusions 
a  positive  diagnosis  is  possible  only  by  the  use  of  the  exploring  needle. 
This  should  be  employed  in  every  case,  as  for  treatment  it  is  im]3ortant  to 
know  at  once  whether  or  not  we  have  a  purulent  effusion  to  deal  with. 
The  amount  of  fluid  in  serous  pleurisy  is  generally  less  than  in  the  puru- 
lent variety. 

Pleurisy  is  further  to  be  differentiated  from  pneumonia,  and  from  tuber- 
culosis. From  pneumonia,  the  acute  cases  are  distinguished  by  the  lower 
temperature,  the  less  severe  prostration,  and  the  fact  that  all  the  general 
symptoms  are  milder,  but  especially  by  the  physical  signs.  The  differential 
diagnosis  by  the  physical  signs  between  effusion  and  the  various  forms  of 
consolidation  is  considered  under  the  head  of  Empyema  (page  596). 

Prognosis. — These  cases,  as  a  rule,  terminate  in  recovery,  death  being 
very  infrequent.  In  cases  coming  on  without  definite  cause  there  should 
always  exist  a  suspicion  of  tuberculosis,  and  hence  every  patient  should  be 
closely  watched  for  the  development  of  the  other  signs  of  that  disease. 

Treatment. — In  the  great  majority  of  cases,  only  symptomatic  treat- 
ment is  required  during  the  acute  period.  The  patient  should  be  kept 
in  bed,  and  pain  relieved  by  opium,  counter-irritation,  or  hot  poultices. 
After  the  fever  has  ceased  the  patient  may  be  allowed  to  sit  up,  but  all 
exertion  should  be  carefully  avoided  if  the  effusion  is  large.  Sudden 
death  has  often  occurred  when  this  rule  has  been  violated.  The  patient 
should  in  suitable  wesither  be  kept  in  the  open  air  as  much  as  possible. 
In  the  course  of  a  few  weeks  the  effusion  usually  subsides  under  simple 
tonic  treatment.  Absorption  may  sometimes  be  hastened  by  counter- 
irritation  and  diuretics;  but  convalescence  is  apt  to  be  slow,  and  it  may 
be  several  months  before  the  health  is  entirelv  restored. 


592  DISEASES   OP   THE   RESPIRATORY  SYSTEM. 

The  removal  of  the  fluid  by  operation  is  indicated  in  the  acute  stage 
when  it  is  accumulating  so  rapidly  as  to  endanger  life  from  the  pressure 
upon  the  heart  and  lungs ;  also  when  there  is  no  tendency  to  absorption 
after  from  two  to  three  weeks  of  constitutional  treatment.  In  such  cases 
nothing  is  to  be  gained  by  waiting,  and  harm  may  be  done  to  the  lung  by 
the  delay.  The  usual  method  is  by  aspiration.  In  the  acute  stage  enough 
should  be  removed  to  relieve  the  patient's  symptoms,  aspiration  being  re- 
peated if  necessary  in  twelve  or  twenty-four  hours.  In  the  sub-acute  stage 
the  removal  of  a  portion  of  the  fluid  may  be  all  that  is  required,  spontaneous 
absorption  of  the  remainder  often  taking  place  then  quite  promptly.  A 
few  cases  of  serous  pleurisy  have  been  incised  and  drained  as  cases  of 
empyema.  Scharlau  (Xew  York)  operated  on  such  a  case  in  an  infant 
two  years  old.  The  effusion  came  on  acutely  and  was  excessive,  the  chest 
having  refilled  very  quickly  after  aspiration.  The  chest  was  incised  and 
drained  and  the  patient  recovered  in  five  days.  In  chronic  cases,  in  which 
there  are  slight  fever  and  a  gradual  failure  of  general  health,  the  opera- 
tion of  incision  is  by  some  preferred  to  aspiration. 

EMPYEMA. 

Fully  nine  tenths  of  the  cases  of  empyema  in  children  under  five  years 
either  occur  with  or  follow  pneumonia,  being  usually  the  sequel  of  the 
form  described  as  jDleuro-pneumonia.  In  some  of  these  cases,  however, 
the  pleurisy  masks  the  pneumonia,  so  that  the  former  apjDcars  to  be  the 
primary  disease.  Tuberculosis  is  a  rare  cause  in  early  childhood,  but  be- 
comes more  frequent  after  the  seventh  year.  Empyema  may  complicate 
scarlet  fever,  measles,  or  any  of  the  other  acute  infectious  diseases.  It  is 
met  with  in  pyaemia  from  all  causes.  It  may  occur  in  the  newly  born  as 
the  result  of  infection  through  the  umbilical  wound  or  the  skin.  It  is 
seen  with  sujDpurative  inflammations  of  the  joints  and  in  osteo-myelitis. 
It  may  complicate  suppurative  processes  in  the  abdomen,  such  as  ap- 
pendicitis or  purulent  peritonitis.  Among  the  local  causes  may  be  men- 
tioned traumatism,  necrosis  of  a  rib,  and  the  rupture  into  the  pleural  cav- 
ity of  abscesses  originating  in  the  mediastinum,  in  the  thoracic  wall,  or 
below  the  diaphragm. 

Bacteriology. — Much  light  upon  the  etiology  of  empyema  has  been 
thrown  by  the  bacteriological  investigations  of  the  past  few  years,  espe- 
cially by  the  work  of  Fraenkel,  "Weichselbaum,  Levy,  and  ]^etter  in 
Europe,  and  Prudden  and  Koi^lik  in  this  country.  Bacteriologically,  we 
may  divide  the  cases  into  several  groups  : 

1.  Those  containing  the  pneumococcus  (micrococcus  lanceolatus),  usu- 
ally in  pure  culture.  This  is  the  largest  group,  and  includes  nearly  all  the 
cases  secondary  to  pneumonia.  The  pleura  is  usually  involved  by  direct 
infection  from  the  lung. 

2.  Those  containing  other  pyogenic  germs,  particularly  the  strepto- 


EMPYEMA.  593 

coccus  and  the  staphylococcus.  Of  these  the  streptococcus  is  the  most 
important.  It  may  be  found  alone,  but  is  usually  associated  with  the 
pneumococcus.  This  combination  is  likely  to  be  found  in  cases  sec- 
ondary to  the  pneumonia  which  occurs  with  the  infectious  diseases.  The 
streptococcus  and  staphylococcus  occur  in  the  pleurisy  of  pyaemia,  and 
usually  also  when  the  disease  is  due  to  the  rupture  of  abscesses  into  the 
pleural  cavity. 

3.  The  cases  due  to  tuberculosis.  In  this  group  the  presence  of  the 
tubercle  bacillus  is  very  often  difficult  to  demonstrate,  and  it  may  be 
absent.  From  this  fact  the  statement  is  made  by  Levy  that,  if  no  bac- 
teria can  be  found  in  a  purulent  exudate,  tuberculosis  should  always  be 
suspected.  It  is  not,  however,  safe  to  conclude  that  under  these  circum- 
stances tuberculosis  is  always  present. 

Of  nineteen  successive  cases  of  empyema  occurring  in  my  own  prac- 
tice, the  pneumococcus  was  found  alone  in  fourteen;  the  streptococcus 
alone  in  three ;  the  pneumococcus  and  streptococcus  in  one ;  and  the 
staphylococcus  alone  in  one. 

Lesions. — Empyema  is  an  inflammation  with  the  production  of 
serum,  fibrin,  and  pus.  In  most  of  the  cases — and  the  younger  the 
child  the  more  frequent  its  occurrence — it  succeeds  pleuro-pneumonia. 
There  is  first  an  exudation  of  fibrin  with  an  excess  of  pus  cells.  As  the 
process  continues,  more  and  more  pus  is  poured  out,  with  serum.  At 
first  the  fluid  collects  in  small  pockets  formed  by  the  slight  adhesions. 
As  it  accumulates  these  are  broken  down,  and  the  pleural  cavity  may  be 
filled  with  pus.  If  the  original  inflammation  involved  but  a  portion  of 
the  pleura  the  empyema  may  be  sacculated.  This  is  often  seen  even  in 
infants.  Sacculated  empyema  is  usually  posterior,  but  may  be  in  any 
part  of  the  chest.  In  very  rare  cases  there  may  be  several  sacs  contain- 
ing pus,  separated  by  septa.  This  I  have  never  seen  in  emp3^ema  follow- 
ing pneumonia.  The  cases  just  described  are  those  in  which,  in  infants 
and  young  children,  the  pneumococcus  is  regularly  found.  The  amount 
of  fibrin  is  large,  covers  both  surfaces  of  the  pleura,  and  many  large 
masses  float  in  the  fluid.  The  pus  is  usually  thick,  creamy,  and  odour- 
less. In  another  group  of  cases  the  evidences  of  inflammation  of  the 
pleura  are  much  less  marked,  and  in  some  they  may  be  slight.  There  is 
but  little  fibrin  in  the  exudate,  and  adhesions  are  rare.  In  this  form  the 
streptococcus  or  the  staphylococcus  arc  the  organisms  usually  found.  In 
these  cases  the  inflammation  may  be  purulent  from  the  outset,  and  the 
pus  is  thinner  than  in  the  preceding  variety.  It  is  rare  that  empyema 
in  a  young  child  results  from  a  serous  effusion  which  has  been  gradu- 
ally converted  into  a  purulent  one.    I  can  recall  but  a  single  instance. 

Even  when  the  fiuid  is  moderate  in  quantity  it  is  not  all  at  the  bottom 
of  the  chest,  but  is  generally  distributed  over  a  considerable  part  of  its 
surface,  and  its  depth  at  the  middle  and  upper  part  of  the  chest  may  be 


594 


DISEASES   OF   THE   RESPIRATORY   SYSTEM. 


only  half  an  inch,  or  even  less.  When  the  accumulation  is  larger,  the 
lung  does  not  float  on  the  surface  of  the  fluid,  but  the  fluid  surrounds 
the  lung,  which  is  compressed  on  all  sides  (Fig.  110).  The  heart  is  dis- 
placed ;  the  diaphragm  and 
the  abdominal  viscera  are 
somewhat  depressed,  and 
there  may  be  bulging  of 
the  chest  on  the  affected 
side.  The  amount  of  fluid 
in  ordinary  cases  is  from 
half  a  pint  to  two  pints, 
although  in  neglected  cases 
it  may  accumulate  until  it 
amounts  to  four  or  five 
pints.  The  effect  upon  the 
lung  will  dejDend  upon  the 
amount  of  fluid  and  the 
duration  of  the  compres- 
sion. When  the  quantity 
is  small,  or  when  the  pres- 
sure is  removed  early,  the 
lung  in  most  cases  readily 
expands,  air  being  forced 
into  it  from  the  opposite 
lung,  especially  during  the 
act  of  coughing.  If  the 
pressure  is  great  and  has 
been  long  continued,  the 
adhesions  over  the  lung 
may  become  so  dense  and  firm  that  expansion  is  difficult,  and  can  at  best 
be  only  j)artial.  In  sucli  cases  recession  of  the  chest  wall  occurs.  In  very 
old  cases,  expansion  is  still  further  interfered  with  by  the  changes  taking 
place  in  the  lung  itself,  usually  a  low  grade  of  interstitial  pneumonia. 

In  cases  of  empyema  receiving  proper  surgical  treatment  reasonably 
early,  full  expansion  of  the  lung  occurs,  and,  with  the  exception  of  adhe- 
sions, recovery  may  be  complete.  Although  wide  in  extent,  the  adhesions 
are  not  usually  strong  enough  to  interfere  seriously  with  the  function  of 
the  lung.  In  cases  receiving  no  treatment,  absorption  of  the  pus  is  pos- 
sible, but  is  not  to  be  expected.  It  generally  seeks  an  external  outlet ;  the 
lung  may  be  perforated  and  the  pus  evacuated  through  the  bronchi,  or 
external  rupture  may  occur,  generally  in  the  neighbourhood  of  the  nipple. 
In  still  other  cases  the  pus  may  burrow  along  the  spine,  or  through  the 
diaphragm  may  reach  the  peritonteum. 

Empyema  is  more  often  of  the  left  than  of  the  right  side,  the  propor- 


FiG.  110.— Section  of  a  lung  to  illustrate  the  distribution  of 
the  fluid  in  the  chest  in  a  moderately  large  ertusion 
(diagrammatic). 


EMPYEMA. 


595 


tion  being  about  three  to  two.  It  is  double  in  about  three  per  cent  of  all 
cases,  but  much  oftener  in  infants.  The  most  serious  complication  in 
young  children  is  pericarditis,  usually  with  empyema  of  the  left  side;  in 
older  children  the  most  frequent  complication  is  pulmonary  tuberculosis. 
Symptoms. — When  it  occurs  as  a  sequel  of  pneumonia,  the  symptoms 
of  empyema  may  follow  those  of  the  original  disease  without  any  inter- 


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Fig.  111. — Empyema  following  pneumonia. 

Private  patient,  girl,  eight  years  old  ;  severe  pneumonia  terminating  by  ly.sis ;  development 
of  empyema  indicated  by  secondary  temperature;  operation  on  seventeenth  day;  recovery. 

mission ;  or  after  the  temperature  has  been  normal  or  nearly  so  for  sev- 
eral days  it  may  rise  again,  sometimes  quite  suddenly,  but  more  often 
gradually.  ^Yith  this  accession  of  fever  there  are  other  symptoms  point- 
ing to  an  increase  in  the  thoracic  disease.  (See  Figs.  Ill  and  112.) 
After  scarlet  fever  or  other  infectious  diseases,  the  onset  of  empyema  is 
often  signalized  by  cough,  rapid  breathing,  and  the  other  usual  symptoms 


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6 

7 

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10 

11 

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Fig.  112. — Empyema  following  pneumonia. 

Hospital  jnitient,  two  years  old;  single-lobe  pneumonia  with  crisis  on  nintli  iliiy  ;  no  reso- 
lution, but  instead  f,n-iidual  development  of  signs  of  empyema  closely  following  the  tuiiipcniture 
curve. 

of  piilinouary  disease.  In  the  cases  where  empyema  appears  to  bo  pri- 
mar}',  the  onset  is  sudden,  with  high  temperature  and  general  and  local 
symptoms  resembling  those  of  pneumonia.    After  such  a  beginning,  the 


596  DISEASES  OF   THE  RESPmATORY   SYSTEM. 

chest  may  be  found  full  of  jdus  by  the  third  or  fourth  day.  In  older  chil- 
dren empyema  may  come  on  with  gradual,  and  even  insidious  symptoms, 
there  being  only  slight  fever,  dyspnoea,  and  cachexia.  Marked  leucocy- 
tosis  is  almost  invariably  present  (see  page  84-i). 

AVhatever  may  have  been  the  mode  of  onset,  when  the  pus  has  been 
in  the  chest  for  some  time  the  symptoms  are  fairly  uniform.  There  are 
cachexia,  pallor,  ansemia,  and  prostration  which  is  generally  sufficient  to 
keep  the  child  in  bed.  The  respirations  are  always  accelerated,  being 
usually  from  forty  to  seventy  a  minute.  Cough  is  present :  there  is  dysp- 
noea, sometimes  marked,  but  more  often  it  is  scarcely  noticeable.  Fever 
is  exceedingly  variable ;  it  is  rarely  high,  not  often  above  102°  or  103°  F. ; 
in  many  cases  it  is  not  over  100°  F.,  and  it  may  be  absent  altogether.  A 
typical  hectic  temperature  with  sweating,  is  in  my  experience  ver}'  rare. 
The  pulse  is  rapid  but  of  fair  strength.  There  is  loss  of  flesh,  sometimes 
even  emaciation  and  anorexia;  occasionally  there  is  diarrhoea.  In 
chronic  cases  the  general  symptoms  closely  resemble  those  of  tuberculo- 
sis. There  may  be  clubbing  of  the  fingers,  albuminuria,  swelling  of  the 
feet,  and  often  marked  lateral  curvature  of  the  spine. 

Diagnosis. — The  physical  signs  do  not  differ  essentially  from  those 
present  in  serous  effusions  (page  590).  If  the  patient  is  under  three 
3^ears  of  age,  the  fluid  is  almost  certain  to  be  purulent;  and  from  the 
third  to  the  seventh  year,  pus  is  much  more  often  found  than  serum.  In 
every  case  in  which  fluid  is  suspected  the  exploring  needle  should  be 
used,  because  of  the  great  importance  of  an  early  diagnosis.  The  skin 
should  be  washed,  the  needle  sterilized,  and  the  arm  raised  so  as  to  sepa- 
rate the  ribs.  Pus  may  not  be  found  because  the  needle  is  too  small,  too 
short,  or  because  it  is  introduced  too  far  into  the  chest;  for  when  the 
layer  of  pus  is  thin  the  needle  may  be  pushed  through  this  into  the  lung. 

The  physical  signs  upon  which  most  reliance  is  to  be  placed  are 
marked  dulness  or  flatness  on  percussion,  feeble  breathing,  and  displace- 
ment of  the  heart.  Wbcn  in  a  yonng  child  these  signs  are  present, 
whether  general  or  localized,  a  needle  should  be  inserted,  and  if  pus  is 
not  found  at  the  first  trial,  repeated  punctures  should  be  made  until  the 
presence  or  absence  of  fluid  is  definitely  settled. 

Empyema  is  most  frequently  confounded  with  unresolved  pneumonia. 
The  differential  points  are  that  in  unresolved  pneumonia  the  dulness  is 
usually  over  a  single  lobe,  rales  or  friction  sounds  are  heard,  and  there  is 
no  displacement  of  the  heart ;  empyema  may  give  flatness  over  the  whole 
lung,  or  over  the  lower  half  of  the  chest  in  front  and  behind,  rales  and 
friction  sounds  are  absent  over  this  area,  and  the  heart  is  usually  dis- 
placed. In  both  conditions  we  may  get  bronchial  breathing  and  voice. 
The  confusion  of  acute  pneumonia  or  tuberculosis  with  empyema,  gen- 
erally arises  from  placing  too  much  reliance  upon  auscultation.  In 
pleuro-pneumonia,  with  an  excessive  exudation  of  fibrin,  the  signs  may 


EMPYEMA.  597 

be  identical  with  those  of  emp5'ema,  except  that  the  heart  is  not  dis- 
placed. I  once  saw  pulmonary  tuberculosis,  with  caseation  of  an  entire 
lobe,  which  gave  signs  that  were  identical  with  those  of  a  sacculated 
empyema.  It  is  by  the  exploring  needle,  and  by  that  alone,  that  empy- 
ema is  positively  differentiated  from  these  pulmonary  conditions. 

There  are  some  other  thoracic  diseases  from  which  the  diagnosis 
may  be  even  more  difficult.  A  large  pericardial  effusion  gives  signs 
which  are  in  some  cases  identical  with  those  of  empyema  of  the  left 
side.  Marked  displacement  of  the  heart  to  the  right  is  always  a  strong 
point  in  favour  of  empyema ;  besides,  such  pericardial  effusions  are  ex- 
tremely rare  in  young  children.  A  pulmonary  abscess  of  considerable 
size — also  a  rare  condition — gives  signs  identical  with  those  of  localized 
empyema,  and  is  only  distinguished  from  it  by  autops}^  or  operation. 
Abscesses  from  broken-down  tuberculous  glands  may  give  signs  resem- 
bling those  of  localized  empyema,  and  may  point  like  an  empyema  be- 
tween the  ribs  in  the  upper  part  of  the  chest.  The  constitutional  symp- 
toms of  empyema  may  at  times  resemble  typhoid  fever  or  malaria ;  but 
it  is  distinguished  from  them  by  the  physical  signs. 

Prognosis. — The  outcome  of  a  case  of  empyema  depends  chiefly  upon 
the  cause,  the  age  and  general  condition  of  the  patient,  the  duration  of 
the  symptoms,  the  presence  or  absence  of  serious  complications,  and  the 
treatment.  The  best  results  are  obtained  in  the  cases  that  follow  pneu- 
monia. Tuberculosis  before  the  seventh  year  is  an  exceedingly  infre- 
quent cause,  and  gangrene  of  the  lung  and  general  pyemia  are  both  rare 
causes  in  early  life.  It  is  these  three  conditions  that  make  the  prognosis 
of  the  disease  in  adults  so  serious.  The  mortality  in  infants  under  one 
year,  particularly  hospital  cases,  is  high — fully  50  per  cent — not  only 
because  of  the  tender  age,  but  because  of  the  wretched  general  condition 
of  most  of  these  patients.  Empyema  in  children  over  two  years  old  seen 
reasonably  earh' — i.  e.,  within  six  or  eight  weeks — and  receiving  proper 
treatment,  almost  invariably  terminates  in  recovery,  unless  the  disease 
is  double  or  serious  complications  exist.  Great  delay  in  operation  makes 
the  prognosis  worse,  because  the  more  difficult  the  expansion  of  the  lung 
the  more  tedious  is  the  disease,  and  the  greater  the  likelihood  of  a  sinus 
remaining.  With  proper  early  treatment  these  patients  not  only  re- 
cover, but  in  most  cases  the  recovery  is  surprisingly  complete.  Eetrac- 
tion  of  the  chest  and  its  resulting  lateral  curvature  of  the  spine  are  rare, 
and  seen  only  in  neglected  cases.  In  very  many  of  the  cases  I  have  seen, 
in  which  a  reasonably  early  operation  was  done,  it  was  impossible,  after 
the  lapse  of  two  or  three  years,  to  detect  any  difference  whatever  in  the 
physical  signs  of  the  two  sides  of  the  chest.  There  are  few  serious  dis- 
eases the  treatment  of  which  is  more  satisfactory  than  that  of  acute 
empyema  following  pneumonia. 

Spontaneous  recovery  in  empyema  may  take  place  by  absorption ;  but 


598  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

this  is  so  rare  that  it  is  not  to  be  expected.  The  pus  may  be  evacuated 
spontaneously  through  a  bronchus,  rupture  having  taken  place  through 
the  visceral  pleura.  "When  this  occurs,  a  large  amount  of  pus  may  be 
coughed  up  in  a  few  hours,  usually  followed  by  immediate,  but  not 
always  lasting,  improvement.  This  is  the  most  favourable  of  the  natu- 
ral terminations.  External  opening  may  take  place,  usually  about  the 
nip^jle.  There  is  an  area  of  redness,  then  a  fluctuating  tumour,  and 
finally  the  j^ointing  of  an  abscess.  The  discharge  may  continue  for 
months,  or  even  for  years.  External  opening  rarely  occurs  until  the 
disease  has  lasted  several  months.  Of  19  cases  of  emj^yema  in  children 
collected  by  Schmidt,  in  which  a  spontaneous  discharge  of  pus  occurred 
either  externall}'  or  through  a  bronchus,  there  Avere  17  deaths  and  2 
recoveries.  Empyema  may  burrow  behind  the  diaphragm  into  the  ab- 
dominal cavity,  appearing  as  a  psoas  abscess;  it  may  burrow  posteriorly 
into  the  lumbar  region;  it  may  rupture  into  the  cesophagus,  or  through 
the  diaphragm  into  the  peritoneal  cavity.  All  these  conditions,  how- 
ever, are  very  rare.  The  chances  of  spontaneous  cure  in  empyema  are 
small.  Of  32  eases,  reported  by  Eilliet  and  Barthez,  which  received 
no  surgical  treatment,  21  proved  fatal.  The  statistics  of  empyema  be- 
fore the  general  adoption  of  surgical  treatment  are  simply  appalling. 
Patients  were  either  worn  out  by  the  jDrotracted  suppuration,  or  died 
from  amyloid  degeneration,  pneumonia,  or  tuberculosis. 

Treatment. — The  medical  treatment  relates  to  the  patient  only;  the 
disease  is  always  to  be  treated  surgically.  Like  any  other  acute  abscess, 
empyema  requires  free  incision  and  drainage  with  proper  aseptic  pre- 
cautions. 

Aspiration  as  a  means  of  cure  has  been  almost  entirely  given  up  in 
ISTew  York.  Unquestionably  it  sometimes  suffices  to  cure  empyema,  most 
frequently  when  it  is  localized.  How  often  this  occurs  is  shown  by  the 
following  statistics :  Of  139  cases  which  I  collected  that  were  treated  by 
aspiration,  25  were  cured,  8  of  these  by  a  single  aspiration;  13  died,  and 
the  remaining  101  were  afterward  subjected  to  other  treatment.  The 
objections  to  aspiration  are,  that  it  is  not  possible  to  remove  all  the  pus; 
that  it  affords  no  opportunity  for  the  removal  of  the  large  fibrinous 
masses ;  and,  finall}^  that  it  is  only  a  possible  means  of  cure.  The  terror 
caused  by  repeated  aspirations  is  almost  as  great  as  that  of  incision  with- 
out anesthesia.  Aspiration,  therefore,  is  to  be  advised  in  children  only 
for  temporary  relief  when  the  amount  of  fluid  is  large  and  the  symp- 
toms are  urgent. 

Simple  incision  and  drainage. — If  possible  I  prefer  to  delay  opera- 
tion until  the  period  of  most  acute  inflammation  has  subsided,  as  shown 
by  lower  temperature  and  stationary  physical  signs.  This  is  usually  seen 
two  or  three  weeks  after  the  pleural  invasion.  Such  delay  is  not  admis- 
•sible  if  either  the  local  condition  or  the  temperature  points  to  a  steady 


EMPYEMA.  599 

increase  in  the  disease;  nor  when  the  general  symptoms  indicate  in- 
creasing prostration  or  sepsis.  The  dangers  attendant  upon  general 
anesthesia  are  considerable,  and  in  most  cases  it  is  better  not  to  em- 
ploy it.  I  have  known  of  four  deaths  on  the  table  during  operation, 
and  in  several  other  cases  have  seen  very  alarming  symptoms  occur. 
Chloroform  is  more  to  be  feared  than  ether.  We  should  therefore  rely 
upon  local  anassthesia  obtained  by  cocaine  or  by  a  spray  of  chloride  of 
ethyl  or  ether.  The  most  favourable  point  for  incision  is  the  poste- 
rior axillary  line  in  the  seventh  intercostal  space  upon  the  right  side, 
the  eighth  upon  the  left.  In  a  case  of  a  localized  empyema,  the  lowest 
point  at  which  pus  can  be  obtained  by  puncture  should  be  chosen.  The 
incision  is  made  in  the  middle  of  the  intercostal  space.  No  matter  what 
has  been  found  by  puncture  on  previous  occasions,  the  exploring  needle 
should  always  be  used  at  the  time  of  operation  and  at  the  site  of  the  inci- 
sion before  the  latter  is  made.  The  cutaneous  incision  should  be  an  inch 
and  a  half  long,  and  the  opening  in  the  pleura  made  large  enough  to  allow 
the  little  finger  of  the  operator  to  pass  into  the  pleural  cavity.  The  haem- 
orrhage is  very  rarely  sufficient  to  require  a  ligature.  The  wound  may  be 
held  open  by  forceps  or  a  tracheal  dilator,  and  as  much  of  the  fibrin  as 
possible  removed  at  the  time;  or,  if  the  patient's  condition  is  bad,  the 
tube  may  be  immediately  inserted  and  the  dressings  applied.  The  drain- 
age tube  should  be  of  heavy  rubber,  fenestrated,  three  eighths  or  half 
an  inch  in  diameter  and  four  or  five  inches  long.  It  is  passed  into  the 
deepest  pocket  of  the  empyema.  To  secure  it  from  slipping  into  the 
cavity,  its  outer  end  should  be  transfixed  by  a  large  safety-pin  before  its 
introduction.  It  is  usually  advisable  for  the  first  few  days  to  insert  two 
tubes  side  by  side.  This  diminishes  the  danger  of  stopping  the  discharge 
by  the  plugging  of  the  tube  with  fibrin.  Gauze  is  placed  over  the 
wound  beneath  the  safety-pin,  and  a  compress  of  the  same  over  the 
opening  of  the  tube,  the  dressing  being  completed  by  a  large  mass  of 
absorbent  cotton  and  a  snug  roller  bandage.  The  pus  now  slowly  escapes 
into  the  dressing  as  the  lung  expands.  When  there  is  no  reason  for  haste 
during  the  operation,  a  larger  part  of  the  pus  may  be  removed  before  the 
application  of  the  dressing.  This  should  be  allowed  to  escape  slowly, 
the  opening  being  closed  from  time  to  time  by  a  compress.  Ten  or  fif- 
teen minutes  may  be  consumed  in  evacuating  the  pus. 

Both  the  original  operation  and  the  subsequent  dressings  should  be 
done  with  strict  aseptic  precautions  on  account  of  the  danger  of  sec- 
ondary infection,  the  occurrence  of  which  adds  to  the  severity  and  ])ro- 
longs  the  course  of  the  disease.  For  the  first  day  or  two  the  dressings 
should  be  changed  twice  daily,  then  once  a  day  for  ten  days  or  two  weeks, 
and  later  at  longer  intervals.  After  the  third  day  the  second  tube  may 
be  omitted  and  tlie  remaining  one  gradually  shortened.  Usually  by 
the  end  of  the  third  week,  and  often  before,  the  tube  may  be  dispensed 


600 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


with  altogether,  the  tract  being  kept  open  by  a  small  roll  of  rubber  tis- 
sue. The  time  of  redressing  and  the  removal  of  the  tube  is  determined 
by  the  amount  of  discharge  and  the  temperature.  While  this  does  not 
usually  rise  after  the  second  day  unless  the  drainage  is  imperfect,  there 

are  a  number  of  conditions  which 
may  cause  it  to  do  so.  The  most 
important  are:  pneumonia,  either 
a  continuance  of  the  old  process 
or  lighting  up  of  a  new  one;  ab- 
scess of  the  lung ;  empyema  of  the 
opposite  side;  pericarditis;  tuber- 
culosis; abscess  from  a  necrosed 
rib;  or  some  cause  outside  the 
chest  —  otitis,  malaria,  indiges- 
tion, or  the  onset  of  some  other 
disease.  The  drainage  should  al- 
ways be  first  suspected.  The  tube 
is  often  blocked  by  masses  of 
fibrin,  even  when  one  of  large  size 
is  used.  At  each  dressing  it  is 
well  to  remove  it  to  see  if  it  is 
clear.  The  mistake  is  often  made 
of  allowing  the  tube  to  remain  for 
too  long  a  time,  so  that  a  sinus 
is  kept  open  which  would  other- 
wise heal.  Another  mistake  is 
that  of  allowing  a  very  large  tube 
to  remain  for  too  long  a  time; 
this  may  cause  erosion  of  the  pe- 
riosteum and  even  necrosis  of  a 
rib.  Washing  out  the  pleural 
cavity  is  indicated  only  in  cases  in 
which  the  pus  is  foul.  A  single 
washing  for  the  purpose  of  re- 
moving fibrin  is  the  routine  prac- 
tice of  some  surgeons.  For  this 
a  warm  sterilized  salt  solution 
should  be  used.  Personally  I  have  not  found  this  necessary.  Eepeated 
irrigations  should  not,  I  think,  be  employed.  The  usual  duration  of 
the  discharge  in  cases  treated  by  simple  incision  is  from  three  to  six 
weeks,  the  average  being  about  five  weeks. 

Resection  of  a  rib. — Many  of  the  best  surgeons  favour  this  as  a  rou- 
tine procedure,  with  the  belief  that  with  the  larger  opening  Avhich  is  thus 
made,  more  perfect  drainage  is  secured,  that  masses  of  fibrin  can  be 


Fig.  113. — Deformity  after  an  old  empyema  of 
the  left  side  for  which  Estlander's  operation 
was  performed.  Portions  of  five  ribs  were 
removed.  (From  a  photograph  seven  years 
after  operation.) 


EMPYEMA. 


601 


Temoved  with  greater  facility,  and  that  it  is  altogether  a  more  certain 
and  efficient  means  of  treatment  than  is  a  simple  incision,  ^yhile  ad- 
mitting some  of  the  advantages  claimed,  my  own  experience  has  been 
that  in  the  great  majority  of  recent  cases  in  young  chiklren,  simple  inci- 
sion ^yith  drainage  is  all  that  is  required.  Rib  resection  is  necessary 
whenever  good  drainage  can  not  be  secured  by  simple  incision;  especially 
if  there  is  overlapping  of  the  ribs,  or  if  the  intercostal  spaces  are  very 
narrow.  These  are  usually  the  cases  in  which  the  disease  has  lasted 
much  longer  than  the  average  time.  One  inch  of  rib  is  all  that  it  is 
necessary  to  remove.  The  periosteum  is  preserved,  and  there  is  rarely 
any  permanent  deformity. 

In  chronic  cases,  or  those  which  have  been  long  neglected,  some  fur- 
ther operative  treatment  is  often  necessary.  The  lung  is  so  bound  down 
by  firm  adhesions  that  further  expansion  is  impossible,  and  even  after 
the  chest  has  receded  to  its  utmost,  so  that  the  ribs  are  in  contact,  there 
still  remains  a  cavity  which  can  not  close.  For  such  cases  the  only  hope 
is  in  an  operation  by  which 
portions  of  several  ribs  are 
removed,  thus  allowing  a 
greater  collapse  of  the 
chest  Avail.  This  is  known 
as  thoracoplasty,  or  Estlan- 
der's  operation.  The  oper- 
ation is  of  itself  a  serious 
one,  and  only  to  be  advised 
as  a  last  resort  in  inveter- 
ate cases.  Such  an  opera- 
tion is,  of  course,  always 
followed  by  very  great  de- 
formity (Fig.  113). 

Methods  of  inducing  ex- 
pansion of  the  lung. — In 
most  of  the  cases,  particu- 
larly the  recent  ones,  com- 
plete expansion  of  the  lung 
takes  place  without  any  dif- 
ficulty, the  chief  agent  be- 
ing the  cough.  In  some  cases  this  may  bo  insufficient.  The  apparatus, 
devised  by  James  (Xew  York),  shown  in  the  accompanying  cut  (Fig. 
114)  serves  at  the  same  time  as  a  toy  for  the  child's  amusement  and 
as  a  most  efficient  means  of  inducing  forced  expiration.  One  bottle  is 
placed  a  few  inches  higher  than  the  other,  and  the  child  blows  a  coloured 
fluid  from  the  lower  into  the  higher  bottle,  allowing  it  to  siphon  back. 
Blowing  soap  bubbles  oft(>n  answers  the  same  jmrpose. 


Fig.  114.- 


Jamcs's  apparatus  for  e.xjiandiug  the  lung 
after  empyema. 


SECTION  y. 

DISEASES  OF   THE  CIRCULATORY  SYSTEM. 
CHAPTER   I. 

PECULIARITIES  OF    THE   HEART  AND    CIRCULATION  IN  EARLY 

LIFE. 

The  Fcetal  Circulation.— During  the  latter  part  of  foetal  life  tlie  circu- 
lation may  be  briefly  described  as  follows  :  The  purified  blood  comes  from 
the  placenta  through  the  umbilical  vein.  Entering  the  body,  it  divides  at 
the  under  surface  of  the  liver  into  two  branches,  the  smaller  one,  the  ductus 
venosus,  communicating  directly  with  the  inferior  vena  cava ;  the  larger 
branch  joining  the  portal  vein,  so  that  its  blood  traverses  the  liver,  and 
then  enters  the  inferior  vena  cava  through  the  hepatic  vein.  From  the 
inferior  vena  cava  the  blood  enters  the  right  auricle,  like  that  returned 
from  the  head  and  upper  extremities  by  the  superior  vena  cava.  A  part 
of  the  blood  now  passes  directly  into  the  left  auricle  through  the  foramen 
ovale  ;  the  remainder,  through  the  tricuspid  orifice  into  the  right  ventricle. 
As  the  requirements  of  the  pulmonary  circulation  are  not  great,  only  a 
small  part  of  the  blood  is  sent  through  the  pulmonary  artery  to  the 
lungs ;  the  greater  portion  passes  from  the  pulmonary  artery  through  the 
ductus  arteriosus  into  the  aorta,  joining  here  the  blood  from  the  left  ven- 
tricle. The  blood  thus  finds  its  way  from  the  right  heart  to  the  left,  onlj 
in  small  part  by  way  of  the  lungs,  the  greater  part  passing  directly  from 
the  right  auricle  to  the  left,  or  from  the  right  ventricle  into  the  aorta 
through  the  ductus  arteriosus.  From  the  aorta,  the  blood  reaches  the 
placenta  through  the  umbilical  arteries,  which  are  a  continuation  of  the 
hypogastric  arteries,  which  in  turn  are  given  off  from  the  internal  iliacs. 

Changes  in  the  Circulation  at  Birth. — With  the  ligation  of  the  umbil- 
ical cord,  the  circulation  through  the  umbilical  vein  and  arteries  and  the 
ductus  venosus  ceases.  With  the  establishment  of  respiration  and  the 
consequent  increased  demands  made  by  the  pulmonary  circulation,  the 
blood  ceases  almost  at  once  to  pass  through  the  ductus  arteriosus,  and  very 
soon  through  the  foramen  ovale.  The  umbilical  vessels  during  the  first 
few  days  of  life  are  filled  with  small  thrombi,  which  become  organized. 
By  the  end  of  the  first  week,  these  vessels,  as  well  as  the  ductus  venosus, 
are  usually  closed  at  their  extremities,  although  they  may  remain  patulous 
throughout  the  greater  part  of  their  extent  for  several  weeks.  They  sub- 
sequently atrophy  to  the  condition  of  small  fibrous  cords.    For  some  weeks. 

602 


THE   HEART   AND   CIRCULATION  IN  EARLY   LIFE.  g,)3 

before  birth  the  circulation  through  the  foramen  ovale  is  slight,  it  being 
gradually  obstructed  by  the  growth  of  a  septum  which  nearly  fills  the  space 
at  birth.  After  the  first  week  of  extra-uterine  life  very  little,  if  any,  blood 
passes  through  it,  although  complete  closure  of  the  foramen  often  does 
not  take  place  until  the  middle  of  the  first  year.  In  fully  one  fourth  of 
the  autopsies  I  have  made  upon  infants  under  six  months  old,  there  have 
been  found  minute  openings  at  the  margin  of  the  foramen  ovale,  but  they 
are  usually  oblique,  and  closed  by  the  valvular  curtain  so  as  effectually  to 
obstruct  the  current  of  blood.  The  ductus  arteriosus  is  first  closed  by  a 
clot,  which  becomes  organized  and  blends  with  the  products  of  a  prolif- 
erating arteritis.  It  is  rarely  found  open  after  the  tenth  day,  and  by  the 
twentieth  it  is  almost  invariably  obliterated. 

Tlie  Pulse. — The  pulse  in  early  life  is  not  only  more  frequent,  but  it  is 
very  much  more  variable  than  in  adults.  The  following  is  the  average 
pulse-rate  in  healthy  children  during  sleep  or  perfect  quiet  : 

Six  to  twelve  months 105  to  1 15  per  minute. 

Two  to  six  years 90  "  105   "         '• 

Seven  to  ten  years 80  "     90   "         " 

Eleven  to  fourteen  years 75  "     85   "  "■ 

The  pulse  is  a  little  more  frequent  in  females  than  in  males,  and  more 
frequent  when  sitting  than  when  lying  down.  Muscular  exercise  or  ex- 
citement increases  the  pulse-rate  by  from  twenty  to  fifty  beats.  Very 
trivial  causes  disturb  not  only  the  frequency  but  the  force  of  the  pulse. 
The  pulse  in  youHg  infants  may  be  irregular  even  in  health  and  during 
sleep.  When  rapid,  it  is  frequently  irregular  without  any  meaning.  Xo 
dicrotism  is  seen  in  the  pulse  wave  of  early  infancy,  according  to  Blanche.* 

The  circulation  is  much  more  active  in  infancy  than  in  later  childhood  ; 
thus,  according  to  Vierordt,  the  entire  round  of  the  circulation  is  accom- 
plished in  the  newly  born  in  twelve  seconds ;  at  three  years,  in  fifteen  sec- 
onds ;  in  the  adult,  in  twenty-two  seconds. 

Size  and  Growth. — The  relative  size  of  the  heart  is  slightly  greater  in 
infancy  than  in  later  life,  it  being  smallest  at  about  the  seventh  year. 
The  average  weight  at  the  different  periods  of  life  is  as  follows :  f 


Age. 

Ounces. 

Grammes. 

Ratio  to  body 
weight. 

Birth 

0-50 
1-25 

1-87 
2-25 

2-80 
5-84 
8-50 

141 
35 

53  r 

64  J 

80 
166 
241 

1  year 

2  years 

3  "     

1  to  225 

7     "     

1  to  280 

14    "     

1  to  222 

Adult 

1  to  226 

*  .See  tracings  in  Arcliives  of  Panliatrics,  vol.  v,  p.  732. 

•f  The  figures  in  infancy  are  from  one  hundred  and  fifty-five  observations  made  in 
the  New  York  Infant  Asvhini ;  the  others  are  taken  from  Sahli. 


504  DISEASES  OF   THE   CIRCULATORY  SYSTEM. 

The  growth  of  the  heart  is  rapid  during  the  first  three  years,  and 
nearly  proportionate  to  that  of  the  body.  It  is  slowest  from  the  third 
to  the  tenth  year,  and  most  rapid  from  the  eleventh  to  the  fifteenth 
year.  At  birth,  the  thickness  of  the  right  ventricle  is  very  nearly  the 
same  as  that  of  the  left,  the  ratio  being  6  :  7.  The  left  ventricle,  how- 
ever, grows  very  much  more  raj)idly  than  the  right,  so  that  at  the  end 
of  the  second  year  the  ratio  is  1:2,  which  is  nearly  that  of  the  rest  of 
childhood. 

Position  of  the  Apex  Beat. — In  the  infant  the  heart  is  placed  some- 
what higher,  and  occupies  a  position  a  little  nearer  the  horizontal  than  in 
the  adult.  This  is  partly  due  to  the  higher  position  of  the  diaphragm. 
The  apex  beat  is  therefore  higher  and  farther  to  the  left  than  in  adult 
life.  According  to  the  observations  of  Wassilewski  and  Starck,  whose 
combined  examinations  with  reference  to  this  point  were  made  upon  over 
2,100  children,  the  apex  beat  is,  as  a  rule,  outside  the  mammary  line  until 
the  fourth  year ;  if  it  is  less  than  one  third  of  an  inch  beyond  the  nipple, 
it  can  not  be  considered  abnormal.  From  the  fourth  to  the  ninth  year, 
the  apex  beat  is  in  or  near  the  mammary  line.  After  the  thirteenth  year, 
under  normal  conditions,  it  is  invariably  within  that  line.  During  the 
first  year  the  apex  beat  is  usually  found  in  the  fourth  intercostal  space ; 
from  the  first  to  the  seventh  year,  it  is  found  with  about  equal  frequency 
in  the  fourth  and  the  fifth  spaces ;  after  the  seventh  it  is  usually,  and  after 
the  thirteenth  year  it  is  always,  when  normal,  in  the  fifth  space.  The 
position  of  the  apex  beat  may  be  considerably  modified  by  severe  deformi- 
ties of  the  chest  resulting  from  rickets.  Pott's  disease,  or  lateral  curvature 
of  the  spine. 

Examination  of  the  Heart. — Inspection. — Bulging  of  the  prsecordia  is 
a  frequent  and  important  sign  of  cardiac  disease  during  childhood.  The 
cardiac  impulse  is  generally  weaker  than  in  the  adult,  and  often  it  is  diffi- 
cult to  locate  the  apex  beat  owing  to  the  thick  layer  of  adipose  tissue 
covering  the  chest. 

Palpation. — This  is  usually  a  much  more  satisfactory  method  than  is 
inspection  for  determining  the  position  of  the  apex  beat.  For  this  pur- 
pose the  child  should  be  in  the  sitting  posture,  with  the  body  inclined 
slightly  forward.  Great  displacement  of  the  apex  beat  is  always  signifi- 
cant, and  should  lead  one  to  suspect  pleuritic  effusion ;  lesser  degrees  of 
displacement  to  the  left  indicate  hypertrophy,  especially  of  the  left  ven- 
tricle ;  to  the  right,  hypertrophy  of  the  right  ventricle,  usually  with  a  con- 
genital malformation. 

Percussion. — This  is  best  done  by  means  of  the  percussion  hammer. 
A  light  blow  should  be  used,  on  account  of  the  thinness  and  elasticity  of 
the  chest  walls.  The  outline  of  the  area  of  "  relative  cardiac  dulness," 
especially  in  small  children,  is  proportionately  larger  than  in  the  adult. 
This  may  lead  to  the  mistaken  opinion  that  the  heart  is  enlarged,  when  it 


THE  HEART  xVXD   CIRCULATION  IN  EARLY  LIFE. 


605 


is  really  of  normal  size.  According  to  Sahli,*  the  limits  of  this  area  are  as 
follows  :  Above,  the  second  space  or  lower  border  of  the  second  costal  car- 
tilage ;  to  the  right,  at  the  para-sternal  line,  sometimes  slightly  beyond  it ;  to 
the  left,  at  or  slightly  beyond  the  mammary  line,  this  depending  upon  the 
age  of  the  child.    The  lower  border  is  indeterminable  on  account  of  the  liver. 

The  area  of  "  absolute  cardiac  dulness,"  or  that  part  of  the  heart  un- 
covered by  the  lung,  resembles  in  shape  the  same  area  in  the  adult,  but  it 
is  relatively  larger.  Its  ujDper 
limit  is  the  upper  border  of  the 
third  intercostal  space,  some- 
times the  third  costal  cartilage  ; 
it  extends  to  the  left  to  a  point 
between  the  para-sternal  and  the 
mammary  lines,  and  to  the  right 
as  far  as  the  left  border  of  the 
sternum.  These  two  areas  will 
be  readily  understood  by  refer- 
ence to  the  accompanying  dia- 
gram (Fig.  115). 

Auscultation. — This  is  of  lit- 
tle value  unless  the  child  is  quiet. 
The  preferable  position  is  the 
sitting  posture.  For  an  accu- 
rate diagnosis  the  stethoscope  is 
indispensable,  but  auscultation 


Fig.  115. — Showing  areas  of  cardiac  dulness :  a  is 
the  mammary  line  ;  6,  the  para-sternal  line  ;  Z, 
the  upper  border  of  the  liver.  The  space  en- 
closed Ijy  the  dotted  line  represents  the  area  of 
relative  dulness  ;  the  heavily  shaded  area,  that 
of  absolute  dulness.  (After  isahli,  slightly  modi- 
lied  by  Unger.) 


should  always  be  practised  with 
the  naked  ear  as  well.  The 
rhythm  and  rapidity  of  the 
•child's  heart  action  are  much 
more  easily  disturbed  than  are 
the  adult's,  and  such  disturbances  are  consequently  much  less  significant. 
The  rapidity  of  the  heart  in  infancy  is  ordinarily  so  great  as  to  make  it 
practically  impossible  to  distinguish  between  diastolic  and  presystolic  mur- 
murs. Normally,  the  loudest  sound  is  the  first  sound  at  the  apex ;  the 
weakest  sound  is  the  second  sound  at  the  aortic  orifice.  According  to 
Hochsinger,  the  accentuation  of  the  child's  heart-sounds  is  upon  the  first 
sound,  and  not  upon  the  second,  as  in  the  adult. 

In  consequence  of  the  small  size  and  the  thin  walls  of  the  chest,  all 
sounds,  both  normal  and  pathological,  appear  relatively  louder  than  in  the 
adult,  and  the  area  of  diffusion  is  therefore  much  greater.  Thus  it  is  a 
frequent  occurrence  for  murmurs  to  be  heard  all  over  the  chest  both  in 
front  and  behind. 


40 


*  Topographische  Percussion  iin  Kindesalter,  1883. 


606  DISEASES  OP   THE  CIRCULATORY  SYSTEM. 

Eeduplication  of  the  heart  sounds,  in  consequence  of  the  valves  of  the 
two  sid^s  not  closing  exactly  together,  is  not  uncommon  in  children,  and 
may  be  due  simply  to  excitement.  During  the  first  four  years  of  life 
nearly  all  the  abnormal  murmurs  heard  are  systolic. 

Accidental  murmurs  may  be  due  to  anasmia  and  other  blood  condi- 
tions, and,  although  not  so  common  as  in  older  patients,  they  are  by  no 
means  rare  even  in  infants. 


CHAPTER   11. 

CONGENITAL  AN031  ALIUS  OF  THE  HEART. 

Etiology. — The  causes  of  congenital  anomalies  of  the  heart  may  be 
grouped  under  three  general  heads  : 

1.  Malformations  resulting  from  imperfect  development  of  certain 
parts  of  the  heart,  most  frequently  one  of  the  septa.  Either  the  ventricu- 
lar or  the  auricular  septum  may  be  affected,  or  that  dividing  the  pulmo- 
nary artery  from  the  aorta.  Such  failure  in  development  perpetuates  condi- 
tions which  are  normal  in  the  early  months  of  foetal  life.  There  may  also 
be  atresia  of  any  one  of  the  orifices,  absence  of  one  or  more  of  the  valvular 
leaflets,  or  of  any  one  of  the  large  vessels. 

2.  Eoetal  endocarditis.  The  effects  of  this  condition  vary  according  to 
the  time  of  its  occurrence.  It  is  almost  invariably  of  the  right  side,  most 
frequently  affecting  the  pulmonic  valves.  Valvular  disease  in  foetal  life 
leads  not  only  to  hypertrophy  and  dilatation,  but  also  interferes  with 
the  normal  development  of  the  heart  by  preventing  the  closure  of  the 
auricular  or  ventricular  septum  or  the  ductus  arteriosus,  these  being  kept 
open  by  way  of  compensation. 

3.  Persistence  of  foetal  conditions,  such  as  the  foramen  ovale  or  ductus 
arteriosus.  This  may  be  the  result  of  valvular  disease,  as  previously 
stated,  or  of  some  condition  of  the  lungs,  such  as  atelectasis. 

Lesions. — In  the  following  table  are  given  the  lesions  found  in  two 
hundred  and  forty-two  cases,  which  I  have  collected  from  medical  litera- 
ture : 

Frequency  of  the  different  lesions  in  S4S  autopsies  upon  cases  of  congenital 

cardiac  anomaly. 

Defect  in  the  ventricular  septum 149  cases  ;  the  only  lesion  in  5  cases. 

Defect  in  the  auricular  septum,  or  patent  foramen 

ovale 126     "  "  "  9      " 

Pulmonic  stenosis  or  atresia 108     "  "  "  6     " 

Patent  ductus  arteriosus 68     "  "  "  3      " 


CONGENITAL   ANOMALIES   OF   THE   HEART. 


607 


Abnormalities  in  the  origin  of  the  great  vessels.  4o 

Pulmonic  insufficiency 17 

Tricuspid  insufficiency G 

Tricuspid  stenosis  or  atresia 3 

Mitral  insufficiency 1 

Mitral  stenosis  or  atresia 6 

Aortic  insufficiency 1 

Aortic  stenosis  or  atresia 6 

Transposition  of  the  heart 2 

Ectocardia 1 


the  only  lesion  in  0  cases. 

0  " 

0  " 

0  " 

0  " 

0  " 

0  " 

0  " 

0  " 
0     " 


The  most  frequent  associated  lesions. 

Pulmonic  stenosis,  with  defect  in  the  ventricular 

septum 92  cases  ;  the  only  lesion  in  20  cases. 

ulmonic  stenosis,  with  defect  in  the  auricular 

septum 52     "  "  "  8     " 

Defects  in  both  septa 82      "  "  "  17     " 

Pulmonic  stenosis  and  defects  in  both  septa 36     "  "  "  21     " 

From  this  table  it  will  be  seen  that,  in  the  great  majority  of  cases, 
several  lesions  are  present,  the  most  frequent  combinations  being  pul- 
monary stenosis  with  defective  ven- 
tricular septum,  pulmonic  stenosis 
with  defective  auricular  septum, 
the  three  lesions  associated,  or  the 
first  two  with  a  patent  ductus  arte- 
riosus. 

Defect  in  the  ventricular  sep- 
tum.— This  is  the  most  frequent 
lesion  in  congenital  cardiac  disease, 
and  in  half  the  cases  was  associated 
with  pulmonic  stenosis.  The  de- 
fect is  generally  at  the  upper  part 
of  the  septum  (Fig.  11(5).  Tt  is 
usually  from  one  fourth  to  one  half 
an  inch  in  diameter,  but  not  infre- 
quently there  is  a  large  defect,  and 
the  septum  may  be  entirely  absent, 
the  heart  then  consisting  of  but 
three  cavities — two  auricles  and 
one  ventricle.  If  the  auricular  sep- 
tum also  is  wanting,  as  is  often  the 
case,  the  heart  has  but  two  cavities. 

Frequently  there  are  also  abnormalities  in  the  origin  of  the  great  vessels. 
The  pulmonary  artery  and  the  aorta  may  be  given  off  from  the  common 
ventricle,  or  the  aorta  may  arise  ])artly  from  one  ventricle  and  partly  from 
the  other.     If  pulmonic  stenosis  or  atresia  is  jn-esent,  the  opening  in  the 


Fig.  116. — Congenital  cardiac  Jlscase.  Tlie  left 
ventricle  is  sliown  witli  a  defect  in  tlie  ven- 
tricular septum,  tlie  opening  being  just  be- 
neath the  aortic  valve.  (From  a  patient  dy- 
ing in  tlie  Babies'  IIo.spital.) 


608  DISEASES   OF   THE   CIRCULATORY  SYSTEM. 

ventricular  septum  is  conservative,  affording  a  channel  for  the  passage  of 
blood  from  the  right  to  the  left  side  of  the  heart. 

Patent  foramen  ovale,  or  defect  in  the  auricular  septum. — Although 
this  is  one  of  the  most  common  congenital  malformations,  it  is  not  one  of 
the  most  important.  It  rarely  occurs  alone,  but  is  frequently  found  with 
pulmonic  stenosis  or  a  defect  in  the  ventricular  septum.  Small  oblique 
openings  in  the  auricular  septum — usually  at  the  foramen  ovale — are  not 
infrequently  met  with  in  autopsies  upon  young  infants,  but  they  are  of  no 
importance.  In  pathological  conditions  the  opening  is  from  one  fourth 
to  one  inch  in  diameter,  and  there  may  be  more  than  on(^,  opening.  A  de- 
fect in  this  septum  is  frequently  secondary  to  pulmonic  stenosis,  or  it  may 
be  a  failure  in  development.  A  patent  foramen  ovale  may  be  due  to 
atelectasis. 

Patent  ductus  arteriosus. — As  a  solitary  lesion  this  is  rare,  but  it  is 
frequently  associated  with  pulmonic  stenosis,  usually  with  a  defect  in  one 
or  both  septa.  It  is  then  one  of  the  channels  by  which  the  blood  may  find 
its  way  to  the  lungs  when  the  pulmonary  orifice  is  obstructed.  It  is  not 
a  malformation,  but  simply  the  persistence  of  a  foetal  condition  usually 
necessitated  by  other  changes  in  the  heart. 

Pulmonic  ste?iosis. — This  is  one  of  the  most  frequent  and  most  im- 
portant lesions.  It  may  be  due  to  foetal  endocarditis,  or  to  a  mal- 
formation. If  the  former,  there  is  usually  stenosis ;  if  the  latter,  there 
may  be  atresia.  It  is  often  a  primary  lesion,  and  when  marked  it  is 
always  accompanied  by  other  changes,  most  frequently  by  a  defect  in  one 
or  both  septa  or  by  a  patent  ductus  arteriosus.  This  is  important,  as  be- 
ing more  constantly  associated  with  cyanosis  than  is  any  other  congeni- 
tal lesion.  The  amount  of  obstruction  varies  from  a  slight  narrowing 
of  the  orifice  to  complete  atresia.  If  there  is  atresia,  the  pulmonary  artery 
is  very  small,  and  may  be  rudimentary. 

Pulmonic  insufficiency. — This  lesion  is  relatively  rare.  It  is  usually 
the  result  of  fcetal  endocarditis,  but  there  may  be  absence  of  the  pulmo- 
nary valve.  It  is  most  frequently  associated  with  a  defect  in  the  ven- 
tricular septum. 

Tricuspid,  mitral,  ajid  aortic  disease  are  all  very  infrequent  and  usu- 
ally seen  in  cases  with  multiple  defects.  Atresia  or  stenosis  is  much  more 
common  than  insufficiency. 

Abnormalities  in  the  origin  of  the  large  vessels. — These  are  quite  fre- 
quent ;  but,  as  will  be  seen  from  the  table,  they  are  always  associated  with 
other  lesions.  Three  forms  are  seen  :  (1)  Transposition  of  the  large  vessels 
— the  pulmonary  artery  is  given  off  from  the  left,  and  the  aorta  from  the 
right  ventricle.  (2)  Both  arteries  arise  from  a  common  trunk.  This  is 
usually  due  to  an  incomplete  development  of  the  lower  part  of  the  sep- 
tum dividing  the  two  arteries.  Usually  the  pulmonary  artery  appears  to 
be  a  branch  of  the  aorta.     This  condition  is  frequently  associated  with 


CONGENITAL   ANOMALIES   OF  THE  HEART.  ^09 

other  abnormalities,  often  with  so  large  a  defect  in  the  ventricular  septum 
that  there  is  really  but  one  ventricle.  (3)  The  aorta  has  an  abnormal 
origin,  arising  from  the  right  ventricle,  or  partly  from  both  ventricles* 
This  also  is  associated  with  a  large  defect  in  the  ventricular  septum. 
When  described  as  arising  from  both  ventricles,  the  aorta  is  usually  given 
off  directly  above  the  line  of  the  septum. 

In  addition  to  these  main  deformities,  there  are  many  others  which 
need  not  be  more  than  mentioned.  An  abnormality  in  the  number  of 
valvular  segments  is  quite  a  frequent  occurrence,  but  does  not  usually 
impair  the  valve's  function.  In  rare  cases  a  valve  is  rudimentary,  and 
it  may  be  entirely  absent,  generally  at  the  pulmonic  or  tricuspid  orifice. 
Absence  of  the  right  auricle  and  absence  of  the  pericardium  have  been 
recorded ;  also  opening  of  the  pulmonary  veins  into  the  right  auricle,  and 
a  single  pulmonary  artery.  In  one  case  in  the  series  there  was  ectocardia, 
this  being  associated  with  a  congenital  fissure  of  the  sternum. 

Transposition  of  the  heart,  or  true  dextro-cardia,  was  recorded  but 
twice  in  this  series  of  cases.  It  was,  however,  simulated  in  several  others, 
including  one  of  my  own,  where  the  apex  beat  was  to  the  right  of  the 
sternum.  There  was  in  this  case  great  hypertrophy  of  the  right  ventricle 
with  a  rudimentary  ventricular  septum. 

Secondary  lesions. — In  congenital  malformations  the  right  heart  is 
usually  found  hypertrophied,  since  there  remain  one  or  more  of  the  foetal 
conditions  in  which  the  greater  part  of  the  work  is  thrown  upon  the 
right  ventricle.  Such  hypertrophy  is  in  most  cases  accompanied  by  some 
dilatation,  and  often  there  is  dilatation  of  the  right  auricle.  Changes  in 
the  wall  of  the  left  heart  alone  are  exceedingly  rare.  In  four  cases  there 
was  evidence  of  malignant  endocarditis,  which  was  the  cause  of  death, 
all  but  one  of  these  patients  being  adults. 

Symptoms. — The  symptoms  of  congenital  cardiac  disease  are  usually 
manifested  soon  after  birth,  although  this  is  not  always  the  case.  Of  128 
cases  in  which  the  time  of  the  first  symptoms  was  noted,  they  were  con- 
genital, or  appeared  during  the  first  month,  in  85  ;  after  one  month  and 
during  the  first  year,  in  18  ;  from  one  to  sixteen  years,  in  15  ;  while  in  10 
no  symptoms  were  observed  until  after  puberty.  Congenital  cardiac  dis- 
ease is  one  of  the  causes,  but  not  a  frequent  one,  of  death  during  the  first 
few  days  of  life.  This  may  be  directly  due  to  convulsions,  asphyxia,  or 
syncope. 

The  most  striking  objective  symptom  is  cyanosis.  This  was  noted  in 
88  per  cent  of  the  cases  in  which  histories  were  given.  Congenital  cardiac 
disease  is  very  apt  to  be  overlooked  when  cyanosis  is  absent,  as  it  may  be 
even  with  very  serious  lesions.  Cyanosis  may  be  slight  and  noticed  only 
upon  exertion,  as  upon  coughing  or  crying,  or  it  may  be  intense  and  con- 
stant, giving  the  skin  a  dark,  leaden  colour,  and  the  mucous  membrane 
of  the  mouth  a  raspberry  hue.     The  view  that  cyanosis  depends  upon  an 


610 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


Fig. 


117. — Clubbing  of  the  fingers  in  congenital  heart  disease. 
(From  a  boy  five  years  old.) 


admixture  of  arterial  and  venous  blood  is  generally  discredited.  In  the 
great  majority  of  the  cases  at  least,  the  explanation  is  a  deficient  oxi- 
dation of  the  blood 
in  the  lungs,  owing 
to  some  interfer- 
ence with  the  pul- 
monary circulation. 
In  63  per  cent  of  the 
cases  of  cyanosis  in 
the  series,  there  was 
found  pulmonic  ste- 
nosis or  atresia,  or 
a  small  pulmonary 
artery.  Cyanosis  is 
of  much  value  in 
diagnosis,  as  it  is 
rarely  seen  in  ac- 
quired cardiac  dis- 
ease. The  degree  of 
cyanosis  and  its 
constancy  are  of 
some  importance  in 
determining  the  gravity  of  the  lesion,  although  these  alone  are  not  to 
be  depended  upon.  Another  frequent  symptom  is  the  enlargement  of 
the  terminal  phalanges  known  as  clubbing  of  the  fingers  (Fig.  117)  and 
toes.  This  enlargement,  which  usually  involves  all  the  phalanges,  is 
probably  due  to  venous  obstruction.  Occasionally  there  are  seen  dysp- 
noea, oedema  of  the  face  or  lower  extremities,  dropsy  of  the  serous  cavi- 
ties, and  hsemorrhages,  particularly  hgemoptysis  and  epistaxis. 

Diagnosis. — The  most  diagnostic  features  of  congenital  cardiac  dis- 
ease are  cyanosis,  the  presence  of  a  loud  cardiac  murmur,  and  signs  of 
enlargement  of  the  right  heart. 

Murmurs  were  present  in  four-fifths  of  the  cases  in  which  histories 
were  given.  The  most  characteristic  is  a  systolic  murmur,  loudest  at  the 
left  base  and  diffused  over  a  large  area.  A  systolic  murmur  alone  was 
heard  in  60  cases,  a  double  murmur  in  11,  a  diastolic  and  a  presystolic  in 
one  case  each.  A  systolic  murmur  may  be  due  to  pulmonic  stenosis,  defi- 
cient ventricular  septum,  patent  ductus  arteriosus,  mitral  regurgitation, 
tricuspid  regurgitation,  or  aortic  stenosis.  Since  these  conditions  are 
very  often  associated,  it  is  difficult  to  tell  upon  which  one  the  murmur 
depends.  In  over  two-thirds  of  the  cases  in  which  the  murmur  was  local- 
ized it  was  at  the  base  of  the  heart,  and  in  the  great  majority  of  these  it 
was  loudest  at  the  left  base,  in  the  second  or  third  space  at  the  border  of 
the  sternum  and  transmitted  toward  the  left  shoulder.     Apex  murmurs 


CONGENITAL  ANOMALIES   OF   THE  HEART.  611 

were  heard  in  but  one-fourth  of  the  cases.  The  murmurs  are  usually 
very  loud,  rough,  and  often  out  of  proportion  to  the  other  signs  present. 
Frequently  they  may  be  heard  all  over  the  chest,  both  in  front  and  be- 
hind. In  a  young  child,  a  loud  murmur  at  the  base,  with  cyanosis,  almost 
always  means  congenital  disease;  in  acquired  disease  loud  murmurs  are 
nearly  always  at  the  apex,  and  are  accompanied  by  marked  hypertrophy. 

Enlargement  of  the  right  heart,  chiefly  from  ventricular  hypertrophy, 
was  present  in  86-5  per  cent  of  the  cases.  In  about  one  half  of  these  there 
was  hvpertrophy  of  the  left  ventricle,  but  this  was  rarely  seen  alone.  The 
signs  of  hypertrophy  of  the  right  ventricle  are:  dulness  extending  to  the 
right  of  the  sternum,  displacement  of  the  apex  beat  to  the  right,  epigastric 
pulsation,  and  sometimes  bulging  of  the  lower  portion  of  the  sternum. 

A  diagnosis  of  the  precise  nature  of  the  malformation  is  very  difficult, 
and  in  the  great  majority  of  cases  only  a  probable  diagnosis  is  possible. 
Nearly  all  the  cases  are  complex,  and  the  variety  of  combinations  is  very 
great.  A  study  of  the  histories  and  autopsies  of  the  cases  in  this  series 
reveals  many  apparently  contradictory  facts.  Loud  murmurs  are  some- 
times heard  which  are  difficult  to  explain  by  the  lesions,  and  murmurs 
may  be  absent  when  there  is  every  reason  from  the  post-morten  findings 
for  expecting  their  presence.  Certain  lesions  like  aortic  stenosis,  mitral 
stenosis,  and  mitral  regurgitation  may  be  accompanied  by  the  same  signs 
as  in  acquired  disease.  With  reference  to  the  other  conditions,  I  can  not 
do  better  than  give  the  more  frequent  clinical  symptoms  with  the  results 
of  the  autopsies  in  the  series  of  cases  which  I  have  collected. 

A  systolic  murmur  at  the  base,  ivith  cyanosis. — This  is  the  most  com- 
mon combination  met  with,  and  was  present  in  about  one  third  of  all  the 
cases.  In  over  80  per  cent  of  the  cases  with  these  symptoms,  pulmonic 
stenosis  was  found.  The  remainder  were  complicated  cases  of  quite  a 
wide  variety.  Pulmonic  stenosis  was  usually  associated  with  a  defect  in 
one  of  the  cardiac  septa,  or  a  patent  ductus  arteriosus. 

A  systolic  murmur  without  cyanosis. — In  the  cases  followed  to  au- 
topsy this  was  not  a  frequent  combination,  being  noted  but  six  times,  and 
-usually  dependent  upon  a  defect  in  the  ventricular  septum  without  pul- 
monic stenosis,  or  upon  tricuspid  regurgitation.  Judging  from  my  own 
clinical  experience,  a  systolic  murmur  without  cyanosis  is  much  more 
common  than  is  indicated  by  these  figures ;  it  may  sometimes  be  due  to 
narrowing  of  the  aorta. 

A  systolic  murmur  at  the  apex  ivith  cyanosis. — Of  the  six  cases  with 
this  combination,  all  were  examples  of  complex  malformation,  the  most 
frequent  lesions  being  a  defect  in  the  auricular  septum,  transposition  of 
the  great  vessels,  and  patent  ductus  arteriosus. 

Cyanosis  without  murmurs  was  noted  fourteen  times.  It  indicates 
either  ]tulmonic  atresia  or  the  transposition  or  irregular  origin  of  the 
great  vessels. 


Q12  DISEASES   OF   THE   CIRCULATORY  SYSTEM. 

Diastolic  murmurs  were  heard  in  two  cases,  and  depended  upon  pul- 
monic insufficiency. 

A  presystolic  murmur  was  noted  in  a  single  case.  It  was  localized  at 
the  right  base,  and  the  only  lesion  was  a  patent  foramen  ovale. 

Absence  of  both  cyatiosis  and  murmurs  was  recorded  in  five  cases. 
The  lesions  found  were :  atresia  of  the  aorta,  both  arteries  arising  from. 
the  right  ventricle,  or  defective  septa. 

It  will  be  seen  that  about  the  only  cases  in  which  a  fairly  positive 
diagnosis  can  be  made  are  those  of  pulmonic  stenosis  with  a  deficient  ven- 
tricular septum.  Enlargement  of  the  right  heart,  being  common  to 
nearly  all  the  varieties,  is  of  no  diagnostic  value. 

Diagnosis  of  congenital  from  acquired  disease. — Congenital  disease- 
may  be  suspected  if  the  patient  is  under  two  years  of  age;  if  there  is  no 
history  of  previous  rheumatism;  if  the  murmur  is  atypical  in  its  location,, 
character,  or  transmission;  if  there  is  a  very  loud  murmur  at  the  base, 
and  if  there  is  evidence  of  enlargement  of  the  right  heart.  If  cyanosis 
and  clubbing  of  the  fingers  are  present  the  diagnosis  is  certain. 

Diagnosis  of  congenital  from  aticemic  murmurs. — This  is  often  a  more 
difficult  matter  than  to  decide  between  congenital  and  acquired  disease. 
From  a  murmur  alone  one  should  be  very  cautious  in  making  a  diagnosis 
of  cardiac  malformation  in  a  very  ansemic  infant.  Ansemic  murmurs  are 
systolic,  basic,  unaccompanied  by  enlargement  of  the  heart ;  usually  heard 
in  the  carotids,  often  in  the  subclavian  arteries,  but  are  seldom  so  loud  as 
those  due  to  malformations.  In  some  cases  it  may  be  necessary  to  watch 
the  effect  of  treatment  or  the  course  of  the  disease  before  deciding  the 
question. 

Prognosis. — Of  225  cases,  60  per  cent  were  fatal  before  the  end  of  the 
fifth  year,  and  nearly  one  half  of  these  during  the  first  two  months ;  while 
16  per  cent  of  the  cases  lived  over  sixteen  years,  and  8  per  cent  over  thirty 
years.  The  prognosis  in  any  given  case  is  to  be  made  from  the  general 
condition  of  the  patient  and  how  well  the  circulation  is  carried  on,  rather 
than  from  the  intensity  of  the  cyanosis  or  the  character  of  the  murmur^ 
although  extreme  cyanosis  is  always  unfavourable. 

In  the  cases  fatal  soon  after  birth  the  usual  lesions  are  large  defects  in 
the  septa,  transposition  of  the  great  vessels,  or  pulmonic  atresia.  In  five 
of  twenty-three  cases  dying  thus  early,  the  heart  had  but  two  cavities.  Le- 
sions which  are  compatible  with  the  longest  life  are  minor  septum  defects, 
and  pulmonic  stenosis  which  can  be  compensated  for  by  hypertrophy  of  the 
right  ventricle.  Many  exceptional  instances  are  recorded  in  which  patients 
have  lived  a  long  time  in  spite  of  extreme  deformities.  One  child  with 
transposition  of  the  pulmonary  artery  and  aorta  lived  two  and  a  half  years. 
Tiedmann's  case  lived  eleven  years  with  a  heart  consisting  of  three  cavities 
— two  auricles  and  one  ventricle — and  with  constant  cyanosis.  In  three 
cases  reported  by  Rokitansky,  the  patients  lived  over  forty  years  with  rudi- 


PERICARDITIS.  613 

mentary  auricular  septa  and  no  cyanosis  mentioned.  Gelpke's  case  had 
cyanosis,  and  lived  twenty-seven  years  with  rudimentary  auricular  and 
ventricular  septa,  and  with  no  tricuspid  opening. 

Treatment. — No  treatment  is  of  the  slightest  avail  in  diminishing  the 
amount  of  deformity  or  promoting  the  closure  of  any  of  the  abnormal 
openings.     All  cases  are  to  be  treated  symptomatically. 


CHAPTER  III. 

PERICARDITIS. 

Inflammation"  of  the  pericardium  is  a  rare  disease  in  infancy  and 
early  childhood,  only  two  cases  being  seen  in  seven  hundred  and  twenty- 
six  consecutive  autopsies  at  the  New  York  Infant  Asylum.  In  later 
childhood  the  disease  is  more  frequent.  In  its  etiology,  symptoms,  and 
course  it  resembles  quite  closely  the  same  disease  in  adults. 

Etiology. — Of  69  cases  of  pericarditis  in  children  under  fourteen  years 
of  age,  24  occurred  before  the  third  year,  12  between  the  third  and  sev- 
enth years,  and  33  between  the  seventh  and  fourteenth  years.  It  has  been 
seen  in  the  newly  born,  and  has  been  found  even  in  the  foetus. 

Pericarditis  is  almost  invariably  a  secondary  disease,  following  (1) 
pleurisy  or  pleuro-pneumonia ;  (2)  acute  rheumatism ;  (3)  acute  infectious 
diseases,  especially  scarlet  fever ;  (4)  pyaemia ;  (5)  tuberculosis ;  (6)  local 
conditions.  The  relative  importance  of  these  causes  differs  w^ith  the  age 
of  the  child.  In  infancy  and  early  childhood  most  of  the  cases  compli- 
cate disease  of  the  lung  or  pleura,  usually  of  the  left  side.  After  the  fourth 
year  rheumatism  takes  the  first  place  as  an  etiological  factor.  Pericar- 
ditis is  then  generally  associated  with  endocarditis,  and  may  precede  or 
follow  the  articular  manifestations  of  rheumatism.  Following  scarlet  fever, 
pericarditis  generally  occurs  in  connection  with  nephritis  or  multiple  joint 
inflammations.  In  typhoid  fever,  also,  it  is  usually  associated  with  pneu- 
monia or  joint  lesions.  Pyremia  may  be  a  cause  in  the  newly  born,  or  it 
may  occur  in  connection  with  disease  of  the  bones  or  joints  in  older  chil- 
dren ;  in  both  it  is  usually  associated  with  similar  lesions  of  other  serous 
membranes.  Tuberculous  pericarditis  is  more  frequent  after  the  third 
year,  and  is  generally  secondary  to  pulmonary  tuberculosis.  Among  the 
local  causes  may  be  mentioned  traumatism,  ulceration  of  a  foreign  body 
from  the  oesophagus  into  the  pericardium,  disease  of  the  sternum,  ribs,  or 
vertebrae,  and  abscesses  resulting  from  cheesy  bronchial  lymph  nodes. 

Lesions. — 1.  Pericardial  transudations,  or  an  increase  in  the  normal 
pericardial  fluid,  are  met  with  in  many  conditions  in  which  there  is  a 


614  DISEASES   OF   THE   CIRCULATORY  SYSTEM. 

very  marked  degree  of  anaemia,  general  dropsy,  or  a  weak  heart,  particu- 
larly of  the  right  side,  G-enerally  from  one  and  a  half  to  two  ounces  of  a 
clear  serum  are  found  in  the  pericardial  sac. 

2.  External  or  mediastinal  pericarditis  is  always  associated  with 
mediastinal  pleurisy,  and  results  in  more  or  less  extensive  adhesions  of 
the  pericardial  and  pleural  surfaces,  with  an  increase  in  the  connective 
tissue  of  the  mediastinum.  It  is  often  a  tuberculous  process.  When 
severe,  it  may  cause  compression  of  the  large  blood-vessels,  and  seldom  in 
any  other  way  produces  symptoms.  With  this  form  there  may  be  inflam- 
mation of  the  internal  layer  of  the  pericardium.  It  is  only  inflammation 
of  the  internal  layer  which  is  ordinarily  considered  as  pericarditis,  the 
other  form  being  preferably  classed  as  mediastinitis. 

3.  Dry  pericarditis. — This  may  be  either  general  or  localized.  If  the 
latter,  it  is  more  often  seen  at  the  base  than  at  the  apex  of  the  heart.  The 
two  opposing  surfaces  are  usually  involved.  As  a  result  of  the  inflamma- 
tion they  are  coated  with  fibrin,  which  may  be  partly  absorbed,  but  usu- 
ally leaves  behind  bands  of  adhesions  of  greater  or  less  extent.  From  re- 
peated attacks  there  may  result  complete  obliteration  of  the  pericardial  sac. 

4.  The  sero-fih7^inous  form — pericarditis  with  effusion. — This  is  the 
most  common  variety.  The  heart  appears  roughened  from  the  exudate 
which  often  completely  covers  it,  forming  bands  which  extend  from  one 
surface  to  the  other.  The  serum  may  be  clear,  or  contain  flakes  of  lymph, 
and  varies  in  amount  from  a  few  ounces  to  a  pint.  In  cases  terminating 
in  recovery  there  is  gradual  absorption  of  the  serum  and  part  of  the 
fibrin,  but  adhesions  more  or  less  extensive  always  remain. 

5.  Purulent  pericarditis. — If  the  inflammation  is  set  up  by  a  foreign 
body  ulcerating  into  the  sac,  by  the  rupture  of  a  mediastinal  abscess,  or 
by  general  pyaemia,  the  process  may  be  purulent  from  the  outset.  More 
frequently,  however,  in  purulent  pericarditis  there  is  first  an  abundant 
exudation  of  fibrin  with  pus  cells  in  its  meshes,  and  subsequently  the 
pouring  out  of  fluid  pus,  precisely  as  in  empyema,  with  which  it  is  very 
often  associated.  If  death  occurs  in  the  early  stage,  both  surfaces  of  the 
pericardium  are  found  coated  with  a  thick  exudate  of  greenish-yellow 
lymph,  but  little  or  no  fluid  pus  may  be  present.  At  a  later  period  the 
pericardial  sac  contains  pus,  which  may  vary  in  amount  from  a  few 
ounces  to  one  or  two  pints.  Purulent  pericarditis,  which  is  secondary  to 
pneumonia  or  pleurisy,  is  usually  due  to  the  pneumococcus.  In  other  cases 
any  of  the  pyogenic  germs  may  be  found. 

6.  Pericarditis  with  an  eff'usion  of  ilocd  is  very  rare  in  children.  It 
may  occur  from  the  rapture  of  organized  adhesions  or  in  certain  blood 
states  such  as  purpura,  and  very  rarely  in  tuberculosis. 

Pericarditis  complicating  pneumonia  and  pleurisy  is  generally  fibrinous 
or  fibrino-purulent ;  that  with  rheumatism  is  sero-fibrinous,  and  often 
accompanied  by  endocarditis.     With  acute  tuberculosis  there  is  usually 


PERICARDITIS.  gl5 

only  a  deposit  of  miliary  tubercles,  or  there  may  be  a  small  serous  or  sero- 
sanguinolent  effusiou.  In  chronic  cases  there  may  be  a  tuberculous  in- 
flammation with  the  formation  of  caseous  nodules,  new  connective  tissue, 
and  extensive  adhesions.  This  generally  occurs  in  connection  with  pul- 
monary tuberculosis — sometimes  with  tuberculous  peritonitis. 

In  any  form  of  pericarditis  complete  recovery,  so  far  as  pathological 
conditions  are  concerned,  is  rare — if,  indeed,  it  ever  occurs.  Generally 
adhesions  remain,  which  may  be  in  the  form  of  a  few  thin  connective- 
tissue  bands,  or  so  extensive  as  to  produce  almost  entire  obliteration  of 
the  pericardial  sac.  Such  adhesions  are  usually  followed  by  secondary 
changes.  The  growth  and  development  of  the  heart  are  interfered  with, 
and  there  may  be  sufficient  pressure  upon  the  coronary  vessels  to  lead  to 
degeneration  of  the  muscular  walls  and  dilatation  of  the  heart.  With 
large  fluid  exudations  there  maybe  an  interference  with  the  systemic  circu- 
lation, enlargement  of  the  spleen  and  liver,  and  sometimes  general  dropsy. 

Symptoms. — A  pericardial  transudation,  or  dropsy  of  the  pericardium, 
is  very  rarely  large  enough  to  make  a  diagnosis  possible. 

External  pericarditis  is  seldom  recognised  during  life,  there  being  no 
symptoms  except  those  of  the  pleurisy  with  which  it  is  associated.  Occa- 
sionally there  may  be  heard,  particularly  if  the  inflammation  is  anterior, 
a  pleuritic  friction  sound  which  is  increased  with  the  systole  of  the  heart. 
The  pulse  may  be  weak  during  inspiration,  and  there  may  be  an  increased 
area  of  cardiac  dulness.  If  the  inflammation  is  chiefly  posterior,  it  causes 
only  the  symptoms  of  mediastinitis,  which  is  recognised  principally  by  its 
pressure  effects  upon  the  great  vessels.  It  may  produce  oedema  of  the 
face  or  of  the  lower  extremities,  ascites,  enlargement  of  the  liver  and 
spleen,  but  rarely  albuminuria.  It  is  usually  progressive,  and  lasts  from  a 
few  months  to  two  or  three  years,  according  to  its  cause. 

Inflammation  of  the  internal  layer  is  the  only  form  usually  described 
as  pericarditis.  This  is  very  frequently  overlooked,  not  only  on  account 
of  its  rarity,  but  from  the  obscurity  of  its  symptoms.  Tlie  difficulty  in 
diagnosis  is  particularly  great  in  young  children.  The  symptoms  are  few, 
and  many  of  them  are  equivocal.  As  this  disease  is  nearly  always  second- 
ary, the  physician  should  be  on  the  watch  for  it  in  infants  with  pleurisy 
or  pleuro-pneumonia  of  the  left  side,  and  in  older  cliildren  in  the  course 
of  articular  rheumatism.  Localized  pain  and  tenderness  may  be  present, 
and  also  a  certain  amount  of  embarrassment  of  the  heart's  action,  usually 
manifested  by  prt^^cordial  distress,  palpitation,  and  slight  irregularity  of 
the  pulse.  There  may  be  dyspnoea,  and  if  there  is  a  large  effusion  present 
there  may  be  orthopncea  and  cyanosis.  Sometimes  there  is  delirium. 
When  pericarditis  follows  pleurisy  or  pleuro-})neunionia  there  are  fre- 
quently no  new  symptoms  added. 

The  physical  signs  in  older  children  resemble  those  in  adults.  In  dry 
pericarditis  there  is  usually  heard  a  double  friction  sound  over  the  pra^cor- 


616  DISEASES  OP  THE   CIRCULATORY  SYSTEM. 

dial  space,  the  area  being  generally  small  and  near  the  base  of  the  heart. 
The  sound  is  not  transmitted,  and  bears  no  relation  to  the  respiratory 
movements.  After  effusion  has  taken  place  the  apex  beat  may  be  dis- 
placed upward,  diffused,  and  somewhat  indistinct,  or  it  may  not  be  found 
at  all.  There  may  be  bulging  of  the  chest  wall.  On  palpation,  there  is  an 
absence  of  vocal  fremitus  over  an  area  usually  occupied  by  the  lung.  Per- 
cussion gives  an  area  of  marked  dulness  or  flatness  of  triangular  shape, 
the  base  being  below  and  the  apex  above.  The  normal  area  of  cardiac 
dulness  is  increased  in  all  directions,  and  this  dulness  extends  beyond  the 
limits  of  the  heart.  On  auscultation,  the  heart  sounds  are  feeble  and  dis- 
tant. Friction  sounds  disappear  as  serum  is  poured  out,  and  reappear  as 
it  is  absorbed.  Endocardial  murmurs  may  also  be  present.  In  infants, 
physical  signs  are  often  entirely  wanting,  or  the  normal  sounds  may  be 
feeble,  distant,  or  absent. 

The  usual  duration  of  acute  pericarditis  is  from  one  to  three  weeks. 
The  ordinary  dry  form,  with  its  resulting  adhesions,  may  be  followed  by  a 
subacute  or  chronic  form  of  the  disease.  In  the  sero-fibrinous  form  the 
serum  is  usually  absorbed  quite  promptly,  and  only  adhesions  are  left,  or 
a  chronic  inflammation  follows,  with  exacerbations  in  each  recurrence 
of  rheumatism.  In  the  purulent  form  of  the  disease  in  young  children, 
death  is  the  most  frequent  termination.  If  the  pus  is  evacuated,  or  spon- 
taneous opening  takes  place,  there  may  be  recovery,  but  always  with  more 
or  less  extensive  adhesions  remaining. 

Prognosis. — Of  thirty-five  cases  in  Steffen's  collection,  only  six  recov- 
ered. This  statement  is  to  be  taken  rather  as  evidence  of  the  great  diffi- 
culty of  diagnosis  than  of  a  very  high  mortality,  although  the  disease  is 
always  a  serious  one.  The  prognosis  depends  chiefly  upon  the  exciting 
cause.  When  due  to  pyasmia  or  the  acute  infectious  diseases,  or  when  ex- 
tending from  pleurisy  or  pneumonia,  the  prognosis  is  bad.  Here  it  is  usu- 
ally the  primary  disease  rather  than  the  pericarditis  which  is  the  cause  of 
death;  the  latter  may  be  the  case,  however,  if  the  effusion  is  large.  The 
cases  in  which  the  pericarditis  itself  is  the  most  important  disease  are 
those  depending  upon  rheumatism.  Although  immediate  danger  to  life 
may  not  often  be  great,  yet  the  remote  consequences  of  the  disease,  by  rea- 
son of  adhesions  and  subsequent  dilatation,  are  frequently  very  serious. 

Diagnosis. — Owing  to  the  very  rapid  action  of  the  heart  in  children, 
acute  dry  pericarditis  presents  difficulties  of  diagnosis  in  early  life  which 
are  not  met  with  in  the  adult.  The  disease  is  fortunately  so  rare  under 
three  years,  that  in  ordinary  practice  it  need  seldom  be  considered.  In 
older  children  the  diagnosis  is  to  be  made  by  essentially  the  same  signs  as 
in  adults.  Pericarditis  with  effusion  is  to  be  diagnosticated  from  dilata- 
tion of  the  heart  and  from  pleuritic  effusions.  From  dilatation,  the  diag- 
nosis is  not  often  difficult  in  childhood,  for  this  is  not  a  common  con- 
dition, and  is  rarely  extreme  except  in  advanced  valvular  disease.    From 


CHRONIC   PERICARDITIS  WITH   ADHESIONS.  617 

pleuritic  effusions  the  diagnosis  is  at  times  almost  impossible.  Signs 
pointing  to  a  sacculated  empyema  of  the  left  side  anteriorly  should  al- 
"wa3^s  be  regarded  with  suspicion,  particularly  if  the  apex  beat  is  not  dis- 
placed to  the  right,  and  if  the  heart  sounds  are  very  feeble.  When  empy- 
ema and  pericarditis  coexist,  it  may  be  impossible  to  recognise  the  condi- 
tion. The  diagnosis  between  serous  and  purulent  effusions  can  be  made 
only  by  aspiration.  Fluid  effusions  in  infants  are  almost  invariably 
purulent,  and  so  also  are  they  in  the  majority  of  cases  in  older  children, 
unless  due  to  rheumatism. 

Treatment. — In  the  early  part  of  an  attack  of  acute  pericarditis  the 
patient  should  be  kept  in  bed  and  as  quiet  as  possible,  and  hot  poultices 
or  counter-irritation  by  mustard  used  over  the  heart.  Sometimes  an  ice 
bag  may  with  advantage  be  substituted.  Excessive  heart  action  may  be 
controlled  by  aconite,  and  severe  pain  requires  usuall}^  opium.  If  the  dis- 
€ase  is  due  to  rheumatism,  anti-rheumatic  remedies  should  be  employed. 
Serous  effusions  usually  subside  under  simple  tonic  treatment.  If  ab- 
sorption is  slow,  it  may  be  hastened  by  counter-irritation.  When  a  large 
effusion  forms  rapidly  there  may  be  danger  of  death  from  syncope. 
Symptoms  which  indicate  an  unfavourable  termination  are  cyanosis, 
weak,  irregular  pulse,  and  great  dyspnoea,  or  orthopnoea.  Under  these 
conditions  aspiration  may  afford  temporary  relief,  and  free  diuresis 
should  be  induced  by  citrate  of  potash  and  caffein.  The  inhalation  of 
oxygen  is  at  times  of  great  value  in  cases  presenting  such  urgent  symp- 
toms. If  pus  is  shown  to  be  present  by  puncture,  incision  and  drainage 
should  be  practised,  as  in  empyema.  The  results  of  aspiration  in  such 
cases  are  extremely  unfavourable.  Of  eighteen  cases  of  aspiration  of  the 
pericardium  collected  by  Keating,  only  four  recovered.  In  puncturing 
the  pericardium  the  point  usually  selected  is  a  little  to  the  left  of  the 
border  of  the  sternum  in  the  fifth  intercostal  space,  the  needle  being 
directed  upward  and  outward. 

CHRONIC   PERICARDITIS  WITH  ADHESIONS, 

This  is  not  a  very  uncommon  condition.  It  may  be  general  or  local- 
ized. The  youngest  case  which  has  come  under  my  observation  was  in  a 
female  child  sixteen  months  old,  who  died  from  acute  bronelii>-]mou- 
monia.  The  adhesions  were  old  and  general,  the  pericardial  sac  being 
completely  obliterated.  Chronic  adhesive  pericarditis  may  follow  single 
or  repeated  attacks  of  acute  rheumatic  pericarditis;  or  tliere  may  be  no 
history  of  any  prior  attack,  the  condition  being  apparently  clironic  from 
the  beginning.  Osier  has  reported  a  case  in  whicli  a  similar  lesion  of  the 
peritonaeum  was  present.  The  pericni-diuiii  iii;iy  hccoiiu'  Ncry  greatly 
thickened  and  its  cavity  obliterated  ;  it  niny  lu'  adbeivnt  externally  to  the 
pleura,  diaphragm,  or  chest  wall.  Olhcr  cli.niges  are  usually  present  in 
IIk'  heart.     It  is  ol'lcn  the  scat  ol'  clironic  invDcai'dil  is;  tlic  cavities  may 


618  DISEASES  OF   THE  CIRCULATORY  SYSTEM. 

be  greatly  dilated,  and  the  heart  walls  very  much  hypertrophied.  Valv- 
ular lesions  may  be  present. 

Partial  adhesions  cause  no  symptoms  by  which  they  can  be  recognised, 
and  even  general  adhesions  sufficient  to  obliterate  the  pericardial  sac  may 
be  found  at  autopsy  when  not  suspected  during  life.  This  is  one  of  the 
conditions  in  which,  after  it  has  led  to  considerable  dilatation  of  the 
heart,  sudden  death  sometimes  occurs. 

The  heart  is  almost  invariably  much  enlarged,  chiefly  from  dilatation. 
On  inspection,  there  may  be  bulging  of  the  chest  wall,  with  a  diffused  and 
often  feeble  or  absent  apex  beat.  The  characteristic  signs  are  a  systolic 
retraction  of  the  chest  at  or  near  the  apex  of  the  heart,  sometimes  at  the 
tip  of  the  sternum.  This  is  due  to  the  external  pericardial  adhesions, 
and  is  often  better  appreciated  by  palpation  than  by  inspection.  It  is 
followed  by  a  rapid  rebound,  associated  with  diastolic  collapse  of  the 
jugular  veins.  A  similar  retraction,  according  to  Broadbent,  is  to  be  seen 
behind  in  the  infra-scapular  region,  sometimes  on  the  left  and  sometimes 
on  the  right  side.  Percussion  shows  an  increase  in  the  cardiac  dulness 
in  all  directions.  The  position  of  the  apex  and  the  percussion  outline  of 
the  heart  do  not  change  with  the  posture  of  the  patient,  and  the  cardiac 
dulness  is  but  little  affected  by  full  inspiration.  A  systolic  murmur  is 
often  present.  The  diagnosis  of  adherent  pericardium  always  presents 
difficulties,  but  it  can  be  made  with  tolerable  certainty  in  a  considerable 
proportion  of  the  cases.  On  account  of  the  enlargement  of  the  heart  and 
the  frequency  of  murmurs,  it  is  usually  mistaken  for  valvular  disease. 
The  lesion  is  a  permanent  one,  and  tends  to  increase.  The  treatment  is 
symptomatic. 

CHAPTER    IV. 
ENDOCARDITIS  AND    VALVULAR  DISEASE. 
ACUTE  SIMPLE  ENDOCARDITIS. 

Acute  endocarditis  may  occur  even  in  foetal  life.  At  this  period  it 
usually  affects  the  right  side  of  the  heart,  and  is  one  of  the  important 
causes  of  congenital  malformations.  In  infancy,  acute  endocarditis  is 
exceedingly  rare,  not  a  single  instance  being  found  in  over  one  thousand 
autopsies  upon  children  under  three  years  of  age  of  which  I  have  records. 
From  the  third  to  the  fifth  year  it  is  not  so  rare,  and  after  this  period  it 
is  quite  common.  Of  95  cases  observed  by  Steffen,  15  occurred  before 
the  sixth  year,  and  80  between  the  sixth  and  fourteenth  j^ears. 

Acute  endocarditis  may  be  primary,  but  it  is  much  more  frequently  a 
secondary  disease.  The  primary  cases  have  been  the  subject  of  much  dis- 
cussion, but  I  agree  with  those  who  regard  the  great  majority  of  these 
as  rheumatic.  Cheadle  (London)  has  well  said  that  we  are  to  look 
upon  endocarditis  in  children  not  as  a  complication  of  rheumatism,  so 


ACUTE   SIMPLE  ENDOCARDITIS.  619 

much  as  a  manifestation — often  the  first — of  that  disease.  Sometimes 
endocarditis  occurs  alone,  and  sometimes  it  is  associated  with  chorea 
^Yithont  articuhir  symptoms;  but  the  latter  almost  invariably  appear 
sooner  or  later.  Endocarditis  is  seen  as  a  frequent  complication  both  of 
acute  and  of  subacute  articular  rheumatism.  The  proportion  of  rheu- 
matic cases  in  which  it  occurs  is  much  larger  in  children  than  in  adults. 
Compared  with  rheumatism,  all  other  causes  of  acute  endocarditis  are 
very  infrecpient.  It  is  seen  occasionally  in  the  course  of  nearly  all  the 
acute  infectious  diseases,  most  often  with  scarlet  fever,  and  it  sometimes 
complicates  pleurisy  and  pneumonia,  being  usually  associated  with  peri- 
carditis. It  may  follow  acute  tonsillitis.  In  infectious  diseases,  and  in 
pleurisy  and  pneumonia,  the  endocarditis  is  probably  excited  by  patho- 
genic germs.  Fraenkel  and  Sanger  have  found  the  staphylococcus  in 
cases  of  simple  endocarditis,  and  cultures  by  others  have  shown  the 
presence  of  other  pyogenic  organisms,  including  the  pneumococcus. 

Lesions. — Acute  inflammation  may  affect  any  part  of  the  endocar- 
dium, but  in  extra-uterine  life  it  usually  affects  the  valves  of  the  left 
side,  involving  the  mitral  much  more  frec|uently  than  the  aortic  valve. 
Steffen's  figures  give  only  four  examples  of  aortic  disease  in  ninety-five 
cases.    (Compare  statistics  of  valvular  disease,  page  637.) 

The  pathological  changes  consist  first  in  an  extensive  growth  of  new 
connective-tissue  cells  and  an  infiltration  of  round  cells  beneath  the  endo- 
thelial layer.  This  results  in  the  formation  of  small  masses  of  granulation- 
tissue  upon  the  valves  or  the  endocardium  of  the  heart  wall,  and  upon 
these  there  is  deposited  fibrin  from  the  blood.  In  this  way  the  tiny  wart- 
like excrescences  known  as  vegetations  are  produced.  Bacteria  may  also 
be  caught  in  the  exudate.  As  a  consequence  of  the  inflammation,  the  valve 
is  swollen,  somewhat  shortened,  and  consequently  insufficient.  The  results 
of  the  process  may  be  ulceration  of  this  new-formed  tissue,  which  in  ordi- 
nary cases  is  small  in  amount,  or  organization  and  cicatrization.  Masses 
of  fibrin  may  be  detached  from  the  vegetations  and  swept  into  the  general 
circulation,  lodging  as  emboli  in  the  kidneys,  spleen,  brain,  or  other 
organs.  This  is  not  common  in  acute  endocarditis,  at  least  not  in  the 
first  attacks. 

In  the  milder  forms  of  inflammation  it  is  possible  for  complete  recov- 
ery to  take  place,  with  the  exception  of  a  slight  valvular  thickening,  not 
enough,  however,  to  interfere  in  any  way  with  the  function  of  the  valves. 
But  this  result  is  rare.  In  most  cases  they  remain  slightly  insufficient,  as 
the  least  serious  consequence  of  the  inflammation.  Unfortunately,  it  more 
often  happens  that  an  acute  inflammation  which  may  not  be  at  first  seri- 
ous, proves  the  beginning  of  the  progressive  changes  of  a  chronic  inflam- 
mation, the  full  effects  of  which  are  not  seen  for  years.  Chronic  inflam- 
mation may  follow  the  first  attack  immediately,  or  after  a  considerable 
interval,  or  occur  after  several  acute  attacks. 


620  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

Symptoms. — When  acute  endocarditis  occurs  as  a  jDrimary  disease,  or 
when  it  is  the  only  manifestation  of  rheumatism,  it  usually  begins  abruptly 
with  rather  severe  general  symptoms — high  temperature,  often  102°  to 
105°  F.,  prostration,  exaggerated  heart  action,  restlessness,  and  some- 
times dyspncBa.  There  is  nothing  distinctive  about  these  symptoms,  and 
it  is  not  until  the  heart  is  examined  that  the  disease  is  recognised.  If  the 
heart  is  not  watched,  the  diagnosis  is  not  made,  and  there  may  be  no  sus- 
picion of  the  nature  of  the  attack  until  some  time  afterward,  when  the 
existence  of  valvular  disease  is  discovered.  If  the  heart  is  carefully 
examined  from  day  to  day,  nothing  abnormal  may  be  found  until  the  third 
or  fourth  day,  or  even  later,  when  there  is  heard  the  characteristic  soft, 
blowing,  systolic  murmur  at  the  apex.  The  murmur  is  generally  trans- 
mitted to  the  left.  It  may  be  accompanied  by  a  thrill  and  by  an  accentu- 
ated pulmonic  second  sound,  and  later  there  may  be  evidence  of  slight  dila- 
tation with  the  usual  signs  of  some  degree  of  cardiac  insufficiency.  The 
murmur  gradually  increases  in  intensity  until  the  maximum  is  reached, 
and  then  in  most  cases  somewhat  subsides. 

Acute  endocarditis  sometimes  occurs  in  the  course  of,  or  simultane- 
ously with  an  attack  of  chorea,  with  symptoms  quite  similar  to  those 
above  described.  Finlayson  (Glasgow)  has  called  attention  to  endocarditis 
as  a  frequent  cause  of  obscure  fever  in  choreic  patients,  either  when  occur- 
ring alone  or  with  articular  symptoms.  It  may  develop  at  any  time 
during  the  choreic  attack  or  subsequent  to  it.  When  endocarditis  oc- 
curs as  a  complication  of  articular  rheumatism,  there  may  be  an  in- 
crease in  the  temperature  and  in  the  severity  of  the  general  symptoms, 
but  rarely  anything  more  definite.  Endocarditis  complicating  other 
diseases  is  recognised  only  by  the  physical  signs. 

The  usual  duration  of  acute  endocarditis  is  from  one  to  three  weeks, 
the  febrile  symptoms  frequently  subsiding  in  a  few  days  and  the  cardiac 
symptoms  slowly  diminishing. " 

The  attack  may  terminate  fatally  in  the  course  of  a  few  weeks,  owing 
to  the  rapid  development  of  acute  dilatation,  accompanied  by  the  usual 
signs  of  cardiac  insufficiency,  with  dropsy,  cyanosis,  and  often  pulmonary 
complications.  Cerebral  embolism  may  occur,  which  usually  produces 
hemiplegia,  but  rarely  results  fatally.  If  emboli  lodge  in  the  spleen  or 
kidneys,  they  may  lead  to  swelling  of  the  spleen  or  to  hfematuria.  The 
patient  may  recover  with  a  murmur  which  lasts  but  a  few  weeks  and 
gradually  disappears— a  rare  result.  Usually  there  is  a  persistent  mur- 
mur, with  the  subsequent  development  of  the  ordinary  signs  of  valvular 
disease.  Lastly,  there  may  be  recurrent  attacks  of  inflammation,  with  the 
ultimate  development  of  chronic  valvular  disease. 

Diagnosis. — The  diagnosis  of  acute  endocarditis  is  very  frequently  not 
made;  not  because  it  is  difficult,  but  because  in  young  children  the  heart 
is  not  examined  as  frequently  and  as  carefully  as  it  should  be.    The  symp- 


ACUTE   SIMPLE   ENDOCARDITIS.  621 

toms  are  few  and  not  diagnostic.  It  is  therefore  of  the  greatest  impor- 
tance that  not  only  in  chorea  and  rheumatism,  but  in  all  acute  febrile 
attacks,  particularly  those  of  obscure  origin,  the  heart  should  be  closely 
watched.  Endocarditis  affecting  the  wall  of  the  heart  can  not  be  diasr- 
nosticated.  The  murmur  of  valvular  endocarditis  may  be  confounded  with 
pericarditis,  or  with  functional  or  blood  murmurs  occurring  in  the  course  of 
acute  febrile  attacks,  or  with  those  of  anaemic  origin.  From  pericarditis  it 
is  distinguished  by  the  fact  that  the  murmur  is  single,  has  a  soft  blowing 
character,  is  usually  located  at  the  apex,  is  transmitted  beyond  the  bor- 
der of  the  heart,  and  is  diminished  by  a  full  inspiration.  Functional 
murmurs  in  febrile  diseases  are  quite  frequent  in  young  children,  and 
may  at  first  be  difficult  to  distinguish  from  those  of  endocarditis.  Usually, 
however,  the  former  are  at  the  base  rather  than  at  the  apex.  They  are 
more  irregular,  both  as  to  time,  transmission,  and  constancy,  than  are  mur- 
murs resulting  from  acute  endocarditis.  The  same  may  be  said  of  anaemic 
murmurs,  which,  as  in  adults,  may  be  heard  in  the  carotids,  and  some- 
times over  any  of  the  large  arteries. 

Prognosis. — The  danger  to  life  in  acute  endocarditis  is  not  often  great, 
as  the  disease  seldom  proves  fatal.  However,  death  may  occur  when  it  is 
associated  with  chorea,  but  here  usually  when  an  acute  jDrocess  is  ingrafted 
upon  an  old  valvular  disease.  In  other  cases,  death  results  from  compli- 
cations, particularly  pneumonia.  Only  the  progress  of  the  case  enables 
one  to  decide  how  extensive  is  the  damage  which  has  been  done  to  the 
valves.     There  is  always  the  danger  of  recurrent  attacks. 

Treatment. — The  most  important  thing  in  the  management  of  these 
cases,  and  the  one  frequently  overlooked,  is  to  secure  for  the  heart  as 
complete  rest  as  possible,  not  only  during  the  period  of  acute  inflamma- 
tion, but  for  several  succeeding  weeks.  With  children  this  can  be  accom- 
plished only  by  keeping  them  in  bed,  after  mild  attacks  for  at  least  a 
month,  after  severe  attacks  for  three  months.  It  is  luring  this  early 
period  of  the  disease  that  changes  take  place  most  rapidly  in  the  heart 
walls,  and  the  gravest  results  sometimes  follow  the  neglect  of  these  pre- 
cautions. Children  are  often  allowed  out  of  bed  as  soon  as  the  fever  has 
subsided,  and  the  heart  disease  is  unnoticed  until  a  grave  amount  of  dila- 
tation has  developed,  with  dropsy,  palpitation,  shortness  of  breath,  slight 
CA'anosis,  irregular  pulse,  and  cough.  All  the  so-called  primary  cases,  as 
well  as  those  occurring  with  chorea  and  articular  symptoms,  should  have 
the  benefit  of  anti-rheumatic  remedies,  as  this  is  the  only  plan  which 
offers  any  chance  of  limiting  the  inflammation,  although  the  effect  upon 
the  heart  is  rarely  striking.  Excessive  cardiac  action  is  sometimes  al- 
layed by  aconite,  sometimes  best  by  opium.  All  children  who  have  once 
suffered  from  endocarditis  should  be  protected  as  much  as  possible 
from  subsequent  attacks  of  rheumatism. 

41 


622  DISEASES   OP  THE   CIRCULATORY   SYSTEM. 

MALIGNANT  ENDOCARDITIS. 

Malignant  or  ulcerative  endocarditis  is  a  rare  disease  in  childhood. 
The  youngest  case  I  have  found  reported  is  that  of  Harris,  which  occurred 
in  a  boy  four  years  old,  and  affected  the  right  side  of  the  heart.  It  was 
secondary  to  a  cardiac  malformation.  Of  the  cases  thus  far  reported  in 
early  life,  about  twenty-five  in  number,  the  great  proportion  have  been  in 
children  over  ten  years  of  age,  in  whom  the  disease  does  not  differ  essen- 
tially from  the  adult  type.  For  the  most  exhaustive  study  of  this  subject 
we  are  indebted  to  Osier's  Gulstonian  Lectures. 

Malignant  endocarditis  rarely  occurs  as  a  primary  affection.  Of  the 
acute  diseases,  it  is  most  frequently  secondary  to  pneumonia,  next  to 
rheumatism  and  meningitis.  It  may  be  met  with  in  any  infectious  dis- 
ease or  septic  process.  In  75  per  cent  of  the  cases,  according  to  Osier,  it 
is  ingrafted  upon  a  previous  valvular  disease.  In  my  series  of  collected 
cases  of  congenital  malformations  of  the  heart,  there  were  four  deaths 
from  malignant  endocarditis,  all  but  one,  however,  occurring  in  adult  life. 
The  bacteria  most  frequently  associated  are  the  staphylococcus  and 
streptococcus,  and,  in  the  cases  complicating  pneumonia,  the  pneumo- 
coccus.  These  micro-organisms  are  believed  to  play  an  important  part 
in  the  production  of  the  disease.  Circulating  in  the  blood,  they  lodge 
upon  the  endocardium  of  the  valves,  all  the  more  readily  when  the 
valves  are  previously  diseased. 

lesions. — Malignant  endocarditis  may  result  in  the  production  of 
vegetations  which  subsequently  break  down,  or  there  may  be  superficial 
ulceration  affecting  only  the  endocardium,  or  deeper  ulceration  involving 
the  valve,  the  septum,  or  even  the  heart  wall.  In  other  cases  there  is  sup- 
puration of  the  deeper  tissues  of  the  valve  first  affected,  with  the  produc- 
tion of  small  abscesses  at  the  base  of  the  vegetations.  These  conditions 
may  lead  to  large  perforations,  or  even  to  the  destruction  of  the  valve,  to 
valvular  aneurisms,  or  to  abscesses  of  the  hgart  wall.  According  to  Osier, 
the  diff'erent  parts  of  the  heart  are  affected  in  the  following  order :  mitral 
valve,  aortic,  mitral  and  aortic  combined,  tricuspid  and  pulmonic  valves, 
and  the  cardiac  wall.  The  secondary  lesions  of  malignant  endocarditis 
are  due  to  emboli.  These  are  most  frequent  in  the  spleen  and  kidney, 
next  in  the  brain,  intestines,  and  skin,  and,  if  the  right  side  of  the 
heart  is  diseased,  in  the  lungs.  These  emboli  lead  to  the  formation  of 
red  or  white  infarctions,  to  hgemorrhages,  or  to  multiple  abscesses  in  the 
various  organs  and  tissues  in  which  they  lodge. 

Symptoms. — Malignant  endocarditis  presents  a  great  variety  of  symp- 
toms, making  the  diagnosis  extremely  difficult  in  perhaps  the  majority  of 
cases.  There  is  generally  a  remittent  type  of  fever,  sometimes  repeated 
rigors,  profuse  sweating,  low  delirium,  stupor  or  coma,  and  extreme  pros- 
tration.   In  many  cases  there  is  a  fine  petechial  eruption  upon  the  skin ; 


CHRONIC   VALVULAR   DISEASE.  623 

diarrhoea  is  also  frequent.  The  cerebral  symptoms  may  be  so  prominent 
as  to  suggest  meningitis.  There  is  usually  a  cardiac  murmur,  the  location 
of  which  depends  upon  the  seat  of  disease.  It  is  most  frequently  the 
murmur  of  mitral  regurgitation.  This  murmur  is  sometimes  faint,  and 
may  be  absent.  The  spleen  is  in  most  cases  enlarged.  From  the  emboli 
there  may  be  hemiplegia,  rapid  swelling  of  the  spleen,  bloody  urine,  cough, 
and  symptoms  of  pneumonia.  The  disease  lasts  from  a  few  days  to  six 
weeks,  death  being  the  almost  invariable  termination.  It  is  due  to  ex- 
haustion or  to  some  embolic  process. 

Diagnosis. — The  most  characteristic  features  of  malignant  endocarditis 
are  the  development  of  pysemic  or  typhoid  symptoms  with  a  petechial 
eruption,  in  a  patient  who  has  previously  had  valvular  disease.  Malignant 
endocarditis  is  differentiated  from  typhoid  fever  by  its  sudden  onset, 
irregular  temperature,  recurring  chills,  profuse  sweats,  petechial  eruption, 
and  dyspnoea.     It  may  be  confounded  with  malarial  fever. 

Treatment. — This  is  entirely  symptomatic ;  no  known  measures  have 
any  influence  upon  the  disease  itself. 

CHRONIC   VALVULAR   DISEASE. 

Chronic  valvular  disease  of  the  heart  in  children  is  usually  the  result 
of  endocarditis ;  in  a  small  number  of  cases  it  depends  upon  congenital 
malformation  ;  but  the  degenerative  lesions  to  which  many  adult  cases  are 
due  have  no  place  in  early  life. 

Lesions. — The  changes  of  chronic  endocarditis  may  be  briefly  described 
as  follows  :  The  valvular  segments  are  thickened  by  the  production  of  new 
connective  tissue,  the  contraction  of  which  results  in  retraction,  shorten- 
ing, puckering,  and  imperfect  closure  of  the  valves.  The  valvular  leaflets 
may  adhere  to  each  other,  so  that  the  opening  is  very  much  narrowed. 
This  is  sometimes  reduced  to  a  funnel-shaped  orifice  barely  admitting  the 
tip  of  the  finger,  and  it  may  even  be  much  smaller.  The  leaflets  are  some- 
times adherent  to  the  wall  of  the  heart;  the  chordae  tendinese  are  short- 
ened, and  sometimes  entirely  disappear  ;  and,  finally,  the  valves  may  be  the 
seat  of  calcareous  dei')osits.  These  changes  take  place  very  slowly,  requir- 
ing many  years  for  their  full  development.  From  time  to  time  there  may 
be  attacks  of  acute  inflammation.  The  changes  described  may  bring  about 
(1)  valvular  insufficiency,  owing  to  imjierfect  closure,  causing  a  regurgita- 
tion of  blood  through  the  opening  guarded  by  the  valve ;  or  (3)  stenosis, 
with  such  a  narrowing  of  the  opening  that  the  outflow  of  blood  is  ob- 
structed.    In  early  life  it  is  usually  the  mitral  valve  that  is  affected. 

Of  141  cases  in  children  under  fourteen  years  old,  observed  clinically  by 
Dr.  F.  M.  Crandall  and  myself,  the  mitral  valve  was  alone  affected  in  79  per 
cent ;  the  aortic  valve  alone  in  3  per  cent ;  and  both  were  associated  in 
18  per  cent.  Lesions  of  the  aortic  valve  in  early  life  are  therefore  com- 
paratively rare. 


624 


DISEASES  OF  THE   CIRCULATORY  SYSTEM. 


Following  valvular  lesions,  important  changes  take  place  in  the  wall 
and  cavities  of  the  heart :  these  are  hypertrophy  and  dilatation.' 

Hypertropliy. — This  consists  in  an  increase  in  the  thickness  of  the 
heart  wall,  due  to  an  increase  in  the  size  and  number  of  the  muscular 
fibres.  It  is  principally  of  the  ventricles,  and  is  always  conservative.  It 
may  continue  indefinitely,  or  it  may  be  followed  by  degeneration  and  dila- 
tation. Hypertrophy  occurs  as  a  result  of  any  obstructive  lesion  at  one  of 
the  cardiac  orifices,  in  renal  disease  when  the  obstruction  is  in  the  small 
arteries,  also  when  extra  work  is  thrown  upon  the  ventricles  as  a  result  of 
regurgitation,  and  it  may  follow  primary  dilatation. 

Dilatation. — This  consists  in  an  enlargement  of  the  cavities  of  the 
heart,  usually  with  thinning  of  their  walls.  It  is  generally  most  marked 
in  the  auricles.  Primary  dilatation  is  produced  by  regurgitation  of  blood 
into  any  of  the  cavities  as  a  result  of  valvular  insufficiency.  This  may  to 
a  slight  extent  be  regarded  as  a  conservative  lesion.  Secondary  dilatation, 
or  that  resulting  from  degeneration  of  the  cardiac  muscle,  is  always  in- 
jurious. It  is  usually  caused  by  imperfect  nutrition  of  the  heart  which 
may  be  due  to  local  or  general  causes.  In  most  of  the  cases  both  hyper- 
trophy and  dilatation  continue  for  a  long  time.  So  long  as  hypertrophy 
predominates,  the  circulation  may  be  well  carried  on ;  but  when  dilatation 
comes  to  exceed  hypertrophy,  there  are  signs  of  great  embarrassment  to 
the  circulation  and  of  cardiac  insuflficiency. 

There  are  other  lesions  accompanying  chronic  valvular  disease,  de- 
pending upon  obstruction  to  the  venous  circulation.  If  this  obstruction 
is  in  the  pulmonary  veins,  it  leads  to  congestion  of  the  lungs,  chronic 
bronchitis,  or  chronic  pneumonia ;  if  of  the  systemic  venous  circulation, 
it  leads  to  chronic  congestion  of  the  spleen,  liver,  kidneys,  peritonaeum, 
and  sometimes  to  general  dropsy. 

Etiology. — The  following  table  gives  the  age  and  sex  in  the  cases  ob- 
served by  Dr.  Crandall  and  myself  : 


Age. 

1 

year. 

2 
years. 

3 
years. 

4 
years. 

5 
years. 

6 
years. 

7 
years. 

8 
years. 

9 
years. 

10 
years. 

11 

years. 

12 
years. 

13 
years. 

14 
years. 

Totals. 

Males 

Females . . . 

1 
1 

2 
3 

2 
5 

4 

7 

6 
9 

4 
10 

9 
3 

8 
11 

6 
12 

5 

14 

7 
4 

6 

2 

1 

3 

55,  or  38^ 
90,  "  62^ 

Total.... 

2 

5 

7 

11 

15 

14 

12 

19 

18 

19 

11 

8 

4 

145 

The  difference  in  sex  is  very  nearly  the  same  as  in  my  cases  of  rheuma- 
tism. Sturges,  in  100  cases  of  chronic  endocarditis  gives  56  per  cent 
females  and  44  per  cent  males.  Sansom's  figures  alone  give  a  predomi- 
nance of  males. 

The  chronic  endocarditis  of  early  life  is,  as  a  rule,  secondary  to  the 
acute  or  subacute  form.  Its  etiological  factors  are  therefore  those  of 
acute  endocarditis.  Of  117  cases  in  my  own  series,  93,  or  80  per  cent^ 
gave  a  history  of  previous  rheumatism — 7  cases  of  chorea  without  ar- 
ticular symptoms  being  included  as  rheumatic.     Of  the  31  cases  w^hich 


CHRONIC   VALVULAR  DISEASE,  f]25 

at  the  first  examiuation  gave  no  history  of  rheumatism,  8  subsequently 
developed  articular  rheumatism,  and  2  chorea,  so  that  nearly  90  per  cent 
of  this  series  of  cases  presented,  to  my  mind,  conclusive  evidence  of  a 
rheumatic  diathesis.  Thirty  per  cent  had  chorea  previously,  or  developed 
it  while  under  observation.  The  more  closely  I  study  cases  of  rheumatism, 
chorea,  and  valvular  disease,  and  the  longer  the  patients  are  kept  under 
observation,  the  deeper  becomes  my  conviction  of  the  very  close  relation- 
ship between  these  three  conditions  in  childhood.  The  percentage  of 
rheumatic  cases  in  this  series  is  considerably  larger  than  that  given  by 
many  writers,  but  it  corresponds  very  closely  with  Cheadle's  careful  obser- 
vations. Valvular  disease  is  occasionally  traced  to  an  attack  of  endo- 
carditis complicating  scarlet  fever,  and  in  rare  cases  to  that  occurring  with 
other  infectious  diseases. 

Symptoms. — The  symptoms  of  chronic  valvular  disease  in  most  cases 
come  on  slowly,  often  insidiously,  and  frequently  there  are  none  until  the 
disease  has  lasted  a  long  time,  the  condition  being  discovered  by  accident. 
The  course  of  valvular  disease  is  usually  divided  into  two  periods,  the  first 
being  that  while  compensation  is  present,  and  the  second  after  compensa- 
tion has  failed.  The  duration  of  the  stage  of  compensation  is  indefinite ; 
it  may  last  a  lifetime.  The  only  subjective  symptom  that  is  of  much  diag- 
nostic value  is  shortness  of  breath  on  exertion.  Occasionally  other  symp- 
toms are  present,  such  as  praecordial  pain,  attacks  of  palpitation,  head- 
ache, epistaxis,  anemia,  and  cough.  These  are  rarely  constant,  but  come 
on  when  the  patient's  general  condition  for  any  reason  is  below  normal. 
As  a  rule,  there  is  in  young  subjects  a  tendency  to  an  increase  in  the  dis- 
ease, although  this  is  often  slow,  and  may  be  interrupted  by  long  periods 
in  which  the  process  appears  to  be  stationary.  At  such  times  the  patients 
either  have  no  symptoms,  or  suffer  only  from  a  slight  amount  of  incon- 
venience on  marked  exertion. 

Failure  in  compensation  is  generally  brought  about  by  one  of  the  fol- 
lowing causes  :  There  may  be  an  intercurrent  attack  of  acute  endocarditis, 
which  in  a  short  time  leads  to  a  very  great  increase  in  the  heart's  disability. 
It  may  be  due  to  additional  work  thrown  upon  the  heart  from  excessive 
muscular  exertion,  or  to  the  strain  of  a  prolonged  attack  of  some  acute  ill- 
ness, especially  one  that  is  liable  to  produce  changes  in  the  heart  muscle, 
such  as  typhoid  or  scarlet  fever.  It  is  sometimes  the  increased  work  which 
is  physiologically  thrown  upon  the  heart  at  the  time  of  puberty,  owing  to 
the  rapid  growth  of  the  body.  It  may  result  from  any  cause  which  seri- 
ously affects  the  patient's  general  nutrition,  particularly  when  this  is 
associated  with  marked  ansemia. 

The  symptoms  indicating  failure  of  compensation  are  those  depending 
upon  a  weak  heart,  with  imperfect  filling  of  the  arteries  and  overfilling  of 
the  veins.  The  embarrassment  of  the  pulmonary  circulation  leads  to  con- 
stant dyspnoia  or  orthopnoea  and  cough,  sometimes  accompanied  by  profuse 


626  DISEASES   OF   THE  CIRCULATORY  SYSTEM. 

expectoration,  wliicli  may  be  bloody,  and  in  rare  cases  there  may  be  larger 
pnlmonary  hemorrhages.  The  obstruction  to  the  systemic  venous  circu- 
lation leads  to  dropsy,  which  begins  in  the  feet.  There  may  be  general 
anasarca  and  dropsy  of  the  serous  cavities,  especially  the  peritonaeum  and 
pleura ;  also  enlargement  and  functional  disturbances  of  the  liver,  en- 
largement of  the  spleen,  dyspeptic  symptoms,  and  chronic  congestion  of 
the  kidney,  with  scanty  urine  and  albuminuria.  There  may  be  dilatation 
of  the  superficial  veins,  with  clubbing  of  the  fingers,  and  cyanosis ;  and 
there  may  be  cerebral  symptoms,  such  as  headache,  dizziness,  and  faint- 
ing attacks.  The  pulse  is  small  and  soft,  and  the  heart's  action  rapid 
and  irregular. 

It  is  rare  to  see  all  the  symptoms  of  cardiac  failure  in  children 
under  ten  years,  but  about  the  time  of  puberty  they  are  not  uncommon. 
The  symptoms  may  increase  in  severity  until  death  occurs,  or  they  may 
be  severe  for  a  time  and  then  nearly  disappear,  to  return  again  after  a 
longer  or  shorter  interval.*    Death  may  be  due  to  sudden  cardiac  paralysis, 


*  The  course  and  termination  of  these  cases  of  chronic  valvular  disease  is  well 
illustrated  by  the  following  history  of  a  little  girl  who  was  under  my  observation  for 
nine  years :  When  first  seen  she  was  seven  years  old,  and  gave  a  history  of  cardiac 
symptoms  for  one  year.  There  was  then  present  a  loud  mitral  regurgitant  murmur, 
with  considerable  hypertrophy.  There  was  general  dropsy,  and  all  the  symptoms 
pointed  toward  acute  dilatation.  Under  treatment,  the  dropsy  and  other  symptoms 
disappeared,  and  she  went  on  comfortably  for  over  a  year.  In  her  eighth  and  ninth 
years  there  were  frequent  attacks  of  subacute  rheumatism,  during  which  time  the 
heart  lesion  steadily  increased  in  severity.  At  twelve  years  there  was  an  eruption  of 
subcutaneous  tendinous  nodules,  which  remained  for  over  two  years.  During  this 
year  there  was  heard  for  the  first  time  a  mitral  direct  murmur,  accompanied  by  a  very 
marked  thrill,  mitral  stenosis  having  been  gradually  brought  about  by  the  slowly  pro- 
gressing endocarditis.  This  murmur  gradually  increased  in  intensity  from  that  time, 
while  the  mitral  regurgitant  murmur  became  less  distinct.  The  apex  beat  was  then  in 
the  sixth  space,  two  and  a  half  inches  to  the  left  of  the  nipjale.  From  the  twelfth  to  the 
fifteenth  year  she  grew  very  little  in  height  or  weight,  and  showed  no  signs  of  matu- 
rity, the  cardiac  symptoms  being  nearly  stationary.  In  the  fifteenth  year  she  devel- 
oped a  marked  enlargement  of  the  liver  and  spleen  with  general  dropsy  and  aU  the 
symptoms  of  cardiac  insufficiency,  these  being  the  first  symptoms  of  this  character 
since  she  was  seven  years  old.  There  was  now  heard  for  the  first  time  an  aortic  re- 
gurgitant murmur  in  addition  to  the  others  formerly  present.  The  symptoms  dis- 
appeared under  treatment  in  the  course  of  a  few  months,  but  six  months  later  returned 
with  greater  severity  and  were  accompanied  by  albuminuria,  the  patient  dying  from 
heart  failure  in  a  few  weeks.  During  the  last  exacerbation  there  was  heard  a  double 
aortic  as  well  as  a  double  mitral  murmur. 

At  autopsy  the  heart  weighed  fifteen  ounces.  There  was  a  very  great  hypertrophy, 
especially  of  the  right  ventricle,  which  was  as  thick  as  the  left.  All  the  cavities  were 
much  dilated.  The  most  important  valvular  lesion  was  mitral  stenosis,  the  orifice  not 
admitting  the  end  of  the  little  finger.  The  valves  were  the  seat  of  calcareous  deposits. 
The  curtains  of  the  aortic  valve  were  thickened  and  adherent ;  there  was  also  thicken- 
ing of  the  pulmonic  and  tricuspid  valves. 


CHRONIC   VALYL^LAR  DISEASE.  627 

to  intercurrent  nephritis,  pneumonia,  embolism,  inflammation  of  the  se- 
rous membranes,  or  to  oedema  of  the  hiugs. 

Clinical  Varieties. — Of  tlie  141  cases  of  valvular  disease  in  children 
under  fourteen  years,  previously  referred  to,  the  following  were  the  forms 
and  combinations  recorded.  It  is  to  be  noted  that  these  figures  are  based 
upon  clinical  and  not  jDathological  examinations : 

Mitral  insufficiency 131  cases  ;  alone  in  99  eases. 

Mitral  stenosis 17      "  "       "     4     " 

Aortic  insufficiency 9      "  "      "     0      "' 

Aortic  stenosis 28     "  "      "     3     " 

Double  mitral 8     " 

Double  aortic 1  case. 

Double  mitral  and  double  aortic 3  cases. 

Mitral  insufficiency  and  double  aortic 3     " 

Mitral  insufficiency  and  aortic  stenosis 18      " 

Mitral  stenosis  and  aortic  insufficiency 3     " 

Mitral  insufficiency. — This  is  usually  the  result  of  attacks  of  acute 
endocarditis.  It  is  by  far  the  most  frequent  form  of  valvular  disease  in 
early  life,  occurring  in  93  per  cent  of  the  above  cases,  and  alone  in  70  per 
cent.  In  mitral  insufficiency  there  is  regurgitation  of  blood  from  the  left 
ventricle  into  the  left  auricle  during  systole.  This  is  compensated  for  by 
hypertrophy  of  both  ventricles.  It  causes  dilatation  of  the  left  auricle, 
increased  pressure  in  the  pulmonary  veins,  afterward  in  the  pulmonary 
arteries,  hypertrophy  of  the  right  ventricle,  and,  finally,  there  is  dilata- 
tion of  the  right  ventricle,  tricuspid  insufficiency,  dilatation  of  the  right 
auricle,  and  general  systemic  venous  obstruction.  Coincident  with  the 
changes  in  the  right  heart  there  is  hypertrophy  of  the  left  ventricle,  fol- 
lowed by  dilatation. 

In  mitral  insufficiency  there  is  heard  a  systolic  murmur  which  is  syn- 
chronous with  the  apex  impulse  and  with  the  first  sound  of  the  heart,  and 
may  in  part  replace  the  first  sound..,  It  is  loudest  at  the  apex,  trans- 
mitted to  the  left,  and  heard  with  almost  equal  distinctness  at  the  inferior 
angle  of  the  left  scapula.  This  is  a  very  diffusible  murmur,  and  may  be 
audible  all  over  the  chest.  It  is  accompanied  by  an  accentuation  of  the 
pulmonic  second  sound  heard  at  the  left  border  of  the  sternum  in  the 
second  space,  and  by  signs  of  hypertrophy  of  the  heart.  When  both  these 
signs  are  wanting,  the  existence  of  mitral  insufficiency  is  somewhat  doubt- 
ful, as  a  similar  murmur  may  be  of  functional  or  accidental  origin.  In 
the  early  stages  of  the  disease  the  signs  of  hypertrophy  predominate  ;  in 
the  later  stages,  those  of  dilatation. 

In  hypertrophy  of  the  left  ventricle  or  of  the  whole  heart,  the  apex 
beat  is  displaced  downward  and  to  the  left.*     It  may  be  in  the  fifth  or 

*  For  normal  position  of  the  apex  in  childhood,  see  page  604. 


628  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

the  sixth  space,  but  rarely  lower,  and  as  far  to  the  left  as  the  axillary  line. 
There  is  often  bulging  of  the  praecordia,  so  marked  as  to  cause  a  deformity 
of  the  chest.  The  impulse  is  forcible  and  heaving,  and  over  a  larger  space 
than  normal.  The  area  of  cardiac  dulness  is  increased  in  all  directions, 
but  particularly  downward  and  to  the  left.  In  hypertrophy  involving 
chiefly  the  right  ventricle,  there  may  be  bulging  of  the  lower  part  of  the 
sternum,  and  the  area  of  dulness  is  increased  to  the  right,  in  extreme  cases 
extending  from  one  to  one  and  a  half  inches  beyond  the  right  border  of  the 
sternum.  The  heart  sounds  in  hypertrophy  are  loud  and  distinct,  and 
often  have  a  somewhat  metallic  character.  With  hypertrophy  of  the  right 
ventricle  there  may  be  reduplication  or  accentuation  of  the  second  sound. 
The  pulse  is  full  and  strong. 

In  dilatation  the  apex  beat  is  indistinct,  diffuse,  and  undulatory. 
There  is  an  increase  in  the  area  of  cardiac  dulness,  the  outline  being  nearly 
square.  The  cardiac  sounds  are  feeble,  and  murmurs  previously  present 
may  be  lost.  The  heart's  action  is  irregular,  and  the  pulse  small  and 
weak. 

Mitral  stenosis. — This  is  apt  to  occur  from  repeated  attacks  of  sub- 
acute rheumatism,  with  a  slowly  progressing  endocarditis.  It  is  usu- 
ally associated  with  mitral  regurgitation.  With  this  lesion  there  is 
obstruction  to  the  flow  of  blood  from  the  left  auricle  into  the  left  ven- 
tricle. It  is  mainly  compensated  for  by  hypertrophy  of  the  right  ven- 
tricle, but  to  a  certain  degree  by  hypertrophy  of  the  left  auricle.  The 
secondary  changes  following  the  lesion  are  hypertrophy  of  the  left  au- 
ricle followed  by  dilatation,  increased  pressure  in  the  pulmonary  veins, 
followed  by  hypertrophy  and  dilatation  of  the  right  ventricle.  The  left 
ventricle  is  usually  normal  or  small. 

Mitral  stenosis  produces  a  presystolic  murmur  which  is  somewhat 
prolonged,  usually  rough  in  character,  and  terminates  sharply  w^ith  the 
first  sound  of  the  heart.  It  is  loudest  at  or  near  the  apex,  but  is  audible 
over  only  a  small  circumscribed  are^.  Quite  as  constant  and  important 
for  diagnosis  is  the  presence  of  a  "  purring  thrill,"  which  is  very  distinct 
upon  palpation,  and  terminates  sharply  as  the  apex  strikes  the  chest  wall. 
The  pulse  of  mitral  stenosis  is  usually  small.  The  symptoms  are  few, 
but  those  which  are  present  depend  chiefly  upon  pulmonary  congestion. 

Ao7-tic  stenosis. — This  is  not  very  common  in  early  life,  and  rarely 
occurs  as  the  only  lesion,  being  most  frequently  associated  with  mitral 
insufficieney.  It  is  sometimes  a  congenital  lesion.  Aortic  stenosis  is 
compensated  for  by  hypertrophy  of  the  left  ventricle,  which  may  be 
complete  for  a  long  period,  but  ultimately  it  is  followed  by  dilatation  of 
the  left  ventricle,  with  mitral  insufficiency  and  its  consequences.  In 
aortic  stenosis  there  is  an  interference  with  the  outflow  of  blood  from 
the  left  ventricle  into  the  aorta.  It  causes  a  systolic  murmur,  wdiicli  is 
usually  loudest  at  the  right  border  of  the  sternum  in  the  second  space. 


CHRONIC   VALVULAR  DISEASE.  629 

and  is  transmitted  upward,  being  distinct  in  the  carotids.  The  second 
sound  is  generally  weak.  There  are  associated  the  signs  of  marked  hyper- 
trophy of  the  left  ventricle. 

Aortic  obstruction  is  more  frequently  confounded  with  conditions  giv- 
ing accidental  or  functional  murmurs  than  is  any  other  valvular  lesion. 
Without  the  signs  of  hypertrophy  of  the  left  ventricle,  a  positive  diagnosis 
should  not  be  made.  On  account  of  the  almost  perfect  compensation, 
this  form  of  the  disease  causes  fewer  symptoms  than  any  other  variety, 
possibly  excepting  mitral  obstruction.  The  danger  of  embolism  is  some- 
what greater  than  in  mitral  disease. 

Aortic  insufficiency. — This  is  one  of  the  rarest  valvular  lesions  in  chil- 
dren. In  no  case  on  my  list  did  it  occur  as  the  only  lesion.  It  causes  a 
regurgitation  of  blood  from  the  aorta  into  the  left  ventricle  during  dias- 
tole. It  is  compensated  for  by  dilatation  and  hypertrophy  of  the  left 
ventricle.  The  order  in  which  the  secondary  changes  take  place  is  :  dila- 
tation followed  by  hypertrophy  of  the  left  ventricle,  ultimately  followed 
by  further  dilatation  due  to  degeneration,  this  leading  to  mitral  insuffi- 
ciency with  all  its  remote  consequences.  The  signs  of  aortic  insufficiency 
are  a  prolonged  diastolic  murmur,  with,  or  taking  the  place  of,  the  second 
sound  of  the  heart,  generally  loudest  at  the  left  border  of  the  sternum  in 
the  second  space,  and  transmitted  downward  to  the  apex  of  the  heart  or  the 
ensiform  cartilage.  This  is  invariably  accompanied  by  signs  of  hyper- 
trophy and  dilatation  of  the  left  ventricle,  which  are  usually  marked. 
In  the  stage  of  compensation  the  signs  of  hypertrophy  predominate,  and 
when  compensation  has  failed,  the  signs  of  dilatation.  A  characteristic 
symptom  is  the  intense  throbbing  of  the  carotids,  with  the  sudden  disten- 
sion and  complete  collapse  of  their  walls,  and  the  "  ball-pulse  "  of  Corri- 
gan.  Early  in  the  disease  there  may  be  headache,  flashes  of  light  before 
the  eyes,  and  other  evidences  of  cerebral  congestion.  In  the  late  stages 
there  may  be  fainting  attacks.  With  this  lesion  compensation  may  be 
complete  for  a  long  time. 

Tricuspid  insufficiency. — This  is  usually  secondary  to  disease  of  the 
left  side  of  the  heart,  occurring  in  its  late  stages.  It  most  frequently  fol- 
lows mitral  insufficiency,  where  it  is  usually  due  to  dilatation  of  the  right 
ventricle  without  changes  in  the  valves.  It  may  be  secondary  to  certain 
diseases  of  the  lungs,  such  as  emphysema,  chronic  interstitial  jDueumonia, 
or  chronic  pleurisy,  and  it  may  be  due  to  congenital  malformation.  Tri- 
cuspid insufficiency  gives  a  systolic  murmur,  loudest  over  the  lower  part  of 
the  sternum,  but  heard  usually  over  a  small  area.  It  is  generally  associated 
with  signs  of  dilatation  of  the  right  ventricle.  The  jugular  veins  stand 
out  prominently,  and  often  show  systolic  pulsation,  especially  upon  the 
right  side.  The  symptoms  associated  with  tricuspid  regurgitation  are  due 
to  general  systemic  venous  obstruction,  already  mentioned  in  connection 
with  mitral  insufficiency. 


630  DISEASES  OF  THE   CIRCULATORY  SYSTEM. 

Tricuspid  stenosis,  pulmonic  stenosis,  and  pulmonic  insufficiency 
are  practically  unknown  in  childhood,  except  in  congenital  cardiac 
disease. 

Prognosis  of  Valvular  Disease. — Complete  recovery  from  valvular  dis- 
ease is  possible  only  when  the  lesions  are  very  slight.  Few  children  die 
from  cardiac  disease  before  reaching  the  age  of  fourteen  years,  sudden 
death  being  extremely  rare.  A  large  proportion  of  the  cases  do  fairly 
well  up  to  about  the  time  of  puberty,  when  they  begin  to  lose  ground, 
often  failing  rapidly.  Others  do  well  until  a  fresh  endocarditis  is  lighted 
up  by  an  intercurrent  attack  of  rheumatism,  after  which  the  disease  may 
make  rapid  progress.  The  proportion  of  children  who  have  serious  cardiac 
lesions  before  the  age  of  eight  years,  and  reach  adult  life  in  good  condition 
is  comparatively  small. 

There  are  several  features  of  cardiac  disease  in  children,  in  conse- 
quence of  which,  serious  lesions  tend  to  progress  more  rapidly  than  in 
adults.  The  muscular  walls  are  less  resistant,  and  hence  rapid  dilata- 
tion occurs  much  more  readily  than  in  adult  life.  The  heart  must  pro- 
vide not  only  for  constant  needs,  but  for  the  growth  of  the  body.  If  the 
patient's  general  nutrition  is  poor  during  the  period  of  most  rapid  growth, 
this  tells  quickly  and  seriously  upon  the  heart,  and  dilatation  makes  rapid 
progress;  but  if  the  general  nutrition  continues  good  the  heart  may  do 
more  than  hold  its  own  throughout  childhood.  The  demands  made  upon 
the  heart  at  puberty  are  especially  severe,  by  reason  of  the  rapid  growth 
of  the  body  and  the  frequency  of  anasmia  and  malnutrition.  There  is 
always  present  the  danger  of  rapid  advances  in  the  disease  from  inter- 
current attacks  of  rheumatism,  from  which  children  are  more  likely  to 
suffer  than  are  older  subjects.  Extensive  pericardial  adhesions  are  fre- 
quent, and  seriously  handicap  the  heart,  greatly  increasing  the  tendency 
to  dilatation.  The  effect  upon  the  heart  of  poor  food,  unhygienic  sur- 
roundings, and  general  malnutrition  is  much  more  marked  than  in  adults. 

These  unfavourable  conditions  are  in  part  offset  by  others  in  which 
the  child  has  an  advantage  over  the  adult.  Disease  of  the  coronary  ar- 
teries is  very  rare,  and  the  valvular  lesions  which  are  most  frequently  met 
with — mitral  insufficiency  and  aortic  obstruction — are  those  which  admit 
of  the  most  complete  compensation. 

In  making  a  prognosis  in  any  given  case,  the  amount  of  hypertrophy 
or  dilatation  which  exists  is  of  much  more  importance  than  the  location 
or  the  special  character  of  the  murmur.  The  condition  of  the  arterial 
and  venous  circulation  must  also  be  taken  into  consideration ;  also  how 
rapidly  the  disease  is  progressing,  the  condition  of  the  patient's  general 
health,  and  how  well  circumstances  will  admit  of  proper  hygienic  and 
general  management.  The  presence  of  valvular  disease  in  childhood  in- 
creases the  danger  from  every  acute  disease,  especially  pertussis,  diph- 
theria, pneumonia,  and  scarlet  fever. 


CHRONIC   VALVULAR  DISEASE.  631 

Diagnosis. — A'alvular  disease  is  to  be  particularly  distinguished  from 
conditions  in  which  there  are  heard  functional  or  accidental  murmurs. 
According  to  my  own  experience  the  latter  are  quite  common  even  in 
young  children.  Mistakes  usually  arise  from  attaching  too  much  impor- 
tance to  the  presence  of  murmurs^  and  too  little  to  the  changes  in  the 
walls  and  cavities  of  the  heart,  with  which  valvular  disease  is  almost  in- 
variably associated.  It  is  not  always  possible  to  decide  whether  a  mur- 
mur is  organic  or  functional  until  the  patient  has  been  for  some  time 
under  observation  and  treatment,  particularly  when  anaemia  is  present. 
The  diagnostic  points,  so  far  as  the  murmurs  are  concerned,  are  men- 
tioned in  connection  with  anaemic  murmurs  (page  634). 

Treatment. — A  child  who  is  the  subject  of  a  serious  chronic  valvular 
disease  should  be  constantly  under  a  physician's  observation.  Irrepa- 
rable harm  often  results  from  wilful,  but  more  frequently  from  ignorant, 
disregard  of  the  simplest  and  most  important  rules  of  life  for  these 
patients.  At  the  very  least  the  patient  should  be  carefully  examined 
three  or  four  times  each  year,  in  order  that  the  physician  may  note  the 
progress  of  the  disease,  and  be  able  to  modify  the  child's  occupation,  ex- 
ercise, and  surroundings  so  as  to  meet,  as  far  as  possible,  the  changing 
conditions. 

Several  distinct  conditions  may  be  present  which  call  for  quite  differ- 
ent management.  The  essential  points  may  be  stated  in  a  few  words : 
for  all  recent  cases  and  during  all  exacerbations,  rest,  complete  and  pro- 
longed ;  for  deformed  valves  with  good  heart  walls  and  perfect  compen- 
sation, fresh  air,  moderate  exercise,  and  general  tonics ;  for  feeble  heart 
walls,  failing  compensation  and  dilatation,  rest  and  specific  heart  tonics. 

During  the  stage  of  compensation,  treatment  directed  especially  to 
the  heart  is  rarely  necessary.  The  main  purpose  should  be  to  maintain 
the  patient's  general  nutrition  at  the  highest  possible  point  during  the 
period  of  active  growth.  To  this  end,  diet,  sleep,  study,  and  exercise 
should  receive  the  most  careful  attention.  If  malnutrition  and  anemia 
are  allowed  to  go  on  unchecked  until  they  become  severe,  the  cardiac  dis- 
ease may  make  rapid  strides,  and  as  much  harm  be  done  in  a  few  months 
as  otherwise  might  not  occur  in  years.  The  question  of  exercise  and  rec- 
reation is  always  a  difficult  one  to  settle.  Often  too  little  latitude  is 
given,  and  the  heart,  like  the  voluntary  muscles,  loses  its  tone.  Every 
form  of  exercise  requiring  a  prolonged  severe  strain  should  be  forbidden, 
particularly  swimming  and  competitive  games,  like  ball  and  tennis,  and 
others  requiring  much  running;  but  skating,  rowing,  mountain-climbing, 
horseback  exercise,  gymnastics,  and  even  cycling  on  the  level — all  in 
moderation — may  be  allowed  not  only  without  harm,  but  with  the  great- 
est benefit ;  but  any  of  these,  used  immoderately,  may  be  productive  of 
great  injury.  All  exercise  should  be  taken  with  regularity  and  system, 
the  amount  being  careful Iv  measured  bv  the  child's  condition.     If  the 


632  DISEASES  OP   THE  CIRCULATORY   SYSTEM. 

patient  is  a  boy  who  must  earn  his  own  living,  the  physician  should  see 
to  it  that  the  occupation  chosen  is  not  one  likely  to  make  special  demands 
upon  the  heart. 

Special  watchfulness  is  required  at  the  time  of  puberty  to  prevent 
overpressure  in  schools,  and  the  development  of  angemia  or  chlorosis. 
The  first  symptoms  of  these  conditions  should  be  treated  energetically, 
and  if  the  heart  seems  to  be  overtaxed  the  child  should  be  put  to  bed. 
Patients  should  be  so  far  as  possible  removed  from  conditions  likely  to 
induce  fresh  attacks  of  rheumatism.  To  this  end,  if  possible,  they 
should  spend  the  winter  and  spring  months  in  a  warm,  dry  climate. 

In  the  stage  of  failing  compensation,  the  same  general  conditions  are 
present  as  in  adults,  and  they  are  to  be  managed  in  pretty  much  the  same 
way.  When  such  symptoms  are  first  seen,  prolonged  rest  in  bed  should 
be  insisted  upon  as  the  thing  most  likely  to  restore  the  normal  conditions. 
Cardiac  dropsy  with  low  arterial  tension  and  weak  pulse,  calls  for  digitalis. 
An  overloaded  venous  circulation  may  be  relieved  by  diuretics,  or,  better, 
by  saline  purgatives.  Iron  and  tonics  generally  are  indicated,  particularly 
strychnine  and  cod-liver  oil.  In  cases  of  sudden  heart  failure,  nitroglycer- 
in, ether,  and  ammonia  are  as  valuable  as  in  adults ;  but  better,  probably, 
than  any  of  these  is  the  use  of  strychnine  hypodermically. 

MYOCARDITIS. 

Disease  of  the  muscular  wall  of  the  heart  is  rare  in  children,  and  of 
comparatively  little  importance,  except  in  connection  with  the  acute  in- 
fectious diseases.  Myocarditis  may,  however,  occur  at  any  age,  even  in 
foetal  life.  As  seen  in  children,  it  is  almost  invariably  a  secondary  lesion, 
usually  the  result  of  some  infectious  process.  The  two  diseases  which 
furnish  most  of  the  cases  are  scarlet  fever  and  diphtheria.  The  most 
important  local  cause  is  pericarditis  with  adhesions. 

Lesions. — In  extra-uterine  life,  myocarditis,  as  a  rule,  affects  the  wall 
of  the  left  ventricle,  the  papillary  muscles,  or  the  septum.  The  heart  is 
pale  or  of  a  yellowish- white  colour,  very  soft  and  flabby,  and  there  is  fre- 
quently dilatation  of  the  cavities.  Small  ecchymoses  may  be  seen  beneath 
the  pericardium. 

Two  varieties  of  myocarditis  are  described :  In  the  parenchymatous 
form  there  is  a  degeneration  of  the  muscle  fibre  which,  according  to 
Romberg,  is  most  frequently  albuminous,  next  fatty,  and  least  frequently 
hyaline.  There  is  a  loss  of  the  transverse  striations,  and  there  may  be 
complete  disintegration  of  the  fibres.  This  process  may  be  circumscribed, 
but  it  is  usually  diffuse.  In  the  interstitial  form  the  lesion  usually  occurs 
in  small,  circumscribed  areas.  There  is  an  infiltration  of  round  cells  be- 
tween the  muscular  fibres  of  the  heart.  The  process,  when  acute,  may  re- 
sult in  absorption  or  in  the  production  of  small  abscesses.  There  may  also 
be  congestion  and  minute  blood  extravasations.     In  chronic  cases  it  may 


ANEMIC   MURMURS.  633 

lead  to  the  formation  of  larger  or  smaller  areas  of  dense  connective  tissue 
resembling  cicatrices,  in  the  heart  wall.  Either  the  interstitial  or  the  pa- 
renchymatous form  may  occur  alone,  but  in  most  of  the  acute  cases  they 
are  combined.  In  addition,  there  is  usually  some  degree  of  mural  endo- 
carditis and  inflammation  of  the  pericardium  next  to  the  heart  wall. 
Dilatation  frequently  follows ;  rarely  abscesses  may  form,  which  may  open 
into  the  heart  or  into  the  pericardium.  Cardiac  aneurism,  and  even  rup- 
ture, have  been  known  to  occur  in  a  child  of  six  years  (Hadden's  case). 

Symptoms. — These  are  very  rarely  sufficiently  marked  to  enable  one 
to  make  a  positive  diagnosis.  In  many  cases  in  which  advanced  lesions 
have  been  found  at  autopsy  there  have  been  no  symptoms  during  life, 
and  in  others  none  until  the  occurrence  of  sudden  death.  This  is  usu- 
ally from  cardiac  paralysis,  rarely  from  rupture.  In  eight  cases  studied 
by  Romberg,  which  occurred  in  the  course  of  diphtheria,  not  one  had 
cardiac  symptoms  during  life  and  two  died  suddenly.  When  symptoms 
are  present,  they  are  generally  those  of  feeble  heart  action — a  faint  apex 
impulse,  a  slow,  weak  pulse  of  irregular  rhythm,  pallor,  dyspncea,  and 
attacks  of  syncope.  In  the  late  stages  there  may  be  the  physical  signs  of 
dilatation,  with  dropsy  of  the  feet  or  the  serous  cavities,  and  scanty  urine, 
sometimes  containing  albumin. 

Diagnosis. — A  positive  diagnosis  of  myocarditis  is  impossible.  It  may 
be  suspected  in  the  course  of  diphtheria,  scarlet  or  typhoid  fever,  when 
cardiac  symptoms  like  those  mentioned  occur,  and  when  pericarditis  and 
endocarditis  can  be  excluded  by  the  physical  examination. 

Treatment. — This  is  mainly  symptomatic.  After  severe  attacks  of 
those  infectious  diseases  in  which  myocarditis  is  liable  to  occur,  and  at 
any  time  when  it  is  suspected,  patients  should  be  kept  recumbent  for 
several  weeks,  and  special  care  exercised  to  prevent  any  sudden  exertion, 
as  death  has  occurred  from  so  slight  a  thing  as  suddenly  sitting  up  in 
bed.  Iron,  alcohol,  and  tonics  should  be  given,  the  best  of  all  of  these 
being  strychnine.  Digitalis  should  be  used  with  caution,  and  never  in 
large  doses.  In  some  cases  with  symptoms  indicating  imminent  heart 
failure,  more  striking  benefit  follows  the  use  of  morphine  hypodermically 
than  any  other  plan  of  treatment. 

ANEMIC  MURMURS. 

As  already  stated,  anajmic  murmurs  are  not  rare  even  in  infancy. 
They  may  be  confounded  with  organic  murmurs,  either  from  congenital 
malformations  or  acquired  disease.  I  have  several  times  found  the  heart 
normal  at  autopsy  in  cases  where  a  diagnosis  of  congenital  disease  had 
been  unhesitatingly  made  during  life,  the  murmur  having  been  of  anaemic 
origin.  In  any  ana?mic  infant,  as  well  as  older  child,  one  should  hesitate 
to  make  a  diagnosis  either  of  congenital  or  acquired  organic  disease,  from 
the  mere  presence  of  a  murmur. 


634  DISEASES  OP   THE   CIRCULATORY  SYSTEM. 

An  angemic  murmur  is  usually  systolic,  heard  at  the  base  of  the  heart, 
also  in  the  carotids,  often  in  the  subclavian  arteries,  and  occasionally  over 
any  of  the  large  trunks  of  the  body.  The  murmur  varies  from  day  to  day, 
and  sometimes  it  is  altered  by  changing  the  position  of  the  patient.  It 
may  be  loud  enough  to  be  heard  over  a  great  part  of  the  chest  in  front, 
and  even  behind.  There  is  frequently  present  a  venous  hum  in  the  neck. 
There  are  no  signs  of  hypertrophy,  nor  is  there  the  accentuated  second 
sound  so  characteristic  of  mitral  disease.  The  pulse  is  not  usually  strong. 
Ansemic  murmurs  diminish  in  intensity  and  ultimately  disappear  with 
improvement  in  the  general  condition  of  the  patient.  In  some  cases  one 
must  wait  for  the  effects  of  treatment  before  giving  a  positive  opinion. 

FUNCTIONAL  DISORDERS  OF  THE  HEART. 

Disturbances  in  the  heart's  action  unconnected  with  organic  disease, 
are  rare  in  infants  and  young  children ;  but  after  the  seventh  year  they 
are  not  uncommon,  becoming  in  fact  quite  frequent  as  puberty  approaches. 
One  of  the  most  important  causes  is  indigestion  ;  another  is  overpressure 
in  schools,  or  anything  else  leading  to  nervous  exhaustion.  In  these  cir- 
cumstances it  is  usually  associated  with  other  mental  or  psychical  dis- 
turbances. An  important  predisposing  cause  is  the  demand  made  upon 
the  heart  by  the  rapid  growth  of  the  body  about  the  time  of  puberty, 
particularly  when  this  is  associated  with  anaemia.  In  some  of  the  cases 
there  is  a  definite  exciting  cause,  such  as  fright  or  great  excitement,  and 
it  may  be  due  to  the  excessive  use  of  tea,  coffee,  or  tobacco,  especially  in 
the  form  of  cigarette-smoking.  In  a  few  instances  it  has  been  traced  to 
masturbation.  It  may  follow  any  acute  disease,  such  as  typhoid  fever, 
malaria,  or  one  of  the  exanthemata,  and  occasionally  it  occurs  in  the 
course  of  these  diseases,  or  with  bronchitis  or  pneumonia. 

Symptoms. — The  usual  manifestations  are  attacks  of  palpitation ;  less 
frequently  there  is  tachycardia  (rapid  heart)  or  bradycardia  (slow  heart). 
The  majority  of  children  complain  more  with  functional  disturbances 
than  with  organic  disease,  certainly  while  the  latter  is  accompanied  by 
compensation.  Attacks  of  palpitation  occur  in  paroxysms.  In  the  severe 
form  there  is  usually  a  sense  of  oppression  in  the  region  of  the  heart, 
with  some  dyspnoea,  or  even  orthopnoea.  The  pulse  is  usually  rapid,  from 
120  to  130,  and  is  irregular  both  as  to  force  and  rhythm.  The  carotids 
pulsate  strongly.  The  apex  impulse  is  felt  over  an  increased  area,  the 
heart  sounds  are  usually  strong  but  irregular,  and  sometimes  a  slight  mur- 
mur is  heard.  The  face  is  pale  or  flushed.  There  may  be  headache,  ver- 
tigo, spots  before  the  eyes,  and  noises  in  the  ears.  Sometimes  there  is 
slight  cyanosis  with  cold  hands  and  feet,  and  general  perspiration.  The 
frequency  of  these  attacks  depends  upon  the  nature  of  the  exciting  cause. 
Their  duration  is  from  a  few  minutes  to  several  hours. 


DISEASES  OP  THE   BLOOD-VESSELS.  G35 

Diagnosis. — Functional  disorders  are  differentiated  from  organic  car- 
diac disease  only  by  careful  and  repeated,  examinations  of  the  heart.  In 
the  diagnosis  of  functional  disturbance  especial  importance  is  to  be  at- 
tached to  a  neurotic  or  neurasthenic  condition  of  the  patient,  to  the 
presence  of  some  adequate  exciting  cause,  the  absence  of  evidence  of 
enlargement  of  the  heart,  and  the  fact  that  the  pulmonic  second  sound  is 
not  increased. 

Prognosis. — This  in  most  cases  is  favourable,  for  with  improvement 
in  the  patient's  general  condition,  with  the  growth  of  the  body,  and  in 
girls  with  the  establishment  of  menstruation,  the  attacks  usually  disappear. 

Treatment. — During  the  attacks,  digitalis  in  moderate  doses  should  be 
given,  also  bromides  or  valerian.  The  curative  treatment  is  to  be  directed 
toward  the  cause.  Where  no  special  cause  can  be  discovered  a  general 
tonic  plan  of  treatment  should  be  adopted,  with  careful  regulation  of 
the  patient's  diet,  exercise,  and  mode  of  life.  All  stimulating  food,  tea, 
coffee,  and  tobacco  should  be  prohibited.  Anaemia  should  receive  its  ap- 
propriate remedies.  The  hours  of  sleep  and  study,  and  the  amount  and 
character  of  exercise  allowed,  should  be  carefully  regulated.  Between 
attacks  no  treatment  of  the  heart  is  necessary. 

DISEASES  OF  THE  BLOOD-VESSELS. 

Abnormally  Small  Arteries  {Arterial  hypoplasia). — This  condition  is 
not  a  very  common  one,  but  it  has  attracted  a  good  deal  of  attention, 
having  been  studied  especially  by  Virchow.  The  only  thing  which  is  ab- 
normal in  the  circulatory  system  may  be  that  the  aorta,  and  sometimes  all 
the  large  vessels  are  only  two  thirds  or  three  fourths  their  usual  calibre, 
or  even  less.  This  may  interfere  seriously  with  the  growth  and  develop- 
ment of  the  body,  especially  of  the  genital  organs,  although  this  result  is 
not  a  constant  one.  The  condition  is  found  occasionally  in  cases  of  chlo- 
rosis, and  in  the  congenital  cases  it  may  be  the  chief  cause.  There  is 
usually  associated  a  certain  amount  of  hypertrophy  of  the  heart.  The 
other  symptoms  are  anaemia,  and  sometimes  an  imperfect  development  of 
the  body.     A  positive  diagnosis  during  life  is  impossible. 

Aneurism  and  Atheroma. — In  early  life  chronic  disease  of  the  blood- 
vessels is  exceedingly  rare,  yet  a  sufficient  number  of  observations  have 
been  recorded  to  show  that  even  young  children  are  not  exempt  from  this 
form  of  disease.  There  had  been  reported  up  to  1890  twenty-eight  cases 
of  aneurism  in  patients  under  twenty  years  of  age  (Jacobi).*  Of  these, 
however,  only  twelve  were  under  fourteen  years.  Sanne  f  records  the 
youngest  case,  which  occurred  in  a  foetus  born  at  about  the  eighth  month, 

*  A.  Jacobi,  Archives  of  Paediatrics,  vol.  vii,  p.  161. 

f  Sanne,  Revue  Mensuelle  des  Maladies  des  I'Enfance,  vol.  v,  p.  56.  In  these  arti- 
cles will  be  found  references  to  most  of  the  reported  cases. 


636  DISEASES  OF  THE   CIRCULATORY   SYSTEM. 

in  whose  body  there  was  found  a  large  aneurism  of  the  abdominal  aorta 
just  below  the  origin  of  the  renal  arteries.  Of  the  eleven  remaining  cases 
occurring  in  children  under  fourteen  years,  in  over  one  half  the  number 
the  arch  of  the  aorta  was  the  part  affected.  In  one  case  the  seat  was  the 
femoral  artery,  in  another  the  external  iliac,  and  in  still  another  the 
abdominal  aorta. 

Probably  the  most  important  etiological  factor,  as  in  adult  life,  is 
syphilis,  but  in  only  a  few  of  the  cases  reported  was  the  evidence  of  syphi- 
lis conclusive.  In  two  cases  there  was  general  tuberculosis.  In  addition 
to  these  general  causes,  aneurism  may  be  due  to  some  local  condition, 
such  as  an  erosion  from  bone,  an  abscess  in  the  neighbourhood,  or  to  em- 
bolism. The  symptoms  and  course  of  aneurism  in  young  children  do  not 
differ  essentially  from  those  of  the  disease  as  seen  in  adults. 

In  addition  to  the  cases  of  aneurism  referred  to  above,  I  have  found 
reports  of  seven  cases  of  atheroma  in  very  young  subjects.  In  Sanne's 
case  the  patient  was  but  two  years  old,  and  patches  of  atheromatous  de- 
generation were  found  in  several  places  in  the  aorta.  In  Hawkins's  case, 
eleven  years  old,  there  was  found  extensive  atheromatous  disease  of  the 
aorta,  subclavian  and  carotid  arteries.  In  Filatoff's  case,  atheromatous 
degeneration  affected  the  arteries  at  the  base  of  the  brain,  causing  death 
from  cerebral  hsemorrhage.  It  is  interesting  to  note  that  in  this  patient, 
who  was  only  eleven  years  old,  there  was  also  present  chronic  diffuse 
nephritis  with  contracted  kidneys.  A  similar  condition  of  the  kidneys 
and  arteries  was  observed  by  Dickinson  in  a  giri  of  six  years. 

Embolism  and  Thrombosis. — Embolism  has  already  been  referred  to  in 
connection  with  acute  endocarditis.  It  may  be  seen  at  any  age,  even  in 
infancy,  but  generally  occurs  in  patients  over  five  years  old.  The  emboli 
are  usually  swept  into  the  circulation  from  vegetations  upon  the  valves 
of  the  heart.  The  symptoms  which  they  produce  will  depend  upon  the 
nature  of  the  emboli  and  the  vessels  occluded  by  them.  If  they  lodge  in 
the  brain  they  may  cause  paralysis  or  convulsions ;  if  in  the  spleen,  pain 
and  swelling  of  this  organ  ;  if  in  the  kidneys,  pain,  tenderness,  and  some- 
times hjematuria ;  if  in  the  lungs,  cough,  sometimes  accompanied  by 
haemoptysis  and  occasionally  by  a  sharp  thoracic  pain.  If  the  emboli  are 
infectious,  they  may  give  rise  to  abscesses.  The  pathological  results  fol- 
lowing embolism  are  similar  to  those  which  are  seen  in  adults. 

The  most  frequent  form  of  thrombosis,  that  occurring  in  the  sinuses  of 
the  brain,  is  discussed  in  connection  with  Diseases  of  the  Nervous  System. 
Cardiac  thrombi,  especially  of  the  right  side  of  the  heart,  are  not  infre- 
quently found  in  patients  dying  from  heart  disease,  pneumonia,  and  occa- 
sionally also  from  other  acute  inflammatory  processes  and  acute  infectious 
diseases,  particularly  diphtheria.  These  thrombi  are  in  most  cases  pro- 
duced during  the  last  few  hours  of  life,  or  just  at  the  time  of  death,  and  are 
of  no  clinical  importance.     They  frequently  extend  from  the  heart  into  the 


DISEASES  OF   THE   BLOOD-VESSELS.  637 

large  blood-vessels,  particularly  the  pulmonary  artery.  Thrombosis  occa- 
sionally occurs  in  all  the  large  vascular  trunks  in  childhood  as  well  as  in 
adult  life. 

Tliromhosis  of  the  internal  jugular  vein. — Pasteur*  reports  a  case  in  a 
child  two  and  a  half  years  old,  in  which  the  middle  of  the  vein  was  filled 
with  an  organized  thrombus,  and  the  lower  portion  obliterated  and  re- 
duced to  a  fibrous  cord.  The  symptoms  were  swelling,  oedema,  and  cya- 
nosis of  the  face,  and  dilatation  of  the  facial  vein,  but  not  of  the  external 
jugular.  There  were  clubbing  of  the  fingers  and  oedema  of  the  feet,  but 
not  of  the  arm.  The  heart  was  found  to  be  dilated  and  hypertrophied, 
but  was  not  the  seat  of  valvular  disease.  The  symptoms  had  existed  since 
an  attack  of  pneumonia,  eighteen  months  before  death. 

Thrombosis  of  the  vena  cava. — Quite  a  number  of  cases  are  on  record 
where  this  has  occurred  as  the  result  of  pressure  from  large  abdominal 
tumours ;  it  has  followed  new  growths  of  the  kidney  and  large  masses  of 
tuberculous  lymph  nodes.  Xeurutter  and  Salmon  have  recorded  a  case  of 
thrombosis,  ajDparently  of  marantic  origin,  in  a  child  seven  years  old. 
The  thrombus  filled  the  vena  cava,  and  extended  to  the  origin  of  the 
hepatic  veins  and  into  both  femorals.  Death  occurred  from  tuberculosis. 
In  Scudder's  case  (seventeen  years  old)  there  was  apparently  obliteration 
(probably  congenital)  of  the  inferior  vena  cava ;  there  was  an  extensive 
varicose  condition  of  all  the  abdominal  veins.  The  symptoms  of  throm- 
bosis of  the  vena  cava  are  swelling  and  oedema  of  the  feet — sometimes  of 
the  abdominal  walls  and  the  groin — and  very  great  dilatation  of  the  super- 
ficial abdominal  veins. 

Thrombosis  of  the  aorta. — A  case  has  been  reported  by  Leopold  in  a 
newly-born  child  which  was  delivered  by  version.  The  thrombus  was  of 
recent  origin,  and  filled  the  lower  aorta,  extending  into  the  femoral  artery. 
A  ease  of  thrombosis  of  the  aorta  occurring  in  a  girl  of  thirteen  years  has 
been  reported  by  Wallis.  The  aorta  was  very  narrow,  and  probably  the 
seat  of  syphilitic  disease.  The  thrombus  extended  from  the  origin  of  the 
renal  arteries  to  the  coeliac  axis. 

Thrombosis  in  infectious  diseases.  —  There  is  occasionally  seen  in 
typhoid  fever,  but  more  frequently  in  diphtheria,  thrombosis  of  some  of 
the  large  venous  trunks,  usually  of  one  of  the  lower  extremities.  The 
symptoms  are  pain,  localized  swelling,  and  partial  paralysis.  If  the  artery 
is  affected,  there  may  be  gangrene. 

*  Lancet,  February  11,  1888. 


42 


SECTIOIsT  YI. 

DISEASES  OF  THE  L'EO-GENITAL  SYSTEM. 

CHAPTER    I. 
TEE   URINE  IN  INFANCY  AND  CEILDHOOD. 

While  a  study  of  the  urine  is  of  much  less  importance  in  early  life 
than  of  the  symptoms  referable  either  to  the  digestive  or  respiratory  sys- 
tem, it  is  deserving  of  much  more  attention  than  it  has  generally  re- 
ceived. In  infancy  especially  it  is  attended  -^ith  difficulty,  owing  to  the 
fact  that  it  is  by  no  means  an  easy  matter  to  secure  specimens  for  exami- 
nation. 

Methods  of  Collecting  TJrine. — In  male  infants  this  may  be  done  by 
placing  the  penis  in  the  neck  of  a  small  bottle  which  lies  between  the 
thighs  and  is  secured  in  position  by  pieces  of  tape  passing  over  the  hips 
and  beneath  the  perinseum.  A  still  better  plan  is  to  use  in  the  place  of  a 
bottle  a  condom  large  enough  to  include  both  the  scrotum  and  penis. 
The  urine  of  female  infants  can  sometimes  be  collected  in  a  similar  way 
by  placing  a  small  cup  over  the  vulva  and  holding  it  in  place  by  the  nap- 
kin. A  plan  nearly  always  successful  is  to  put  the  infant  upon  a  chamber 
after  a  long  sleep.  It  should  be  done  on  the  instant  of  waking,  or  the 
child  may  be  wakened  for  the  purpose.  A  cold  hand  over  the  bladder 
facilitates  matters.  A  small  amount,  sufficient  to  test  for  albumin,  may 
often  be  obtained  by  placing  absorbent  cotton  over  the  vulva  or  penis. 
The  most  certain  of  all  means,  however,  is  catheterization;  in  females 
sometimes  nothing  else  will  answer  the  purpose.  A  soft  rubber  catheter, 
size  6  or  7,  American  scale  (9  or  11  French),  should  be  used  for  infants. 

Daily  Quantity. — This  is  relatively  much  larger  in  infants  than  in 
older  children  and  in  adults,  on  account  of  the  more  active  metabolism  of 
the  young  child  and  the  large  amount  of  water  taken  with  the  food.  The 
quantity  fluctuates  widely  from  day  to  day  according  to  the  amount  of 
fluid  food  taken  and  the  activity  of  the  skin  and  bowels.  The  following 
figures  are  the  averages  obtained  by  combining  the  results  of  the  investi- 
gations of  Schabanowa,  Cruse,  Camerer,  Pollak,  ]\Iartin-Ruge,  Berti, 
SchifP,  and  Herter : 

638 


THE    URINE   IN   INFANCY  AND   CHILDHOOD.  539 

Average  Daily  Quantity  of  Urine  in  Health. 


Age.  Grammes. 


Ounces. 


First  twenty-four  hours 0  to  60  0  to    2 

Second  twentv-four  hours 10  "  90  J-  •'  3 

Three  to  six  days 90  "  250  ;^  "  8 

Seven  davs  to  two  months 150  •'  400  5  "  13 

Two  to  .six  months 210"  500  7  "  16 

Six  months  to  two  years 250  "  600  s  "  20 

Two  to  live  years  .  ■ 500"  800  IG  "  26 

Five  to  eight  years 600  "  1,200  20  "  40 

Eight  to  fourteen  years 1,000  "  1,500  32  "  48 


Frequency  of  Micturition. — This  is  greatest  in  young  infants,  and 
diminishes  steadil}'  as  age  advances.  In  the  first  two  years,  during  the 
waking  hours,  the  urine  is  generally  passed  as  often  as  twice  an  hour,  while 
during  sleep  it  is  retained  from  two  to  six  hours.  By  the  third  year  the 
urine  may  be  held  during  sleep  for  eight  or  nine  hours,  and  at  other  times 
for  two  or  three  hours.  Such  control  of  the  sphincter  of  the  bladder  is 
often  obtained  at  two  years,  and  sometimes  even  at  an  earlier  period. 
From  slight  nervous  disturbances  or  minor  ailments  of  any  kind,  this  con- 
trol is  impaired,  and  the  water  may  be  passed  by  children  of  four  or  five 
years  with  the  frequency  seen  in  infants. 

Physical  Characters. — The  urine  of  the  newly  born  is  usually  highly 
coloured.  During  later  infancy  it  is  pale  and  frequently  turbid,  even 
when  practically  normal,  owing  to  the  presence  of  mucus ;  this  turbidity 
often  no  amount  of  filtration  will  entirely  remove.  Less  frequently  tur- 
bidity depends  upon  urates.  The  urine  of  the  first  few  days  of  life  often 
shows  a  deposit  of  urates  or  uric  acid  in  the  form  of  a  reddish-yellow 
stain  upon  the  napkin.  The  reaction  of  the  urine  at  this  time  is  usu- 
ally strongly  acid,  but  throughout  the  rest  of  infancy  it  is  faintly  acid  or 
neutral. 

The  specific  gravity  is  higher  during  the  first  two  days  than  at  any 
time  in  infancy  on  account  of  the  scanty  supply  of  fluid  taken ;  it  is 
usually  lowest  from  the  third  to  the  sixth  day,  but  from  this  time  it  rises 
steadily  until  puberty  is  reached.  The  specific  gravity  will  of  course  vary 
with  the  quantity.  From  the  writers  already  referred  to  the  following 
figures  are  taken : 

Specific  g^ravity. 

First  to  third  day 1  '010  to  1-012 

Fourth  to  tenth  day 1-004  "  1-008 

Tenth  day  to  sixth  month 1-004  "  1-010 

Six  months  to  two  years 1-006  "  1-012 

Two  to  eight  years 1-008  "  1  -016 

Eight  to  fourteen  years 1-012  "  1-020 

Microscopically,  the  urine  of  the  newly  born  shows  the  presence  of 
many  squamous  epithelial  cells,  mucus,  granular  matter,  and  crystals  of 


640  DISEASES   OF   THE   URO-GENITAL   SYSTEM. 

uric  acid  and  amorphous  or  crystalline  urates.  It  is  not  uncommon  to 
find  hyaline  and  even  granular  casts.  Martin-Euge  found  hyaline  casts 
in  the  urine  of  fourteen  out  of  twenty-four  healthy  nursing  infants  ex- 
amined during  the  first  week.  Granular  casts  were  much  less  frequent. 
The  microscopical  appearances  of  the  normal  urine  of  later  infancy  and 
chi-ldhood  present  no  peculiarities. 

Composition. —  Urea. — The  following  figures  show  the  average  daily 
quantity  of  urea  eliminated  at  the  different  ages  : 

Age.  Daily  quantity  of  urea. 

First  day 0-076  to    0-114  gramme. 

Second  to  seventh  day 0-140"    0-660 

One  to  two  months 0-90     "     1-40  " 

Three  to  five  years 13-09     "  14-01    grammes. 

Five  to  thirteen  years 16-05     "21-03 

Ui'ic  acid. — Few  observations  have  been  made  upon  the  elimination 
of  uric  acid,  but  all  authorities  agree  that  it  is  much  higher  in  the  newly 
born  than  at  any  subsequent  period  of  life.  The  quantity  is  better  ap- 
preciated by  giving  the  ratio  between  the  uric  acid  and  urea  than  by  the 
absolute  quantity  of  the  former.  The  figures  here  given  for  the  newly 
born  are  taken  from  Martin-Ruge ;  the  others  are  from  Herter. 

Ratio  of  Uric  Acid  to  Urea. 

In  the  newly  born 1  to  14 

Under  one  year 1  "  60-80 

From  two  to  five  years 1  "  50-70 

From  five  to  fifteen  years 1  "  45-60 

The  inorganic  salts  (phosphates,  chlorides,  sulphates)  are  all  present 
in  the  urine  of  the  newly  born,  but  in  relatively  small  quantities,  increas- 
ing as  age  advances.    The  colouring  matters  are  also  less  abundant. 

Albumin  is  often  present  in  the  urine  during  the  first  days,  but  usu- 
ally in  small  amount.  Cruse  found  it  twenty-eight  times  in  ninety  obser- 
vations upon  healthy  infants ;  usually  the  quantity  was  small,  amounting 
to  traces  only,  but  in  two  cases  it  was  quite  large  upon  the  second  day. 
These  observations  are  confirmed  by  the  investigations  of  Martin-Euge, 
and  also  of  Pollak. 

Sugar  is  frequently  found  in  the  urine  of  healthy  infants  during  the 
first  two  months.  This  subject  is  referred  to  later  under  the  head  of 
Grlycosuria. 

FUNCTIONAL  OR  CYCLIC  ALBUMINURIA. 

Etiology. — This  condition,  although  a  rare  one  in  young  children,  is 
occasionally  seen  between  the  ages  of  ten  and  sixteen  years.  I  shall  not 
in  this  connection  include  cases  sometimes  classed  as  febrile  albumi- 
nuria, in  which  there  is  usually  present  the  condition  described  as  acute 
degeneration  of  the  kidneys. 


FUNCTIONAL  OR  CYCLIC  ALBUMINURIA.  641 

The  causes  of  functional  or  physiological  albuminuria,  and  the  cir- 
cumstances in  which  it  has  been  observed,  are  many  and  varied.  It  is 
much  more  common  in  males  than  in  females.  In  many  patients  it  is 
regularly  e3'clic  in  character,  albumin  being  absent  in  the  urine  passed 
during  the  night  or  early  morning,  but  present  during  the  day,  diminish- 
ing in  the  evening  and  absent  at  bed-time.  In  a  case  reported  by  Tie- 
mann,  the  morning  urine  showed  no  trace  of  albumin  in  seventv-eight  of 
eighty-four  examinations.  At  noon  albumin  was  present  iu  ninety-eight 
of  one  hundred  and  thirteen  examinations.  In  certain  cases  albuminuria 
is  distinctly  traceable  to  cold  bathing ;  in  others,  to  fatigue  following  ex- 
cessive muscular  exercise;  in  still  others,  to  dyspeptic  conditions.  It 
may  be  associated  with  a  diet  rich  in  nitrogenous  food.  Sometimes  none 
of  these  conditions  exist,  and  there  is  simply  the  occasional  presence  of 
albumin  in  the  urine. 

Many  theories  have  been  advanced  in  explanation  of  cyclic  albuminuria. 
Sometimes  it  appears  to  be  clearly  traceable  to  irritation  of  the  kidney  by 
uric  acid,  urates,  or  oxalates.  Kinnicutt  believes  this  to  be  one  of  the 
prominent  causes,  and  that  albuminuria  is  due  to  vaso-motor  disturbances 
in  the  kidney.  Delafield  compares  the  exudation  of  serum  from  the  ves- 
sels of  the  kidney  to  the  dropsy  of  the  feet  seen  in  ansemia.  Da  Costa 
believes  that  it  always  depends  upon  slight  changes  of  an  evanescent  char- 
acter in  the  kidney. 

Symptoms. — Many  of  the  patients  exhibiting  cyclic  or  periodical  al- 
buminuria are  well  nourished,  and  have  no  other  signs  of  disease;  others 
show  dyspeptic  symptoms,  and  are  anaemic  and  poorly  nourished,  suffering 
from  headaches  and  other  neuroses.  In  the  cases  distinctly  periodical  the 
amount  of  albumin  is  commonly  small.  It  is  not  infrequently  associated 
with  temporary  glycosuria.  As  a  rule,  casts  are  absent,  altho'ugh  it  is  not 
uncommon  to  find  a  few  hyaline  casts,  and  occasionally  granular  casts  are 
also  present.  A  gouty  family  history  exists  in  a  certain  proportion  of  the 
cases,  and  some  of  the  patients  themselves  present  other  evidences  of  this 
diathesis. 

Diagnosis. — Pavy  mentions  the  following  points  as  characteristic  of 
physiological  or  functional  albuminuria :  (1)  The  time  of  its  occurrence. 
The  absence  of  albumin  early  in  the  morning,  its  presence  in  the  fore- 
noon, and  diminution  toward  evening.  When  this  is  repeated  day  after 
day  the  diagnosis  is,  he  believes,  quite  positive.  (2)  The  absence  of  seri- 
ous impairment  of  the  general  health  and  of  the  characteristic  symptoms 
of  nephritis,  such  as  dropsy,  cardiac  hypertrophy,  a  pulse  of  high  tension, 
retinal  changes,  etc.  (3)  The  fact  that  casts  are,  as  a  rule,  absent.  (4) 
That  crystals  of  oxalate  of  lime  are  present,  and  the  urine  is  of  high 
specific  gravity. 

Too  much  stress  is  certainly  laid  by  Pavy  and  many  other  writers 
upon  the  fact  that  the  albumin  is  found  in  the  urine  only  at  certain 


642  DISEASES   OF  THE  UEO-GEXITAL  SYSTEM. 

times  in  the  day.  This  is  not  peculiar  to  functional  albuminuria,  as  the 
same  thing  occurs  in  many  cases  of  chronic  nephritis,  especially  in  the 
early  stages  when  the  amount  of  albumin  present  is  small.  All  these 
cases  must  be  carefully  watched  for  a  long  time  and  many  observations 
made,  before  nephritis  can  positively  be  excluded. 

Prognosis. — The  prognosis  in  cases  of  purely  functional  albuminuria  is 
good.  It  is  to  be  remembered  that  patients  who  for  a  considerable  time 
have  been  regarded  as  having  only  functional  albuminuria  have  ultimately 
developed  nephritis ;  hence  an  absolutely  favourable  prognosis  is  possible 
only  after  a  long  period  of  observation.  If  albumin  is  constantly  present 
it  is  probably  pathological,  and  the  longer  it  continues  the  more  serious  is 
the  outlook. 

Treatment. — This  is  to  be  directed  toward  the  patient's  general  condi- 
tion rather  than  to  the  kidneys  and  the  urine.  The  dyspeptic  symptoms 
must  be  relieved,  the  patient's  mode  of  life  regulated,  only  moderate  exer- 
cise allowed,  and  a  simple  diet  given  which  does  not  consist  too  largely  of 
nitrogenous  food.  If  the  urine  is  of  high  specific  gravity,  and  contains 
oxalate-of-lime  crystals,  alkalies  and  mineral  waters  should  be  given  in 
addition.     Iron  is  indicated  if  there  is  ansemia. 

H^MATUEIA. 

Haematuria  is  characterized  by  the  presence  of  red  blood-cells  in  the 
urine,  and  is  to  be  distinguished  from  haBmoglobinuria  where  only  blood 
pigment  is  present. 

Hfematuria  may  result  from  local  or  general  causes.  In  infancy  it 
may  be  due  to  new  growths  of  the  kidney.  In  such  cases  the  haemor- 
rhages are  often  abundant,  and  may  be  the  first  symptom  of  the  condition. 
Haematuria  may  occur  also  as  a  symptom  of  acute  nephritis,  especially 
that  complicating  scarlet  fever,  or  it  may  result  from  the  irritation  of  a 
calculus- in  the  kidney,  the  ureter,  or  the  bladder.  In  rare  instances  its 
cause  is  a  new  growth  of  the  bladder,  and  it  may  be  due  to  traumatism. 
Among  the  general  causes  the  most  important  are  :  the  heemorrhagic  dis- 
ease of  the  newly  born  ;  the  blood  dyscrasiae,  such  as  scurvy,  purpura,  and 
haemophilia  ;  and  infectious  diseases,  particularly  malaria,  typhoid,  variola, 
scarlet  fever,  and  influenza.  In  most  of  these  cases  the  amount  of  blood 
passed  is  small.  When  it  is  large  it  may  appear  in  the  urine  as  clear 
blood,  or  as  clots,  or  it  may  impart  simply  a  reddish  or  smoky  colour  to 
the  urine.  The  colour,  however,  is  not  a  reliable  guide ;  the  best  of  all  is 
the  microscopical  examination.  For  a  simple  chemical  test  guaiacum  may 
be  used. 

To  discover  the  source  of  the  blood  may  be  quite  difficult.  Large 
haemorrhages  are  much  moi'e  likely  to  come  from  the  kidneys  than  from 
the  bladder.    The  presence  of  blood  casts  from  the  renal  tubules,  or  larger 


GLYCOSURIA.  643 

ones  from  the  ureter,  are  conclusive  evidence  of  the  renal  origin  of  the 
haemorrhage. 

In  children,  renal  haemorrhage  in  itself  rarely  requires  treatment; 
when  it  does,  the  same  remedies  are  indicated  as  in  the  adult,  viz.,  ergot, 
gallic  acid,  and  rest  in  bed.  Some  obstinate  cases  have  been  cured  by 
drinking  water  from  alum  springs. 

HEMOGLOBINURIA. 

In  this  condition  blood  j)igment  appears  in  the  urine  in  large  quantity, 
but  red  blood-cells  are  very  few  in  number,  or  are  absent  altogether.  In 
severe  cases  the  urine  may  be  almost  black.  There  is  commonly  a  small 
amount  of  albumin.  This  condition  may  be  recognised  by  the  appearance 
of  granules  of  pigment  under  the  microscope,  or  by  Heller's  test ;  the 
most  conclusive  means  of  diagnosis,  however,  is  the  spectroscope. 

Epidemic  haemoglobinuria  (Winckel's  disease)  has  already  been  de- 
scribed in  the  chapter  on  Diseases  of  the  Newly  Born.  Hemoglobinuria 
may  be  due  to  certain  poisons,  as  carbolic  acid  or  chlorate  of  potash,  or  to 
certain  infectious  diseases,  as  scarlet  fever,  typhoid  fever,  malaria,  syphilis, 
and  erysipelas. 

Paroxysmal  hgemoglobinuria  occurs  in  childhood,  although  it  is  an 
exceedingly  rare  condition.  A  typical  case  in  a  child  of  four  and  a  half 
years  has  been  reported  by  Mackenzie.  This  was  a  delicate  child  of  syphi- 
litic parents ;  the  haemoglobinuria  was  preceded  by  fever  and  chills,  with- 
out any  other  evidence  of  the  presence  of  malaria. 

The  exact  pathology  of  haemoglobinuria  is  at  present  unknown,  and 
its  treatment  is  very  unsatisfactory. 

GLYCOSURIA. 

By  this  term  is  understood  the  occasional  or  transient  appearance  of 
sugar  in  the  urine.  This  is  not  very  infrequent  in  children,  and  may  be 
met  with  even  during  the  first  month  of  life.  Grosz  has  published  some 
careful  investigations  upon  the  glycosuria  of  early  infancy.*  He  made 
many  observations  upon  fifty  infants  during  the  first  month  of  life,  from 
which  the  following  conclusions  were  drawn  :  Glycosuria  is  not  uncommon 
in  nursing  infants;  but  it  is  not  seen  in  nursing  infants  who  are  per- 
fectly healthy.  It  occurs  particularly  with  certain  disturbances  of  diges- 
tion, whether  functional  or  inflammatory.  The  sugar  found  in  the  urine 
under  these  conditions  reacts  strongly  to  the  reduction  test  (Fehling's), 
but  not  to  the  fermentation  test ;  sometimes  the  polariscope  shows  that  it 
has  the  power  of  dextro-rotation.  This  is  believed  to  be  milk  sugar,  or  one 
of  its  derivatives.     It  is  not  of  constant  or  regular  occurrence.     It  may  be 

*  Jahrbuch  f  lir  Kindcrheilkunde,  Bd.  xxxiv,  p.  83. 


644  DISEASES   OF   THE   URO-GENITAL   SYSTEM. 

produced  artificially  by  increasing  the  amount  of  milk  sugar  above  that 
which  can  be  normally  absorbed.  This  quantity  Grosz  places  at  3-3 
grammes  for  each  kilogramme  of  the  body  weight.  If  more  than  this  is 
given,  or  if  there  is  diminished  capacity  for  the  absorption  of  sugar,  gly- 
cosuria occurs. 

Koplik  has  made  some  observations  upon  the  urine  of  patients 
fed  chiefly  upon  infant  foods  composed  largely  of  sugar.  He  found 
sugar  in  five  out  of  ten  cases  examined ;  in  three,  the  sugar  responded 
both  to  Fehling's  and  the  fermentation  test ;  in  two  cases  to  Fehling's 
test  only. 

There  seems  to  be  no  doubt  regarding  the  existence  of  dietetic  glyco- 
suria in  infants  and  in  older  children.  Eepeated  examinations  of  the 
urine  are,  however,  necessary  in  order  to  exclude  more  serious  disease. 

PYURIA. 

Pus  in  the  urine  may  exist  as  an  acute  or  a  chronic  condition.  In 
either  case,  in  a  child,  it  is  much  more  likely  to  come  from  the  pelvis  of  the 
kidney  than  from  any  other  source.  It  may,  however,  come  from  any  part 
of  the  genito-urinary  tract — the  kidney  or  its  pelvis,  the  ureters,  the  blad- 
der, the  urethra,  or  the  vagina.  Sometimes  it  comes  from  an  outside 
source,  as  when  an  abscess  from  perinephritis,  appendicitis,  or  caries  of 
the  spine  opens  into  the  urinary  tract. 

Coming  from  the  pelvis  of  the  kidney,  pus  may  indicate,  if  the  con- 
dition is  an  acute  one,  pyelitis,  pyelo-nephritis,  or  pyonephrosis ;  if  it  is 
chronic,  it  points  to  renal  tuberculosis  or  calculus.  The  amount  of  pus 
in  any  of  these  conditions  may  be  quite  large.  The  urine  is  turbid  and 
usually  acid  in  reaction.  It  contains  many  epithelial  cells  of  the  transi- 
tional variety.  A  urine  containing  much  pus  is  always  albuminous.  A 
turbidity  due  to  pus  may  be  mistaken  for  an  excessive  deposit  of  urates; 
they  are  distinguished  by  the  microscope  and  by  the  fact  that  urates 
clear  uj)  on  heating.  It  is  rare  that  pus  comes  from  the  ureters  except 
in  connection  with  congenital  malformations  or  the  impaction  of  cal- 
culi. Pus  from  the  bladder  is  not  usually  in  large  quantity,  and  may  be 
mixed  with  mucus.  The  urine  may  be  alkaline  or  acid  in  reaction;  there 
may  be  associated  the  sym^stoms  of  vesical  irritation  or  of  cystitis.  Pus 
from  the  lower  genital  tract  is  rare  in  children,  and  its  causes  may  often 
be  recognised  by  a  local  examination.  When  the  cause  of  pyuria  is 
the  opening  of  an  abscess  into  the  urinary  tract  there  is  generally  a 
sudden  appearance  of  pus  in  large  amount.  The  pyuria  is  in  most  cases 
of  short  duration,  possibly  only  a  few  days,  and  it  may  disappear  quite 
rapidly. 

The  treatment  of  pyuria  depends  altogether  upon  its  cause.  Improve- 


LITHURIA.  645 

ment  in  the  sj^mptoms  nearly  always  follows  the  use  of  urotropin,  which 
may  be  given  in  closes  of  from  two  to  five  grains  three  times  a  day  to  a 
child  of  five  years. 

LITHURIA. 

Lithuria  is  a  condition  in  which  there  is  an  excessive  elimination  in 
the  urine  of  uric  acid  or  of  urates.  The  amount  of  nitrogen  compounds 
eliminated  by  the  kidneys  as  uric  acid  and  urea,  varies  much  from  day  to 
day  with  the  nature  of  the  food  and  other  conditions.  Hence  in  estimat- 
ing an  excess  of  uric  acid,  the  absolute  quantity  eliminated  in  twenty- 
four  hours  is  much  less  significant  than  the  ratio  of  the  uric  acid  to  the 
urea  (page  640).  Whenever  this  ratio  is  continuously  disturbed,  the  ex- 
cretion of  uric  acid  may  be  considered  abnormal,  except,  of  course,  in 
grave  pathological  conditions  of  the  kidney,  where  there  is  an  insufficient 
elimination  of  urea.  Eegarding  the  source  of  uric  acid,  the  theory  of 
Horbaczewski  is  that  most  widely  accepted,  viz.,  that  it  results  from  the 
destruction  of  the  nuclein  of  the  cells  of  the  body,  particularly  of  the 
white  blood-cells. 

For  accurate  knowledge  as  to  the  amount  of  uric  acid  eliminated, 
nothing  short  of  a  quantitative  chemical  analysis  can  be  depended  upon. 
But  if  amorphous  urates  are  deposited  in  large  amount,  uric  acid  may  be 
considered  excessive  if  the  specific  gravity  is  not  high  (above  1.025).  If 
the  specific  gravity  is  high,  the  precipitation  may  be  explained  simply  by 
the  concentration  of  the  urine.  The  deposition  of  the  crystals  of  uric 
acid,  forming  the  familiar  brick-dust  deposit,  is  not  in  itself  evidence  of 
excessive  elimination.  For  a  quantitative  clinical  test,  that  of  Haycroft 
is  probably  the  best.* 

Lithuria  is  not  a  specific  condition,  but  rather  a  very  general  symp- 
tom associated  with  many  kinds  of  disturbances  of  nutrition.  It  may  be 
found  in  anemia,  malnutrition,  chorea,  rheumatism,  chronic  dyspepsia, 
and  in  a  great  variety  of  other  disorders.  Regarding  the  significance  of 
lithuria,  thus  much  may  be  positively  asserted :  The  excessive  elimination 
of  uric  acid  when  continuous  is  always  evidence  of  a  serious  disturbance  of 
nutrition.  The  gravity  of  the  condition  will  depend  upon  the  degree  of 
this  excess  and  upon  its  duration. 

The  treatment  of  lithuria  is  the  treatment  of  the  condition  upon 
which  it  depends.  The  essential  pathological  condition  is  not  so  much 
excessive  elimination  as  excessive  production. 

Urine  containing  Crystals  of  TJric  Acid  in  the  Form  of  Brick-Dust 
Deposit. — This  condition  is  not  to  be  confounded  with  the  one  just  de- 
scribed. As  already  stated,  such  precipitation  is  not  to  be  taken  as  evi- 
dence of  an  excess  of  uric  acid,  and,  in  fact,  in  most  of  these  cases  there 

*  See  Hai.u'  on  Uric  Acid  in  Ileiilth  and  Disease. 


646  DISEASES   OF  THE  URO-GENITAL  SYSTEM. 

is  no  excess.  The  condition  is  rather  one  in  which  the  solvent  power  of 
the  urine  for  uric  acid  is  much  reduced.  Such  urine,  as  a  rule,  is  high- 
coloured,  strongly  acid,  and  may  have  a  high  specific  gravity. 

This  condition  also  is  dependent  upon  a  disturbance  of  nutrition,  and 
one  which  is  most  frequently  associated  with  a  gouty  diathesis.  It  is 
not  very  common  in  children  except  in  those  of  gouty  antecedents.  In 
such  patients  it  is  only  occasionally  present,  and  is  usually  associated 
with  some  other  disturbance  of  nutrition,  often  of  digestion.  It  is  fre- 
quently the  cause  of  local  irritation  of  the  urinary  passages,  which  is 
frequently  manifested  by  incontinence  of  urine. 

In  my  experience  these  cases  are  most  improved  by  cutting  off  sugar 
from  the  diet  almost  entirely,  by  greatly  reducing  the  amount  of  starchy 
food  and  substituting  a  diet  rich  in  nitrogen  and  fat,  viz.,  meat,  milk, 
and  cream,  together  with  plenty  of  outdoor  exercise.  The  continued  use 
of  alkaline  waters  is  also  of  decided  advantage  in  most  cases. 

INDICANURIA. 

Indicanuria  is  a  condition  characterized  by  the  presence  of  indican  in 
the  urine.  To  Herter  is  due  the  credit  of  bringing  this  subject  promi- 
nently to  the  minds  of  the  profession  in  this  country.  Indican  (indoxyl- 
potassium  sulphate)  is  derived  from  indol,  which  is  formed  in  the  intes- 
tine by  the  agency  of  bacteria  from  the  excessive  putrefaction  of  the 
proteids.  It  may  also  be  produced  in  other  parts  of  the  body  where  putre- 
factive processes  are  going  on,  as  in  extensive  suppuration  without  drain- 
age, in  pulmonary  cavities,  empyema,  etc.  Indican  is  only  one  of  the 
ethereal  sulphates  produced  in  the  manner  above  indicated,  and  when 
other  conditions  like  those  mentioned  are  excluded  it  may  be  taken  as  an 
index  of  the  amount  of  putrefaction  going  on  in  the  intestine. 

The  presence  of  indican  in  the  urine  is  demonstrated  by  adding  certain 
oxidizing  agents,  which  produce  an  indigo-blue  colour.*     The  existence 

*  The  commonly  employed  test  for  indican  is  that  known  as  JafEe's  test.  It  is 
described  by  Herter  as  follows :  Pour  into  a  test-tube  equal  quantities  of  urine  and 
strong  hydrochloric  acid  so  as  to  fill  the  tube  to  within  half  an  inch  of  the  top,  and 
shake.  If  there  is  much  indican,  a  dark  blue  or  purple  colour  will  be  produced.  Then 
add  sufficient  chloroform  to  completely  fill  the  tube  and  shake  thoroughly.  It  is 
important  that  the  chloroform  should  completely  fill  the  tube  so  that  no  air  bubbles 
get  in  by  the  agitation.  If,  after  standing,  the  chloroform  assumes  a  deep-blue  or  vio- 
let colour,  there  is  certainly  an  excess  of  indican.  The  reaction  may  not  appear  at 
first,  but  may  come  out  after  standing  several  hours,  or  if  slight  at  first  it  may  in- 
crease in  intensity.  Sometimes,  when  no  reaction  is  obtained,  it  may  be  produced  by 
adding  one  drop  of  a  saturated  solution  of  chloride  of  lime  or  of  peroxide  of  hydro- 
gen. Xo  more  than  one  drop  should  be  added  at  a  time,  or  the  blue  colour  may  be 
bleached.  In  alkaline  urine  the  indican  is  usually  destroyed,  so  that  the  test  may  be 
negative. 


ACETONURIA— DIACETONURIA.  647 

of  indicanuria  in  children  was  formerly  believed  to  be  pathognomonic  of 
tuberculosis.  Later  investigations  have  shown  that  this  is  not  the  case ;  for 
in  cases  of  tuberculosis  indican  is  almost  as  frequently  absent  as  present. 

Herter  gives  the  following  as  the  conditions  under  which  indicanuria 
is  likely  to  be  present :  It  is  found  in  chronic  intestinal  indigestion ;  in 
very  many  cases  of  chronic  constipation ;  in  many  cases  of  epilepsy,  just 
about  the  time  of  the  seizures ;  in  some  cases  of  masturbation ;  frequently 
in  children  who  are  the  subjects  of  night  terrors,  and  in  whom  there 
are  usually  disturbances  of  digestion.  According  to  other  observers, 
it  is  found  with  great  constancy  in  acute  putrefactive  diarrhoeas.  With 
the  exceptions  above  noted,  the  source  of  the  indican  is  always  the 
same,  viz.,  the  excessive  putrefaction  of  the  |)roteid  substances  in  the 
intestine. 

Indicanuria  is  most  frequently  a  symptom  either  of  acute  or  chronic 
intestinal  disease.  It  is  important  as  being  a  guide  by  which  we  may 
estimate  the  other  symptoms  in  these  conditions,  and  the  effects  of 
treatment.  While  a  trace  of  indican  is  frequently  present  in  health,  a 
strong  indican  reaction  is  always  to  be  considered  abnormal  in  a  child. 
The  indications  for  treatment  are  to  diminish  intestinal  putrefaction. 
This  is  mainly  dietetic.  Indicanuria  is  usually  increased  by  a  meat  diet 
and  diminished  by  a  milk  diet.  Other  measures  are  referred  to  in  the 
treatment  of  chronic  intestinal  indigestion. 

ACETONURIA— DIACETONURIA. 

Acetone  exists  in  small  quantities  in  the  urine  of  healthy  children. 
According  to  Baginsky  and  Schrach,  it  is  found  in  large  quantities  in 
many  febrile  diseases.  It  increases  with  the  height  of  the  fever  and 
subsides  with  it.  Acetone  is  probably  formed  from  the  destruction  of 
the  nitrogenous  material  of  the  body,  as  it  is  increased  by  a  nitrogenous 
diet,  and  may  disappear  by  a  diet  of  carbohydrates.  Baginsky  found  it 
also  in  children  with  epilepsy,  sometimes  during  the  attacks.  It  is  not, 
however,  believed  to  be  the  cause  of  the  convulsive  seizures,  as  it  is  absent 
in  convulsions  occurring  under  other  conditions.  It  has  no  relation  to 
rickets.  According  to  Schrach,  there  is  no  connection  between  acetonuria 
and  the  nervous  symptoms  accompanying  fever.  Von  Jaksch  found  ace- 
tone in  a  case  of  diabetic  coma. 

Binet  found  diacetic  acid  in  sixty-nine  out  of  one  hundred  and  iifty 
examinations  in  febrile  diseases,  chiefly  in  scarlet  fever,  measles,  and  pneu- 
monia. In  diabetes  this  condition  often  precedes  the  development  of 
coma,  otherwise  it  is  of  no  prognostic  significance.  Schrach  found  diace- 
tonuria  exceedingly  common  in  all  cases  of  continuous  high  fever.  It  is 
more  frequently  present  than  acetonuria,  and  ceases  with  the  fever.* 

*  For  literature,  see  Baginsky,  Archiv  fiir  Kinderheilkunde,  Bd.  xi,  p.  1. 


648  DISEASES  OF   THE  UEO-GENITAL   SYSTEM. 


ANURIA. 

By  this  term  is  meant  an  arrest  of  the  urinary  secretion.  To  that  form 
which  occurs  in  the  course  of  renal  disease  the  term  "  suppression  ^'  is  gen- 
erally applied.  Anuria  is  to  be  carefully  distinguished  from  retention, 
from  the  scanty  secretion  which  occurs  whenever  food  is  refiised  or  with- 
held on  account  of  illness,  and  also  from  that  which  accompanies  acute 
diarrhoea,  with  large,  watery  discharges.  Anuria  is  sometimes  seen  in  the 
newly  born,  where  it  depends  upon  some  malformation  of  the  genital 
tract ;  or,  more  frequently,  upon  uric-acid  infarctions  in  the  kidneys.  The 
first  urine  passed  after  such  an  attack  is  very  often  highly  acid,  and 
may  contain  an  abundance  of  uric-acid  crystals  and  larger  masses  visible 
to  the  naked  eye.  Other  cases  admit  of  no  such  explanation,  and  the 
condition  must  be  regarded  as  of  nervous  origin.  For  the  time,  the 
secretion  appears  to  be  completely  arrested,  as  the  bladder,  both  by  pal- 
pation and  catheterization,  is  found  to  be  empty.  This  condition  is  not 
a  very  uncommon  one  in  infancy,  and  it  may  continue  for  from  twelve 
to  thirty-six  hours.  So  long  as  infants  appear  to  be  perfectly  normal 
in  every  other  respect,  the  suspension  of  the  urinary  secretion  even  for 
twenty-four  hours  need  excite  no  anxiety. 

The  treatment  is  very  simple  and  effectual,  and  consists  in  the  admin- 
istration of  sweet  spirits  of  nitre,  either  alone  or  in  combination  with  the 
acetate  or  citrate  of  potash,  and  plenty  of  water.  To  an  infant  of  three 
months  one  minim  of  the  nitre  and  one  grain  of  the  citrate  of  potash  may 
be  given  every  hour  in  half  an  ounce  of  water  until  the  urinary  secretion 
is  established,  which  will  usually  be  in  six  or  eight  hours.  If  the  urine  is 
very  highly  acid,  and  stains  the  napkins,  the  potash  should  be  continued 
for  several  days.  Hot  fomentations  over  the  kidneys  may  be  used  with 
advantage. 

DIABETES   INSIPIDUS   (POLYURIA). 

This  is  a  chronic  disease  characterized  by  the  excretion  of  a  very  large 
amount  of  pale  urine  of  low  specific  gravity.  It  is  invariably  accompanied 
by  polydipsia.     The  disease  is  an  exceedingly  rare  one  in  children. 

The  exact  pathology  of  diabetes  insipidus  is  not  known  ;  but  from  the 
conditions  under  which  it  occurs  it  is  believed  to  be  a  neurosis.  The 
irritation  which  gives  rise  to  it  may  be  in  or  near  the  floor  of  the  fourth 
ventricle,  or  it  may  affect  the  renal  nerves. 

Etiology. — Of  eighty-five  cases  collected  by  Strauss,  twenty-one  were 
under  ten  years  of  age  and  nine  under  five  years.  In  Eoberts'  collection 
of  seventy  cases,  the  disease  began  in  twenty-two  before  ten  years,  and 
in  seven  during  infancy.  In  some  cases  it  begins  soon  after  birth.  Males 
are  more  frequently  affected  than  females,  and  in  certain  cases  heredity  is 
an  important  factor.     Weil  has  published  a  remarkable  example  of  the 


DIABETES  INSIPIDUS. 


649 


disease  existing  iu  many  members  of  a  single  family.  Falls  or  blows  upon 
the  head,  concussion  of  the  brain,  tumours  of  the  brain,  especially  of  the 
occipital  region,  tuberculous  or  cerebro-spinal  meningitis  or  chronic  hy- 
drocephalus, all  have  been  found  associated  with  diabetes  insipidus.  It 
sometimes  has  followed  the  acute  infectious  diseases;  but  in  many  cases 
no  cause  whatever  can  be  found. 

Symptoms. — The  quantity  of  urine  is  enormous,  usually  exceeding  even 
that  in  diabetes  mellitus.  From  five  to  twenty  pints  daily  may  be  passed. 
The  urine  is  pale,  the  specific  gravity  from  1-001  to  1-006,  and  it  contains 
neither  albumin  nor  grape  sugar.  In  a  few  cases  the  j)resence  of  inosite 
(muscle  sugar)  has  been  found.  Eestricting  the  amount  of  fluid  taken 
causes  a  very  marked  diminution  in  the  amount  of  urine.  The  intense 
thirst  leads  patients  to  drink  enormously  of  water  and  other  fluids.  Vari- 
ous contradictory  statements  are  made  by  different  writers  regarding  the 
quantity  of  uric  acid  and  urea  eliminated  in  these  cases.  The  following 
are  the  results  obtained  in  a  case  recently  under  observation  in  the  Babies' 
Hospital.*  The  child  was  three  years  old,  quite  ansemic,  and  losing  in 
■weight.  On  January  20th  the  fluids  were  unrestricted,  on  the  other  days 
they  were  restricted : 


Date. 

Daily  quantity  of 
urine. 

Specific 
gravity. 

Total 
urea. 

Total 
uric  acid. 

Indican 

reaction. 

Inosite. 

January  20 

Grammes. 
3,300 
750 

775 
1,320 

Ounces. 

lOU 

25' 

25+ 

49' 

1-006 
1-010 
1-010 
1-007 

Grammes. 

22-276 
9-049 
6-478 

12-113 

Grammes. 
0-173 
0-072 

6-ii6 

None. 
Strong. 

None. 

None. 

25 

None. 

26 

None. 

February  8 

None. 

The  elimination  of  urea  in  this  case  is  excessive,  but  the  uric  acid  is 
not  far  from  the  normal. 

Nervous  symptoms  are  usually  present.  There  may  be  disturbed  sleeji 
from  the  frequent  micturition,  palpitation,  flushing  of  the  face  and  other 
vaso-motor  disturbances,  headache,  restlessness,  and  neuralgia.  There 
may  be  incontinence  of  urine.  The  skin  is  pale  and  dry,  and  j)erspiration 
is  scanty.  The  general  health  may  not  be  disturbed.  In  most  cases,  how- 
ever, it  is  somewhat  affected,  and  there  may  be  the  usual  symptoms  of 
malnutrition,  and  even  neurasthenia.  If  it  affects  young  children,  their 
growth  may  be  considerably  retarded.  The  appetite  usually  remains  quite 
good.  The  temperature  is  at  times  slightly  subnormal.  The  course  of 
the  disease  is  indefinite.  It  is  very  chronic,  and  may  last  for  many  years, 
death  taking  place  only  from  intercurrent  affections. 

Prognosis. — A  few  of  the  cases  recover  spontaneously.  Those  of  short 
duration  are  often  cured  by  treatment.     Of  the  chronic  cases  in  which 


*  The  analyses  wore  uiudc  by  Dr.  C.  A.  Herter. 


650  DISEASES   OF  THE  URO-aENITAL  SYSTEM. 

the  disease  is  well  established  very  few  are  controlled.  The  prognosis  is 
worse  if  there  are  marked  disturbances  of  the  digestive  tract  or  organic 
brain  disease. 

Diagnosis. — This  is  easily  made  from  the  two  marked  symptoms,  ex- 
cessive thirst  and  polyuria.  From  diabetes  mellitus  it  is  easily  distin- 
guished by  the  lower  specific  gravity  and  the  absence  of  sugar  from  the 
urine.  In  older  children,  chronic  nephritis  with  contracted  kidney  may 
be  confounded  with  it. 

Treatment. — Fluids  should  be  moderately  restricted.  It  is  a  serious 
mistake  to  reduce  the  quantity  of  fluids  too  much,  since  the  drinking  is 
not  the  cause  of  the  diuresis.  The  diet  should  be  simple  and  nutritious, 
consisting  largely  of  meat,  with  a  moderate  amount  of  carbohydrates.  The 
general  treatment  should  be  directed  to  the  condition  of  malnutrition. 
The  clothing  should  be  warm,  and  a  moderate  amount  of  exercise  should 
be  allowed.  Drugs  are  of  little  use ;  those  which  have  sometimes  been 
beneficial  are  arsenic,  belladonna,  ergotine,  the  bromides,  and  antipyrine.. 
Treatment  must  be  continued  for  many  months  to  be  of  any  value. 


CHAPTER  II. 

DISEASES  OF  THE  KIDNEYS. 

MALFORMATIONS   AND   MALPOSITIONS. 

Malformations  of  the  kidney  are  not  infrequent.  In  seven  hun- 
dred and  twenty-six  consecutive  autopsies  at  the  New  York  Infant  Asy- 
lum malformations  of  the  kidney  or  ureters  were  met  with  in  seventeen 
cases.  This  does  not  represent  the  actual  frequency  with  which  they 
occur,  for  in  about  half  that  number  of  autopsies  in  two  other  institutions 
only  a  single  example  was  seen.  Adding  to  the  cases  mentioned  two 
others  seen  elsewhere,  there  are  twenty  cases  of  renal  malformation  of 
which  I  have  notes,  classed  as  follows  : 

Fusion  of  the  kidneys,  or  horseshoe  kidney 4  eases. 

Supernumerary  ureters 4     " 

Hydronephrosis  (alone) 8     " 

Cystic  degeneration  of  the  kidney  (alone) 2     " 

Hydronephrosis  and  cystic  kidney 1  case. 

Single  kidney 1     '• 

In  all  malformations  the  left  kidney  is  much  more  frequently  affected 
than  the  right,  the  proportion  being  nearly  two  to  one.  Malformationa 
are  more  often  seen  in  males  than  in  females. 


MALFORMATIONS  AND   MALPOSITIONS  OF  THE   KIDNEY.       651 

Fusion  of  the  Kidneys. — In  one  case,  in  a  child  who  died  of  pneumonia 
at  the  age  of  three  years,  the  kidneys  were  fused  into  one  irregular  ovoid 
mass,  lying  upon  the  lumbar  vertebras ;  in  another  case  the  mass  lay  upon 
the  promontory  of  the  sacrum  ;  in  both  there  were  two  renal  arteries  and 
two  ureters.  In  the  two  other  cases  the  organs  were  united  at  their  lower  ex- 
tremities, and  in  both  of  these  there  were  two  ureters  passing  in  front  of  the 
kidney.  In  one  there  was  also  hydronephrosis  and  chronic  diffuse  nephritis. 
The  children  died  at  the  ages  of  four  and  five  months  respectively. 

Cystic  Degeneration  of  the  Kidneys. — In  two  of  these  three  cases  the 
right  kidney  was  affected,  and  in  one  the  left.  The  ages  at  which  the  chil- 
dren died  were  from  seven  to  ten  months.  No  renal  symptoms  were  pres- 
ent. In  all  the  cases  the  cystic  kidney  was  very  small,  about  an  inch  and 
a  half  in  length  and  one  inch  in  width.  The  organ  was  entirely  made  up 
of  smaller  and  larger  cysts  containing  a  clear  fluid,  held  together  by  loose 
connective  tissue.  The  ureter  was  small  and  rarely  pervious  throughout. 
In  one  case  there  was  hydronephrosis  of  the  opposite  side ;  in  the  others 
the  opposite  kidney  was  considerably  enlarged,  being  about  one  half  larger 
than  normal.  In  addition  to  these  small  cystic  kidneys  there  has  been 
described  a  cystic  degeneration  in  which  very  large  cysts  have  formed  even 
in  utei'O,  sometimes  filling  the  abdominal  cavity  of  the  child  and  seriously 
interfering  with  delivery. 

Single  Kidney,  the  other  being  rudimentary  or  absent. — Of  this  I  have 
seen  but  one  example,  which  was  found  in  a  young  man  twenty- two  years 
of  age,  who  died  of  typhus  fever  in  Bellevue  Hospital.  The  right  kidney 
weighed  seven  and  a  half  ounces ;  the  left  was  represented  by  a  nodular 
mass  about  the  size  of  an  ovary,  showing  no  trace  of  renal  tissue.  The 
ureter  was  pervious  to  within  four  inches  of  the  kidney ;  the  suprarenal 
capsule  was  normal.  Macdonald  has  reported  a  case  in  which  there  was 
no  trace  whatever  of  the  right  kidney  ;  the  left  was  greatly  enlarged,  and 
weighed  nine  ounces.  There  were  two  suprarenal  capsules  but  only  one 
ureter.  Schaeffer  has  reported  absence  of  both  kidne3'S  in  a  seven-months' 
foetus,  associated  with  many  other  malformations. 

Hydronephrosis. — Of  the  ten  cases  of  which  I  have  notes,  this  existed 
as  the  principal  deformity  in  eight.  In  two  cases  it  was  associated  respec- 
tively with  cystic  degeneration  of  the  opposite  kidney  and  horseshoe  kid- 
ney. In  seven  cases  only  the  left  side  was  affected ;  in  three  there  was 
double  hydronephrosis.  Seven  patients  were  males  and  three  females. 
Six  died  before  they  were  six  months  old,  and  only  two  lived  to  be  two 
years  old.  This  condition  is  undoubtedly  the  result  of  some  obstruction 
to  the  outflow  of  urine  in  the  ureter,  bladder,  urethra,  or  prepuce,  but  in 
only  three  of  my  cases  could  there  be  found  an  obstruction  sufficient  to 
explain  the  deformity.  In  two  there  was  marked  hypertrophy  of  the 
bladder.  In  no  case  was  a  calculus  found  as  the  cause  of  the  obstruction. 
In  most  of  the  cases  the  ureter  was  dilated  to  a  diameter  of  from  one 


652  DISEASES  OP  THE  UEO-GENITAL  SYSTEM. 

fourth  to  one  half  of  an  inch,  and  in  two  it  was  so  large  as  to  be  easily 
mistaken  for  the  small  intestine.  Usually  the  ureters  appeared  much- 
elongated  and  sacculated;  the  pelvis  of  the  kidney  was  dilated  to  the 
capacity  of  half  an  ounce  or  more,  the  calices  forming  pockets  about  half 
an  inch  in  diameter.  Less  frequently  the  greater  part  of  the  kidney  was 
destroyed,  leaving  only  a  series  of  communicating  pockets  surrounded 
by  a  thin  cortex  of  renal  tissue  from  one  fourth  to  one  eighth. of  an 
inch  in  thickness.  In  five  cases  there  was  chronic  diffuse  nephritis  of 
the  affected  side,  and  sometimes  both  kidneys  were  involved,  even  though 
the  hydronephrosis  was  unilateral.  The  nephritis  was  usually  of  a  very 
advanced  type.  In  two  cases,  typical  examples  of  the  atrophic  form  (con- 
tracted kidney)  were  seen,  one  of  these  children  dying  at  the  age  of  one 
month.*    The  organs  are  shown  in  Fig.  118. 

Urinary  symptoms  were  noted  in  but  one  case,  and  in  that  they  were 
due  to  pyelo-nephritis  dependent  upon  the  presence  of  calculi  in  the  kidney 
not  the  seat  of  hydronephrosis.  In  no  other  case  was  the  malformation  sus- 
pected during  life.  Four  patients  died  of  marasmus,  two  of  acute  broncho- 
pneumonia, and  one  of  ileo-colitis.  In  only  one  was  there  any  malforma- 
tion outside  the  urinary  tract,  this  being  a  case  of  congenital  heart  disease. 
Double  hydronephrosis  is  generally  associated  with,  or  results  in,  such 
changes  in  the  kidneys  that  the  patients  die  during  infancy,  commonly 
in  the  first  year.  At  this  age  it  rarely  gives  rise  to  a  tumour,  and  is  rec- 
ognised only  by  the  changes  in  the  urine  or  by  the  other  symptoms  of 
nephritis.  There  may  be  the  general  and  local  symptoms  of  chronic  dif- 
fuse nephritis,  or,  when  infection  of  the  genital  tract  occurs,  there  are 
added  the  symptoms  of  pyelitis.  In  the  great  majority  of  cases  the  con- 
dition is  unrecognised,  the  patient  dying  of  some  disease  not  perhaps  in 
itself  fatal,  but  rendered  so  by  the  condition  of  the  kidneys. 

If  hydronephrosis  is  unilateral  there  may  be  no  symptoms  until  the 

*  This  was  in  every  way  a  remarkable  case.  The  child  died  apparently  of  maras- 
mus. There  was  double  hydronephrosis,  the  ureters  being  three  fourths  of  an  inch  in 
diameter.  The  right  kidney  was  nodular  upon  the  surface,  and  had  a  very  adherent 
capsule.  Just  beneath  the  capsule  there  were  small  cysts  containing  pus.  The  left 
kidney  was  the  seat  of  hydronephrosis,  only  its  cortex  remaining,  this  being  about  one 
sixth  of  an  inch  in  thickness.  Microscopical  examination  showed  great  thickening  of 
the  capsule  of  the  right  kidney,  and  several  small  abscesses  situated  in  the  cortex 
just  beneath  the  capsule.  The  rest  of  the  kidney  was  converted  into  a  mass  of  dense 
fibrous  tissue  in  which  were  scattered  many  uriniferous  tubules,  the  epithelium  of 
which  was  clear,  nucleated,  and  of  the  embryonic  type.  The  left  kidney  was  the  seat 
of  chronic  diffuse  nephritis  of  the  atrophic  variety,  with  well-marked  changes  in  the 
medullary  portions.  The  cortex  showed  much  exudation  and  less  atrophy,  being  nearly 
normal  in  thickness.  The  small  size  of  the  organ  was  due  chiefly  to  atrophy  of  the 
pyramids.  The  walls  of  the  bladder  were  greatly  hypertrophied,  being  in  places  one 
fourth  of  an  inch  thick.     The  urethra  and  prepuce  were  normal. 


MALFORMATIONS   AND   MALPOSITIONS   OF   THE   KIDNEY.       053 

dilatation  of  the  pelvis  of  the  kidney  has  reached  a  sufficient  size  to  form 
an  abdominal  tumour.  In  most  of  the  cases  in  children  this  condition 
has  been  noted  between  the  third  and  the  eleventh  years.  This  tumour 
may  be  situated  in  the  lumbar  region,  or  it  may  fill  the  abdomen.  It  is 
cystic,  and  may  be  confounded  with  a  dermoid  cyst  of  the  ovary.     On 


Fig.  118.— Congenital  hydronephrosis,  dilated  ureters,  and  hyperlrophied  bladder.    (From  a  child 

one  month  old.) 

aspiration  a  fluid  is  withdrawn  which  may  be  clear,  or  of  a  brownish 
colour,  and  recognised  as  urine  by  the  fact  that  it  contains  urates  and 
urea.  After  aspiration  the  urine  passed  per  uretliram  may  be  bloody. 
Aspiration  affords  only  temporary  relief,  as  the  tumour  quickly  refills.  If 
an  incision  is  made  and  the  kidney  drained,  a  cure  may  result  with  the 
formation  of  a  fistula.  This  may  continue  indefinitely,  or  infection  of 
the  fistulous  tract  may  occur  and  suppurative  nephritis  be  set  up,  which 
43 


654  DISEASES  OF   THE  URO-GENITAL  SYSTEM. 

speedily  carries  off  the  patient.  A  better  operation  is  nephrectomy, 
which  ma}^  result  in  a  permanent  cure  if  the  opposite  kidney  is  healthy, 
which  is  usually  the  case  if  the  child  is  over  three  years  of  age  for  the 
reason  above  stated,  viz.,  that  a  child  with  malformation  of  both  kidneys 
usually  dies  in  infancy. 

Supernumerary  Ureters. — These  were  noted  in  four  cases,  more  fre- 
quently on  the  left  side.  The  usual  deformity  was  for  two  ureters  to  be 
given  off,  one  from  the  upper  and  one  from  the  lower  part  of  the  kidney, 
each  ureter  having  a  separate  pelvis.  The  ureters  either  joined  just 
above  the  bladder,  or  entered  this  organ  by  separate  openings.  This 
condition  is  of  no  practical  importance,  and  was  not  found  associated 
with  other  renal  changes. 

Malposition  of  the  Kidney. — This  was  noted  in  my  series  of  autopsies 
only  once,  in  the  case  of  fusion  of  the  kidneys  already  mentioned.  Of 
21  cases  collected  b}^  Eoberts,  the  displacement  was  alwa5^s  of  one  kidney 
only;  the  left  being  displaced  15  times,  the  right  6  times.  iSTorthrup 
has  reported  two  cases,  both  displacements  of  the  left  kidney;  in  one, 
the  organ  lay  in  the  hollow  of  the  sacrum ;  in  the  other,  in  the  median 
line,  partly  above  and  partly  below  the  promontory  of  the  sacrum.  Mal- 
positions of  the  kidney  are  compatible  with  perfect  health  and  develop- 
ment.    In  most  of  the  eases  there  is  iio  other  deformity  present. 

Movable  Kidney. — This  is  a  very  rare  condition  in  early  life.  Comby 
(Paris)  has  collected  18  cases,  of  which  16  were  in  girls  and  2  in  boys. 
Movable  kidney  was  recognised  before  the  tenth  year  in  8  cases,  and  in 
2  of  these  before  the  fourth  month.  It  has  been  ascribed  to  too  long  a 
pedicle,  which  may  be  congenital;  also  to  pressure  from  abdominal 
tumours,  and  to  injury.  The  most  important  symptoms  are  paroxysmal 
pain  which  may  follow  exertion,  and  a  movable  tumour.  A  twist  in  the 
ureter  may  produce  hydronephrosis. 

URIC-ACID   INFARCTIONS. 

These  consist  in  a  deposit  in  the  straight  tubes  of  the  kidneys  of  uric 
acid  or  of  amorphous  or  crystalline  urates ;  usually  both  kidnej's  are  af- 
fected, and  all  the  pyramids  of  each  kidney.  The  infarctions  appear  to 
the  naked  eye  as  fine,  brownish,  fan-shaped  striee.  Associated  with  them 
there  may  be  granular  deposits  of  uric-acid  salts  in  the  pelvis  of  the  kid- 
ney, and  sometimes  evidences  of  catarrhal  inflammation  of  the  pelvis, 
including  even  the  presence  of  blood.  This  condition  probably  occurs, 
to  some  degree  at  least,  in  nearly  all  infants  during  the  first  ten  days 
of  life.  It  was  formerly  supposed  that  the  discovery  of  these  appear- 
ances was  proof  that  an  infant  had  breathed,  and  a  certain  medico-legal 
importance  was  therefore  attached  to  them.  This  is  now  known  not  to 
be  the  case,  as  they  are  sometimes  found  in  still -l)orn  infants. 

The  cause  of  this  condition  is  the  excretion  of  uric  acid  before  there 


CHRONIC  CONGESTION  OF  THE  KIDNEY  655 

is  sufficient  water  to  dissolve  it,  so  that  the  crystals  are  deposited  in  the 
tubes.  Uric-acid  infarctions  are  found  chiefly  in  children  dying  before 
the  end  of  the  second  week,  although  it  is  not  uncommon  to  see  them  as 
late  as  the  third  or  fourth  or  even  the  sixth  month.  In  most  of  the 
cases,  as  the  urinary  secretion  becomes  more  abundant,  the  deposits  are 
washed  out  in  the  urine  and  appear  as  brownish  red  or  pink  stains  upon 
the  napkins.  Infarctions  may  give  rise  to  a  slight  inflammation  of  the 
renal  tubules,  but  very  rarely  to  any  serious  lesion;  sometimes  they  re- 
main as  deposits  in  the  calicos  or  the  pelvis  of  the  kidney  or  in  the 
bladder,  forming  the  nucleus  of  a  calculus.  The  symptoms  to  which 
they  give  rise  are  mainly  scanty  urination  during  the  first  week  of  life, 
and  occasionally  anuria  for  the  first  day  or  two.  Sometimes  there  is 
evidence  of  severe  pain ;  priapism  may  be  present,  and  there  is  the  stain 
upon  the  napkin  already  referred  to.  The  treatment  is  to  give  water 
freely  and  some  alkaline  diuretic  such  as  citrate  of  potash.  One  grain 
should  be  given  every  two  hours  until  the  secretion  is  fully  established; 
this  in  most  cases  will  be  within  twenty-four  hours. 

ACUTE  CONGESTION  OF  THE  KIDNEY. 

In  acute  congestion  of  the  kidney  all  its  blood-vessels  contain  much 

more  blood  than  normal,  and  from  them  there  may  be  an  escape  of  serum 

and  even  of  the  red  blood-cells  by  diapedesis.     This  congestion  may 

result  from  traumatism,  the  ingestion  of  certain  poisons,  from  any  of 

.the  infectious  diseases,  or  from  cold. 

The  urine  is  usually  scanty,  of  high  specific  gravity,  and  contains 
albumin  and  red  blood-cells,  sometimes  blood  casts.  This  may  be  only  a 
temporary  condition  passing  off  in  a  few  days  without  further  symptoms, 
or  it  may  exist  as  the  first  stage  of  acute  nephritis.  It  is  most  serious 
when  it  occurs  in  kidneys  already  the  seat  of  serious  disease.  There  are 
sometimes  no  symptoms  except  those  of  the  urine;  or  there  may  be 
headache,  pain  in  the  back,  and  some  general  indisposition. 

The  treatment  consists  in  free  catharsis,  the  use  of  hot  va]")our 
baths,  and  counter-irritation  over  the  kidneys  by  means  of  hot  poultices 
or  dry  cups. 

CHRONIC   CONGESTION    OF   THE    KIDXF.Y. 

This  results  from  intfrruvcuee  witli  the  n'tiirn  circ'ulation  of  the 
kidney,  and  may  be  caused  l)y  congenital  malformation  or  valvular  dis- 
ease of  the  heart,  chronic  bronclio-])U('uiiioiiia  or  clironic  pleurisy;  also 
by  the  pressure  of  any  abdominal  luinoiir  upon  tlic  inferior  vena  cava 
or  the  renal  veins. 

The  kidneys  are  generally  enlarged,  lii-mei-  llian  normal,  and  dark- 
Goloured.  All  the  ea))illary  vessels  are  swollen  and  distended  with  blood, 
and  their  walls  are  thickened.     In  nddilioii  (o  the  syini)(oms  of  the  pri- 


656  DISEASES  OF   THE   URO-GEXITAL  SYSTEM. 

mar}^  disease,  the  amount  of  urine  passed  is  usually  scanty  and  of  high 
sjjecific  gravity.  Albumin  and  casts  are  generally  present,  but  are  not 
constant.  The  treatment  should  be  directed  toward  the  primary  con- 
dition, and,  in  addition,  an  effort  should  be  made  to  increase  the  urine 
by  alkaline  diuretics,  caffein,  digitalis,  and  the  sweet  spirits  of  nitre. 

ACUTE   DEGEXERATIOX  OF   THE  KIDNEYS. 

In  the  succeeding  pages  devoted  to  the  kidney  I  have  followed  in 
the  main  Prudden's  classification. 

In  acute  degeneration  of  the  kidney  the  principal  or  only  change  is 
in  the  epithelium  of  the  tubules.  It  is  exceedingly  common  both  in  in- 
fancy and  in  childhood,  being  found  to  a  greater  or  less  degree  in  all 
autopsies  upon  patients  dying  of  acute  infectious  diseases,  but  it  is  most 
marked  in  cases  of  scarlet  fever,  diphtheria,  and  acute  pleuro-pneumo- 
nia.  It  may  be  found  in  any  disease  characterized  by  prolonged  high 
temperature;  and  it  is  the  explanation  of  the  cases  of  so-called  febrile 
albuminuria.  The  cause  is  in  all  probability  direct  irritation  of  the 
epithelium  of  the  tubules  by  the  toxins  eliminated  by  the  kidneys.  It 
may  also  be  induced  by  irritating  drugs,  such  as  cantharides  or  turpen- 
tine. By  some  writers  these  cases  have  been  classed  as  examples  of 
acute  nephritis ;  hence  the  great  discrepancy  which  exists  in  statements 
made  as  to  the  frequency  of  nephritis  in  the  different  infectious  diseases. 

The  kidneys  are  usually  slightly  enlarged,  softer,  and  paler  than 
normal.  On  section  the  cortex  may  be  somewhat  thickened,  and  the 
straight  tubules  marked  by  yellowish-gray  lines.  It  is  the  appearance 
commonly  spoken  of  as  cloudy  swelling.  The  kidneys  are  seldom  much 
congested.  The  microscope  shoAvs  a  granular  degeneration  and  death  of 
the  epithelium  of  the  tubules,  and  when  severe  this  may  be  accompanied 
by  congestion  and  the  exudation  of  serum. 

Acute  degeneration  of  the  kidneys  gives  rise  to  no  symptoms  in  addi- 
tion to  those  of  the  original  disease,  except  the  appearance  of  a  moderate 
amount  of  albumin  in  the  urine,  with  a  few  hyaline,  epithelial,  or  gran- 
ular casts.  It  can  not  be  said  that  such  a  condition  adds  much  to  the 
danger  from  the  original  disease.  In  cases  that  recover,  the  condition  of 
the  kidney  entirely  clears  up.  The  development  of  the  symptoms  of 
degeneration  of  the  kidneys  in  infectious  diseases  calls  for  no  special 
treatment  beyond  a  continuance  of  the  fluid  diet. 

ACUTE   DIFFUSE   NEPHFJTIS. 

Synonyms  :  Acute  interstitial  nephritis,  acute  exudative  nephritis, 
glomerulo-nephritis,  acute  Bright's  disease. 

Etiology. — This  variety  of  nephritis  occurs  apparently  as  a  primary 
disease  both  in  infants  and  in  older  children.  Most  such  cases  are  un- 
doubtedly of  infectious  origin,  although  the  point  of  entrance  of  the 


ACUTE  DIFFUSE   XEPHRITIS.  657 

infection  may  be  difficult  or  impossible  to  determine.  Acnte  diffuse 
nephritis  is  very  frequently  secondary  to  the  acute  infectious  diseases, 
especially  to  scarlet  fever  and  diphtheria.  It  occasionally  follows 
measles,  varicella,  empyema,  typhoid  fever,  acute  diarrhoeal  diseases, 
pneumonia,  meningitis,  influenza,  and  malaria.  It  is  the  characteristic 
variety  of  secondary  nephritis  occurring  in  severe  septic  conditions.  The 
exciting  cause  of  the  inflammation  is  in  some  cases  the  irritation  from 
toxins;  but  usually  there  is  in  addition  the  entrance  of  pathogenic  or- 
ganisms carried  by  the  circulation.  Thus  in  post-scarlatinal  nephritis, 
of  which  the  one  under  consideration  is  the  characteristic  form,  the 
cause  is  now  generally  admitted  to  be  the  toxins  of  the  primary  disease, 
to  which  in  many  cases  is  added  infection  by  the  streptococcus.  While 
nephritis  is  more  frequent  after  severe  attacks  of  scarlet  fever,  it  may 
occur  after  those  which  are  very  mild,  even  when  patients  have  been  kept 
in  bed  throughout  the  disease.  Exposure,  however,  may  precipitate  an 
attack  in  a  patient  who  might  otherwise  have  escaped.  An  important 
etiological  factor  in  some  cases  is  the  too  early  use  of  solid  food.  The 
frequency  of  nephritis  as  a  sequel  of  scarlet  fever  varies  much  in  different 
epidemics;  in  some  it  is  rarely  seen,  while  in  others  it  may  occur  in 
nearly  half  the  cases ;  the  average  is  from  six  to  ten  per  cent. 

Lesions. — In  severe  cases  the  kidneys  are  usually  enlarged,  soft,  and 
redematous.  The  capsule  is  non-adherent.  The  cortex  is  thickened, 
either  reddened  or  pale ;  frequently  it  is  mottled  with  red,  owing  to  the 
presence  of  small  haemorrhages.  There  may  be  congestion  of  the  entire 
-organ;  or  the  pyramids  may  seem  unusually  red  by  contrast  with  the 
pale  and  thickened  cortex. 

All  the  structures  of  the  kidney — glomeruli,  tubular  epithelium,  and 
interstitial  tissue — are  involved  in  the  inflammatory  process.  The  cells 
covering  the  glomerular  tufts  of  capillaries  are  swollen  and  proliferated. 
They  have  frequently  undergone  fatty  degeneration  and  separated.  The 
epithelial  cells  lining  Bowman's  capsule  may  undergo  the  same  changes, 
but  usually  to  a  lesser  degree.  The  space  between  the  capsule  and  the 
tuft  may  contain  exfoliated  epithelium  in  considerable  quantity,  also 
cell-detritus,  albuminous  (granular)  exudate,  leucoc3^tes,  and  red  blood- 
cells.  The  tubular  epithelium  undergoes  albuminous  and  fatty  degen- 
eration and  may  desquamate.  Thus  the  tubules  may  contain  epithelial 
fragments,  serum,  red  blood-cells  and  leucocytes,  and  some  form  of  casts. 
The  interstitial  connective  tissue  is  infiltrated  with  serous  or  fibri- 
nous exudate  and  in  places  with  small  round  cells.  In  cases  of  longer 
duration  a  general  increase  of  the  connective  tissue  may  lake  place, 
which  is  permanent. 

When  the  glomerular  cliaiiges  are  especially  marked,  as  in  acute 
ne])hritis  following  scarlet  fever.  Ibc  ]n*ocess  is  often  spoken  of  as 
glomenilo-iirpJiriti.'i.     Jf  the  degciicral ion  of  Ibe  iuV)ular  epithelium  is 


658  DISEASES   OF   THE  URO-GEXITAL  SYSTEM. 

extreme,  as  in  severe  cases  of  diphtheria  dying  shortly  after  the  onset, 
the  nephritis  may  be  described  as  the  parencJiymatous  or  degenerative 
type.  In  the  Jicemorrhagic  form  there  are  haemorrhages  into  the  tubules, 
glomeruli,  or  interstitial  tissue.  In  infants  and  young  children  the 
exudative  type  of  acute  diffuse  nephritis  is  especially  frequent.  In 
this  there  is  an  exudative  inflammation  with  large  accumulations  of 
leucocytes,  serum,  and  red  blood-cells  in  the  glomeruli  and  tubules,  the 
parenchyma  and  interstitial  tissue  sometimes  being  markedly  and  some- 
times but  slightly  changed.  Should  the  interstitial  tissue  suffer  early  and 
severely,  the  nephritis  becomes  of  the  productive  or  interstitial  type. 
This  form  is  most  frequently  seen  with  severe,  protracted  cases  of  scarlet 
fever  and  diphtheria,*  especially  in  older  children.  It  sometimes  occurs 
as  an  apparently  independent  process. 

Symptoms. — 1.  Primary  form  in  infants. — These  eases  are  not  com- 
mon, and  the  symptoms  are  so  obscure  that  they  are  usually  overlooked. 
In  1887  f  I  published  five  cases  of  my  own,  and  collected  from  literature 
fourteen  other  examples  of  nephritis,  apparently  primary,  in  children 
under  two  years  of  age.  Since  that  time  five  additional  eases  have  come 
under  my  observation.  The  inflammation  in  most  of  them  was  of  the 
exudative  type. 

In  the  exudative  type  the  onset  in  nearly  every  instance  was  abrupt, 
usually  with  high  fever  and  vomiting,  the  temperature  being  in  several 
cases  over  104°  F.  Dropsy  was  very  exceptional,  being  noted  in  but  six 
cases ;  in  most  of  these  it  was  slight,  and  seen  only  toward  the  close  of 
the  disease.  Fever  was  present  in  all  cases.  In  those  observed  by  my- 
self it  was  high  and  irregular  in  t}"pe,  ranging  from  101°  to  105°  F.  The 
duration  of  the  disease  was  from  eight  days  to  four  weeks,  the  average 
being  about  two  and  a  half  weeks.  Vomiting  and  diarrhcea  were  noted 
in  half  the  cases,  but  were  rarely  prominent,  and  marked  either  the  onset 
of  the  attack,  or  were  traceable  to  indigestion  accompanying  the  fever; 
very  rarely  did  they  exist  as  symptoms  of  ursemia.  AuEemia  was  a 
prominent  symptom  in  nearly  every  case,  and  it  was  this  which  enabled 
me  in  several  instances  to  make  a  correct  diagnosis.  Xervous  symp- 
toms were  usually  prominent.  In  several  patients  there  was  dyspnoea 
without  pulmonary  disease,  partly  due.  no  doubt,  to  the  anasmia.  In 
nearly  all  cases  there  was  marked  restlessness  or  muscular  twitchings, 
and  in  three  there  were  convulsions.  Dulness  and  apathy  were  present 
in  the  majority  of  the  fatal  cases,  but  deep  coma  was  never  seen.  Sev- 
eral patients  presented  the  t^'pical  symptoms  of  the  typhoid  condition. 
The  uruie  was  rarely  scanty  until  near  the  close  of  the  disease,  and 
sometimes  not  even  then.     Suppression  of  urine  occurred  in  but  a  few 

*  Councilman,  Mallory,  and  Pearce.  Diphtheria  :  A  Study  of  the  Bacteriology  and 
Pathology  of  Two  Hundred  and  Twenty  Fatal  Cases,  1001. 
f  Archives  of  Paediatrics,  vol.  iv,  pp.  1,  103 ;  and  ix,  p.  ^Qo. 


ACUTE  DIFFUSE  NEPHRITIS.  659 

cases.  Albumin  was  frequently  absent  early  in  the  attack,  but  was  in- 
variably present  at  a  late  period,  although  rarely  in  large  amount.  Casts 
were  found  in  all  cases  that  were  carefully  examined  microscopically. 
They  were  not  usually  numerous,  and  were  chiefly  of  the  hyaline,  granu- 
lar, and  epithelial  varieties.  No  blood  casts  were  seen.  There  were 
usually  many  pus  cells  and  renal  epithelial  cells,  together  with  red 
blood-cells  in  moderate  numbers. 

Of  the  twenty-four  cases,  sixteen  died  and  eight  recovered.  Of  my 
own  ten  cases,  nine  were  fatal,  the  diagnosis  being  confirmed  by  autopsy 
in  every  case  but  two.  Whether  these  figures  represent  the  actual  mor- 
tality of  the  disease  it  is  difficult  to  say.  No  doubt  there  are  many  mild 
eases  which  are  unrecognised.  The  severe  ones,  however,  are  quite  uni- 
formly fatal,  chiefly  on  account  of  the  tender  age  of  the  patients. 

2.  Primary  form  in  older  children. — This  also  is  a  rare  form  of  renal 
disease.  As  compared  with  the  same  condition  in  infants,  the  onset  is 
usually  less  abrupt,  the  febrile  symptoms  are  less  marked,  and  the  ter- 
mination is  less  frequently  fatal.  Dropsy  is  rarely  marked,  and  often 
there  is  none  at  all.  The  urine  is  only  slightly  diminished  in  quantity ; 
the  amount  of  albumin  is  small;  casts  are  not  numerous,  and  usually 
hyaline,  epithelial,  or  granular ;  very  rarely  is  there  much  blood  present. 
Uraemia  is  very  infrequent,  and  the  prognosis  is  much  more  favourable 
than  in  infancy. 

The  interstitial  type  may  begin  abruptly  with  febrile  symptoms, 
dropsy,  headache,  lumbar  pains,  scanty  urine,  and  often  with  vomiting; 
or  it  may  come  on  somewhat  insidiously  with  few  constitutional  symp- 
toms, but  with  dropsy  and  changes  in  the  urine. 

3.  Secondary  form. — The  secondary  nephritis  of  acute  infectious  dis- 
eases usually  occurs  at  the  height  of  the  febrile  process,  and  its  severity 
is  generally  proportionate  to  the  intensity  of  the  infection.  The  general 
symptoms  of  nephritis  are  often  not  marked,  and  dropsy  is  rare ;  so  that 
unless  the  urine  is  examined  the  condition  may  be  overlooked.  The 
urinary  changes  are  essentially  the  same  as  those  already  mentioned  in 
the  primary  cases.  Suppression  of  iirine  and  the  development  of  the 
symptoms  of  acute  uremia  are  infrequent.  While  the  involvement  of  the 
kidneys  adds  to  the  danger  from  the  primary  disease,  nephritis  is  not 
usually  itself  the  cause  of  death,  although  such  may  be  the  case  in  scarlet 
fever  or  diphtheria. 

The  characteristic  type  of  nephritis  which  follows  scarlet  fever  most 
frequently  develops  during  the  third  or  fourth  week  of  the  disease.  The 
onset  is  usually  graflual,  (Iroi)sy  boing  first  noticed.  At  oilier  times  it 
begins  more  abruptly  with  headache,  vomiting,  scanty  urine,  and  fever. 
The  temperature  generally  ranges  from  100°  to  101-5°  F.,  Iml  in  very 
severe  attacks  it  may  be  104°  or  105°  F.  Dropsy  is  almost  invariably 
present.    It  is  first  seen  in  the  face,  next  in  the  feet,  legs,  and  scrotum; 


660  DISEASES   OP   THE   URO-GENITAL  SYSTEM. 

there  may  be  general  anasarca,  with  dropsy  of  the  serous  cavities  of  the 
body,  the  pleura,  or  the  peritoneum,  rarely  the  pericardium.  As  the 
•disease  progresses  there  is  always  a  very  marked  degree  of  anemia. 

The  urine  is,  as  a  rule,  greatly  diminished  in  quantity,  and  may  be 
suppressed.  Albumin  is  invariably  present,  and  usually  in  large  amount, 
often  enough  to  render  the  urine  solid  upon  boiling.  The  urine  is  of  a 
dark,  reddish  brown  or  smoky  colour,  owing  to  the  presence  of  red  blood- 
cells  or  hgemoglobin.  The  total  amount  of  urea  eliminated  is  far 
below  the  normal.  The  specific  gravity  may  be  low,  even  though  the 
■quantity  is  very  small.  Casts  are  present  in  great  numbers,  chiefly  hya- 
line, granular,  and  epithelial  casts  from  the  straight  tubes;  not  in- 
-frequently  there  are  blood  casts.  Occasionally  twisted  or  cork-screw 
casts  are  seen.  Red  blood-cells  are  present  in  great  numbers ;  also  many 
leucocytes^  and  always  a  large  amount  of  renal  epithelium. 

The  duration  of  the  active  symptoms  in  cases  terminating  in  recovery 
is  from  one  to  three  weeks.  The  temperature  and  dropsy  gradually  sub- 
side. Improvement  in  the  urine  is  shown  by  an  increase  in  quantity,  by 
increased  elimination  of  urea,  and  by  a  diminution  in  the  amount  of 
blood,  albumin,  and  the  number  of  casts.  A  few  casts  may  persist  for 
several  weeks,  and  a  small  amount  of  albumin  for  two  or  three  months. 

In  the  graver  cases,  where  the  onset  is  accompanied  by  high  temper- 
ature, pain  in  the  back  and  loins,  and  a  rapid,  full  pulse  of  high  tension, 
the  urine  is  very  scanty  and  is  often  suppressed.  Then  follow  the  symp- 
toms of  ursemia.  In  children  this  is  usually  manifested  by  vomiting, 
great  restlessness  or  apath}^,  and  often  by  diarrhcea.  Less  frequently 
there  is  headache,  dimness  of  vision,  stujoor  developing  into  coma,  or 
convulsions.  If  the  secretion  of  urine  is  re-established,  the  nervous 
symptoms  abate  and  the  patient  may  recover.  This  has  been  known  to 
occur  after  complete  suppression  has  lasted  thirty-six  hours.  Care 
should  be  taken  not  to  mistake  retention  for  suppression.  If  doubt 
exists,  percussion  of  the  bladder  and  the  use  of  the  catheter  will  quickly 
settle  the  question. 

There  are  several  complications  for  which  the  physician  must  con- 
stantly be  on  the  lookout  during  attacks  of  acute  nephritis;  the  most 
frequent  are  pneumonia,  pleurisy,  pericarditis,  and  endocarditis;  more 
rarely  there  may  be  meningitis  and  oedema  of  the  glottis.  It  is  from 
complications  or  acute  uremia  that  death  usually  occurs. 

Prognosis. — This  is  to  be  considered  from  two  points  of  view:  first, 
the  danger  to  life  during  the  acute  stage  of  the  disease,  and,  secondly, 
the  danger  of  the  development  of  chronic  nephritis.  The  great  majority 
of  patients  survive  the  acute  stage,  and  not  infrequently  even  those  re- 
cover who  have  presented  grave  symptoms  of  uremic  poisoning.  The 
quantity  and  specific  gravity  of  the  urine,  and  the  number  and  variety  of 
the  casts,  are  a  much  better  guide  in  prognosis  than  the  amount  of  albu- 


ACUTE   DIFFUSE   NEPHRITIS.  661 

niin.  The  existence  of  severe  nervous  symptoms,  such  as  stupor,  intense 
headache,  dimness  of  vision,  and  persistent  vomiting,  add  much  to  the 
gravity  of  the  case,  as  does  also  the  presence  of  any  serious  complication. 
In  general  it  may  be  said  that  if  there  is  no  suppression  of  urine,  or  if 
there  are  no  symptoms  of  urasmia  and  no  complications,  recovery  is 
almost  certain  if  the  child  is  over  three  years  old;  in  younger  children 
the  outlook  is  less  favourable.  The  general  opinion  prevails  that  acute 
diffuse  nephritis  in  childhood,  whether  it  is  primary  or  occurs  as  a  com- 
plication of  scarlet  fever,  is  rarely  followed  by  the  chronic  form  of  the 
disease;  and  such  was  the  view  I  formerly  held.  Larger  experience, 
however,  has  convinced  me  that  this  sequel  is  not  very  uncommon.  The 
interval  of  apparent  health  may  sometimes  cover  a  period  of  several 
years,  and  the  later  nephritis  may  be  attributed  to  other  causes ;  but  all 
cases  of  scarlatinal  nephritis  should  be  carefully  watched  for  a  long  time,. 
and  after  a  severe  attack  a  guarded  prognosis  should  always  be  given  as 
regards  the  ultimate  result.* 

Treatment. — Prophylaxis  is  important,  and  relates  principally  to  the 
secondary  form  which  occurs  in  the  course  of  infectious  diseases,  espe- 
cially post-scarlatinal  nephritis;  but  the  measures  here  outlined  apply 
equally  to  all  varieties.  The  inflammation  of  the  kidney  being  in  most 
of  these  cases  the  result  of  direct  irritation  by  the  toxins  which  are  elim- 
inated by  them,  it  follows  that  elimination  through  the  skin  and  intes- 
tines should  be  increased,  and  that  the  urine  should  be  rendered  as  little 
irritating  as  possible  by  largely  increasing  its  quantity.  The  first  indi- 
cation is  met  by  frequent  sponging,  warm  baths,  and  keeping  the  bowels 
freely  opened  by  saline  cathartics,  sufficient  being  given  to  produce  one  or 
two  loose  movements  daily.  To  meet  the  second  indication,  the  patient 
should  be  kept  upon  a  fluid  diet,  preferably  milk,  at  least  for  the  three 
weeks  of  the  disease,  and,  if  possible,  for  a  full  month.  At  the  same 
time  he  should  drink  very  freely  of  alkaline  mineral  waters,  or  of  plain 
water  to  which  a  small  dose  (two  or  three  grains)  of  some  alkaline  diu- 
retic like  the  citrate  of  potassium  has  been  added.  If  milk  is  not  well 
borne,  kumyss,  whey,  buttermilk,  or  junket  may  be  used,  or  thin  gruels 
mixed  with  milk.  When  the  first  trace  of  albumin  appears  in  the  urine 
this  plan  of  treatment  should  invariably  be  followed.  In  addition  to 
these  measures,  after  an  attack  of  scarlet  fever  the  patient  should  be 
kept  in  bed  for  at  least  a  week  after  the  temperature  has  become  noi-mal. 

*  The  following  case  may  be  cited  as  an  illustration  of  this  point :  A  girl  at  the  age 
of  seven  years  had  scarlet  fever,  followed  by  nephritis;  the  dropsy  having  lasted,  it 
was  reported,  for  three  months.  She  was  believed  to  have  recovered  poi-fectly,  and 
remained  in  apparent  health  until  she  was  sixteen,  when,  as  a  supposed  result  of  a 
severe  chilling,  she  developed  dropsy  and  all  the  symptoms  of  acute  nojihritis.  From 
that  time,  although  she  lived  for  three  years,  and  was  often  for  nmnllis  at  a  time 
seemingly  in  the  best  of  health.  Imr  urine  was  never  free  from  casts  and  albumin,  and 
she  finally  died  in  urajmic  conviilsicuis. 


QQ2  DISEASES  OF  THE  URO-GENITAL  SYSTEM. 

The  mild  cases  of  acute  nephritis  tend  to  spontaneous  recovery  under 
the  hygienic  and  dietetic  treatment  mentioned — i.  e.,  rest  in  bed,  fluid 
diet,  the  drinking  of  large  quantities  of  water,  and  attention  to  the 
action  of  the  skin  and  bowels.  These  measures  should  be  continued  so 
long  as  the  urine  contains  any  considerable  amount  of  albumin,  or  so 
long  as  the  patient's  general  condition  will  permit.  Should  he  become 
very  ansemic,  or  lose  much  in  weight,  it  may  be  necessary  to  enlarge  the 
diet  by  the  addition  of  solid  food.  This  should  at  first  be  of  the  car- 
bohydrates only,  usually  in  the  form  of  some  farinaceous  food.  An  in- 
crease in  the  diet  and  exercise  should  be  made  very  gradually,  and  the 
efEect  upon  the  urine  carefully  watched. 

The  severe  cases,  with  scanty  urine,  fever,  and  marked  dropsy,  require 
more  active  treatment.  Free  diaphoresis  should  be  maintained  by  the 
hot  pack  or  vapour  bath  (page  54).  Active  counter-irritation  should 
be  maintained  over  the  kidneys  by  dry  cups  followed  by  poultices,  or 
the  mustard  paste.  Two  or  three  loose  movements  'from  the  bowels 
should  be  secured  by  the  administration  of  calomel,  or,  better,  by  Eo- 
chelle,  or  Epsom  salts.  Harm  is  sometimes  done  by  carrying  this  deple- 
tion too  far,  and  its  effect  upon  the  patient's  general  condition  must 
be  closely  watched.  If  suppression  of  urine  occurs  with  the  development 
of  ursemic  symptoms — delirium,  high  temperature,  flushed  face,  vomit- 
ing, and  a  pulse  of  high  tension — nitroglycerin  is  indicated ;  a  child  of 
five  years  may  take  gr.  ^o^  every  hour  for  five  or  six  doses,  or  until  an 
effect  is  produced. 

In  addition  to  these  measures  rectal  injections  of  a  normal  salt  solu- 
tion should  be  given  high  in  the  colon,  at  a  temperature  of  from  104° 
to  108°  F.  At  least  a  pint  should  be  given  several  times  a  day,  to  be 
continued  until  a  free  flow  of  urine  is  established.  This  is  one  of  the 
most  valuable  means  we  possess  of  increasing  elimination  by  the  kidneys 
and  skin. 

The  nervous  symptoms  of  ursemia  are  best  relieved  by  chloral  or 
chloralamid,  which  should  be  given  per  rectum.  When  such  symptoms 
are  marked,  from  six  to  ten  grains  are  required  for  a  child  of  five  years,  to 
be  repeated  in  two  hours  if  no  improvement  is  seen.  UrEemic  convulsions 
may  sometimes  be  averted  by  the  use  of  morphine  hypodermically.  In 
extreme  conditions  not  relieved  by  the  measures  mentioned,  venesection 
should  by  all  means  be  practised ;  from  three  to  six  ounces  of  blood  may 
be  drawn  from  a  child  of  five  years,  according  to  his  general  condition 
and  the  urgency  of  the  symptoms.  The  depressing  effect  may  largely  be 
overcome  by  immediately  following  this  with  an  intravenous  injection 
of  a  normal  salt  solution.  Twice  as  much  as  the  fluid  drawn  should  be 
introduced.  This  will  almost  invariably  give  at  least  temporary  relief, 
which  may  afford  time  for  the  operation  of  other  measures  such  as  ca- 
tharsis and  diaphoresis.     Pulmonary  cedema  is  no  contra-indication  to 


CHRONIC  NEPHRITIS.  663 

bleeding;  the  best  of  all  guides  as  to  its  use  is  a  pulse  of  very  high 
tension. 

One  should  ahvavs  be  on  the  lookout  for  complications,  especially 
dropsy  of  the  serous  cavities,  pericarditis  or  endocarditis,  and  oedema  of 
the  lungs.  Convalescence  is  nearly  always  sIoav,  and  a  patient  who  has 
suffered  from  nephritis  needs  careful  attention  for  a  long  time.  Anaemia 
is  always  present,  and  iron  is  required.  The  diet  must  consist  largely  of 
fluids  for  several  months.  If  the  disease  tends  to  pass  into  a  subacute 
form,  the  child  should,  if  possible,  be  sent  to  a  warm  climate,  and  kept 
there  during  the  succeeding  winter,  and  every  means  taken  to  improve 
the  general  nutrition.  Flannels  should  be  worn  next  to  the  skin,  and 
special  precautions  taken  against  any  exposure  which  might  cause  an  ex- 
acerbation of  the  disease. 

CHRONIC  NEPHRITIS. 

Chronic  inflammation  of  the  kidney  is  an  infrequent  condition  in 
childhood.  In  infancy  it  is  almost  unknown,  except  in  connection  with 
congenital  hydronephrosis  or  other  malformations  of  the  kidney.  Two 
pathological  varieties  are  met  with :  ( 1 )  Chronic  diffuse  nephritis  of 
the  parenchymatous  or  degenerative  type.  (2)  Chronic  diffuse  nephri- 
tis of  the  interstitial  or  productive  type.  As  the  disease  progresses  the 
former  may  assume  the  characteristics  of  the  latter  variety. 

Etiology. — Chronic  nephritis  is  most  frequently  seen  as  a  sequel  of 
the  acute  nephritis  of  scarlet  fever.  It  also  occurs  with  the  prolonged 
suppuration  of  chronic  bone  or  joint  disease,  where  it  may  be  chronic 
from  the  beginning.  The  only  other  important  causes  in  early  life  are 
hereditary  syphilis,  alcoholism,  chronic  tuberculosis,  and  valvular  dis- 
ease of  the  heart.  Nearly  all  the  cases  occur  in  children  over  flve  years, 
of  age. 

Lesions. — The  lesions  of  chronic  nephritis  in  childhood  do  not  differ 
essentially  from  those  seen  in  later  life.  In  the  chronic  parenchymatous 
type  the  kidneys  are  usually  enlarged,  the  surface  is  smooth  or  slightly 
nodular,  and  the  thickened  cortex  yellowish  white  on  section.  These  are 
often  called  "  large  white  kidneys."  On  the  other  hand,  the  kidneys  may 
be  nearly  normal  in  appearance,  or  smaller  and  with  a  thinner  cortex 
than  is  usual.  In  the  so-called  "  large  red  kidneys  "  the  cortex  is  red  or 
mottled  red  and  yellow,  owing  to  hasniorrhages  into  the  tubules  or  inter- 
stitial tissue.  The  microscope  shows  that  the  renal  epithelium  is 
swollen,  granular,  fatty,  and  degenerated.  The  tubes  contain  leucocytes, 
red  cells,  cast  matter,  and  the  detritus  of  broken-down  epithelial  cells. 
In  some  places  they  are  dilated,  in  others  atrophied.  In  the  glomeruli 
there  is  a  growth  of  capsule  cells,  compression  and  atrophy  of  the  tufts, 
with  the  formation  of  new  connective  tissue.  AYhen  there  is  waxy  de- 
generation, the  kidneys  are  usually  considerably  enlarged,  and  of  a  glis- 
tening gray  colour.     Amyloid  degeneration  is  seen  especially  in  the 


664  DISEASES  OF   THE   URO-GENITAL  SYSTEM. 

small  arteries  of  the  kidney  and  the  capillary  vessels  of  the  tufts.  With 
iodine  the  mahogany-brown  reaction  is  obtained.  Amyloid  changes  in 
the  kidney  are  nearly  always  associated  with  similar  lesions  in  the  liver 
and  spleen,  and  sometimes  also  in  the  intestinal  villi. 

In  the  chronic  difEuse  nephritis  of  the  interstitial  type  (granular 
kidney)  the  organs  are  smaller  than  normal,  with  a  nodular  surface  and 
adherent  capsule.  The  cortex  is  thinned,  and  the  colour  is  gray  or  red. 
In  addition  to  the  lesions  found  in  the  preceding  variety,  there  is  an 
extensive  production  of  new  connective  tissue,  which  is  irregularly  dis- 
tributed throughout  the  kidneys.  The  tubules  in  some  places  are  dilated 
to  form  cysts  of  considerable  size,  while  in  others  they  have  comj^letely 
disappeared.  The  glomeruli  may  be  atrophied  to  little  fibrous  balls; 
or  if  chronic  congestion  has  preceded  the  inflammation,  some  may  be 
large  and  the  capillaries  dilated. 

Symptoms. — 1.  Chronic  nephritis  of  the  parenchymatous  type. — This 
form  of  the  disease  may  be  chronic  from  the  outset,  or  follow  an  acute 
attack  from  which  the  patient  is  often  believed  to  have  recovered  com- 
pletely. The  symptoms  sometimes  immediately  follow  the  acute  attack ; 
at  others  there  is  an  interval  of  apparent  recovery,  extending  over  a  few 
months  or  even  years.  Very  rarely  no  such  history  of  an  antecedent 
acute  attack^can  be  obtained,  and  the  symptoms  come  on  gradually  and 
insidiously.  Such  cases  occur  chiefly  in  older  children,  and  their  clinical 
features  do  not  difEer  essentially  from  those  of  adult  life. 

As  a  rule  dropsy  is  present,  although  it  is  variable  in  amount,  and 
fluctuates  considerably  from  time  to  time.  There  may  be  not  only 
oedema  of  the  cellular  tissue,  but  effusion  into  the  pleura,  peritoneum, 
and  even  the  pericardium.  As  the  case  progresses,  anemia  is  always  a 
marked  symptom.  There  are  various  disturbances  of  digestion — loss  of 
appetite,  occasional  vomiting,  and  attacks  of  diarrhoea.  From  time  to 
time  nervous  symptoms  may  be  quite  prominent,  such  as  headaches, 
sleeplessness,  neuralgia,  fatigue  upon  slight  exertion,  and  dyspnoea.  At- 
tacks of  epistaxis  are  not  infrequent. 

For  the  greater  part  of  the  time  the  urine  contains  albumin  and  casts. 
They  vary  much  in  amount  at  different  periods  in  the  disease,  according 
to  the  rapidity  of  its  progress.  During  periods  of  exacerbation,  both 
albumin  and  casts  are  very  abundant,  while  in  the  intervals  the  amount 
of  albumin  may  be  small  and  the  casts  few.  The  casts  are  hyaline, 
granular,  epithelial,  and  fatty.  The  daily  quantity  of  urine  is  much  re- 
duced during  the  periods  of  exacerbation,  while  at  other  times  it  may  be 
nearly  normal.    The  specific  gravity  is  usually  normal  or  high. 

If  waxy  degeneration  is  present,  there  are  generally  associated  with 
the  renal  symptoms,  others  dependent  upon  waxy  changes  in  other  or- 
gans. The  spleen  and  liver  are  enlarged;  there  may  be  ascites  and 
diarrhrea,  and  there  is  usually  present  the  peculiar  "  alabaster  cachexia." 


CHRONIC  NEPHRITIS.  665 

The  duration  of  this  form  of  chronic  nephritis  depends  much  upon 
the  surroundings  of  the  patient  and  the  treatment.  It  is  rarel}^  shorter 
than  two  years,  and  it  may  last  for  many  years.  The  progress  is  always 
irregular,  and  marked  by  periods  of  exacerbation  and  remission.  The 
patients  die  from  acute  urtemia,  or  from  complicating  pneumonia,  pleu- 
risy, pericarditis,  endocarditis,  or  from  pulmonary  oedema. 

2.  Chronic  nephritis  of  the  interstitial  type. — This  is  a  very  rare 
disease  in  early  life,  being  much  less  frequent  even  than  the  preceding 
variety  of  nephritis.  In  some  cases  there  is  a  history  of  hereditary 
syphilis ;  in  others,  of  chronic  alcoholism.  The  early  symptoms  are  few, 
and  the  disease  usually  develops  insidiously.  The  urine  is  pale,  exces- 
sive in  amount,  and  of  low  specific  gravity — 1  "001  to  1  -008.  Albumin 
is  often  absent,  and,  when  found,  the  quantity  is  small.  Dropsy  like- 
wise is  rare,  and  never  marked.  Nervous  symptoms  are  often  prominent, 
such  as  headache,  attacks  of  spasmodic  dyspnoea  resembling  asthma, 
neuralgias,  and  disturbances  of  vision.  High  arterial  tension  and  hyper- 
trophy of  the  left  ventricle  are  regular  symptoms;  and  even  atheroma- 
tous degeneration  of  the  arteries  may  be  present.  Dickinson  reports  an 
instance  of  this  in  a  patient  only  six  years  of  age.  Late  in  the  disease, 
haemorrhages  may  occur,  and  these  may  be  the  cause  of  death.  FilatofE 
has  reported  a  cerebral  hgemorrhage  in  a  child  of  eleven.  Acute  urgemia 
is,  however,  the  usual  termination  of  this  form  of  nephritis.  The  course 
is  slow,  and  the  disease  may  be  overlooked  until  the  final  urasmic  symp- 
toms occur. 

Prognosis. — The  prognosis  of  chronic  nephritis  as  to  complete  re- 
covery is  always  unfavourable;  and  although  cases  are  seen  in  which 
symptoms  are  absent  for  several  years,  they  almost  invariably  return. 
Cases  have  been  reported  of  recovery  from  waxy  degeneration  of  the 
kidney  after  removal  of  the  bone  disease  upon  Avhich  the  condition 
depended.  An  extended  period  of  observation  is  necessary  before  the  pa- 
tient can  be  pronounced  cured.  As  to  the  duration  of  the  disease,  no 
exact  prognosis  can  be  given,  because,  from  the  symptoms,  it  is  difficult 
or  impossible  to  determine  exactly  the  extent  of  the  disease  in  the  kidney 
and  the  rapidity  of  its  progress.  The  continued  passage  of  a  large 
amount  of  urine  of  low  specific  gravity  is  invariably  to  ho  intor]iroto(l  as 
evidence  of  fibroid  changes  in  the  Malpighian  tufts,  ami  is  a  had  syiiip- 
toiii.  A  large  amount  of  dropsy,  the  coexistence  of  valvular  disease  of 
the  heart,  and  uiai'lccd  renal  insufficiency,  as  shoM-n  by  the  quautitative 
examination  of  llic  ui'ine,  are  all  very  unfavourable  symptoms. 

Diagnosis. — C-hronic  nephritis,  like  llie  acute  forms,  is  likely  to  be 
overlooked  because  of  the  failure  to  examine  the  urine  in  children. 
Regular  and  frequent  examinations  should  be  made  in  all  cases  of  con- 
vulsions, of  persistent  or  freciuent  headaches,  severe  anaMuia.  liyjier- 
tropliy  of  the  heart,  high  arterial  tension  and  of  general  malnutiition, 


666  DISEASES  OF   THE  URO-GEXITAL  SYSTEM. 

as  Tvell  as  when  the  more  obvious  symptoms  of  renal  disease,  such  as 
dropsy  and  scanty  urine,  are  present.  Xor  should  one  be  too  ready  to 
make  the  diagnosis  of  functional  albuminuria  because  he  finds  albumin 
only  occasionally  and  in  small  quantity.  All  such  cases  demand  most 
careful  observation  and  the  closest  attention  for  a  long  period  before 
excluding  organic  renal  disease. 

Treatment. — Children  with  chronic  nephritis  are  to  be  treated  on  the 
same  general  plan  as  adults.  The  purpose  of  treatment  is  to  retard  as 
much  as  possible  the  progress  of  the  disease  and  to  relieve  the  symptoms 
as  they  arise.  It  is  of  the  greatest  importance  to  remove  the  patient 
from  conditions  in  which  exacerbations  are  liable  to  occur.  If  it  is 
possible,  he  should  be  sent  to  a  warm,  dry  climate  in  winter,  and  all 
exposure  to  cold  avoided;  an  out-door  life  is  desirable.  Most  patients 
rec^uire  general  tonic  treatment  with  very  moderate  but  regular  exer- 
cise, never  carried  to  the  point  of  fatigue,  as  much  rest  as  possible  in  a 
recumbent  position,  a  fluid  diet,  consisting  largeh'  of  milk  as  long  as 
this  can  be  borne,  and  the  administration  of  iron,  particularly  the  tinc- 
ture of  the  chloride.  Excessive  dropsy  calls  for  diuretics,  saline  cathar- 
tics, and  heart  stimulants.  If  ursemia  develops,  with  high  arterial  ten- 
sion and  stupor,  headache,  and  convulsions,  venesection  should  be  re- 
sorted to,  or  nitroglycerin  used.  Morphine  ma}"  be  given  hypodermically 
if  the  pupils  are  dilated  and  nervous  symptoms  are  very  marked. 

TUBERCULOSIS   OF   THE   KIDNEY. 

In  general  tuberculosis,  miliary  tubercles  are  frequently  seen  both 
upon  the  surface  of  the  kidney  and  in  its  substance.  These  give  rise  to 
no  S3'mptoms  and  are  of  no  clinical  importance.  Larger  tuberculous 
deposits  are  extremely  rare  in  early  life.  They  usually  occur  in  patients 
who  are  the  subjects  of  general  tuberculosis,  and  are  associated  with 
tuberculosis  of  other  parts  of  the  genito-urinary  tract,  or  they  may  exist 
as  the  primary,  or  even  the  only,  tuberculous  lesion  in  the  body.  Hamill* 
(Philadelphia)  observed  one  case  of  ^Drimary  renal  tuberculosis  in  an 
infant  seven  months  old,  and  collected  5-i  others  in  children  under  four- 
teen years.  A  number  of  these,  however,  are  very  doubtful.  Boys  were 
more  often  attacked  than  girls.  Only  2  cases  were  under  one  year  of 
age ;  13  were  between  one  and  five  years ;  11  were  between  five  and  ten 
years  old. 

A  study  of  these  cases  shows  that  ascending  infection  occurs  occa- 
sionally but  that  it  is  rare ;  and  that  nearly  all  cases  are  of  the  descending 
type — i.  e.,  primary  in  the  kidney.  Infection  of  the  kidney  therefore 
generally  takes  place  through  the  circulation  and  not  from  the  bladder. 

*  S.  M.  Hamill,  Primary  Tuberculosis  of  the  Kidney  in  Children.  From  the- 
Pepper  Laboratory  for  Clinical  Medicine,  Philadelphia,  1896.  International  Medical 
Magazine,  1896,  v,  No.  2. 


MALIGNANT  TUMOURS  OF  THE  KIDNEY.  QQ'J 

Aldibert's  figures  show  that  in  children  the  bladder  usually  escapes  even 
when  the  kidneys  are  tuberculous,  for  of  13  cases  of  renal  tuberculosis 
the  bladder  was  involved  in  but  2.  The  disease  when  primary  begins  in 
the  cortex,  but  soon  extends  to  the  mucous  membrane  of  the  pelvis  and 
the  calices  of  the  kidney,  and  also  to  the  pyramids.  As  a  rule,  but  one 
kidney  is  affected.  The  process  may  be  confined  to  the  pyramids,  where 
are  found  cheesy  nodules  which  may  be  single  or  multiple.  These  iilti- 
mately  break  down  and  form  abscesses.  The  process  may  result  in  al- 
most complete  destruction  of  the  pyramids,  and  even  of  portions  of  the 
cortex,  so  that  the  kidney  ma}^  consist  of  a  mere  shell  of  renal  tissue. 
Suppuration  in  the  neighbourhood  of  the  kidney  (perinephritic  abscess) 
often  coexists. 

The  symptoms  are  cjuite  indefinite.  There  may  be  localized  pain  and 
tenderness  in  the  region  of  the  kidney,  and  a  tumour  if  there  is  perine- 
phritis. The  symptoms  of  irritability  of  the  bladder  may  be  almost  as 
severe  as  in  cases  of  calculus.  Pus  usually  appears  in  the  urine  as  a  con- 
stant symptom,  and  blood  is  often  present.  But  the  only  thing  that  is 
diagnostic  is  the  discovery  of  tubercle  bacilli  in  the  urine. 

The  treatment  of  renal  tuberculosis  is  purely  surgical.  Of  the  17 
cases  collected  by  Hamill  in  which  operation  was  done  for  this  condition, 
there  were  11  recoveries  and  6  deaths,  2  of  the  deaths,  however,  not 
being  traceable  to  the  operation  or  to  the  original  disease.  ISTephrotomy 
was  done  4  times,  with  2  recoveries,  1  improvement,  and  1  death.  Ne- 
phrectomy was  done  9  times,  with  5  recoveries,  1  improvement  (died 
later  from  perforation  of  the  duodenum),  and  3  deaths.  IsTephrectomy 
followed  nephrotomy  in  4  cases,  of  which  2  recovered,  1  died,  and  1 
improved.  ISTo  recurrence  had  taken  place  in  one  case  at  the  end  of 
eight  years,  and  none  in  another  after  three  j^'ears. 

MALIGNANT   TUMOURS  OF  THE   KIDNEY. 

In  the  great  majority  of  cases  tumours  of  the  kidney  are  malignant. 
Of  51  cases  collected  by  Aldibert  which  were  operated  upon,  48  were 
malignant  and  3  benign. 

Malignant  growths  are  almost  invariably  primary.  In  children  under 
five  years,  although  not  common,  they  are  yet  more  frequent  than  any 
other  variety  of  malignant  tumour  of  the  abdomen.  The  earlier  cases 
reported  were  classed  as  carcinoma.  It  is  now  well  esta1)lisliod  tlinl  car- 
cinoma is  very  infrequent,  and  that  nearly  all  the  cases  are  varieties  of 
sarcoma.  Fiselior  ro])orts  19  of  sarcoma  and  2  of  carcinouia  ;  Aldi- 
bert, 38  of  sarcoma  and  5  of  carcinonin.  The  sarcoma  may  be  round- 
er spindle-celled,  or  myo-sarcoma.  In  some  of  the  cases  there  are 
both  sarcomatous  and  carcinomatous  features,  so  that  they  might  be 
classed  as  sarcomatous  carcinoma.  Tlie  tumour  grows  from  the  cor- 
tex of  the  kidney,  or  from  the  pelvis,  sometimes  from  the  adrenals. 


^68  DISEASES  OF  THE  URO-GENITAL  SYSTEM. 

It  may  infiltrate  the  whole  kidne}^,  so  that  there  is  no  trace  of  renal 
structure  remaining,  or  it  ma}^  form  an  immense  tumour  on  one  side  of 
the  kidney,  which  is  only  partially  invaded.  These  tumours  are  very 
rarely  cystic,  but  they  are  quite  soft,  and  haemorrhages  often  occur  into 
their  substance.  There  may  be  secondary  growths  in  the  liver,  the  lungs, 
the  retroperitoneal  glands,  in  the  opposite  kidne}'',  in  the  intestines,  or 
in  the  pancreas.  Pressure  of  the  tumour  upon  the  ureter  may  lead  to 
hydronephrosis ;  and  ujDon  the  inferior  vena  cava,  to  thrombosis  of  that 
vessel.  As  it  grows,  the  tumour  sometimes  becomes  adherent  to  nearly 
all  the  abdominal  organs  by  localized  peritonitis.  It  may  lead  to  ascites, 
but  it  very  rarely  causes  general  peritonitis.  The  growth  may  reach  a 
great  size,  usually  from  5  to  15  pounds,  but  in  1  case  reported  by 
Jacobi  it  weighed  36  pounds.  In  Seibert's  collection  of  48  eases  the  right 
kidney  was  involved  in  24,  the  left  in  22,  and  both  kidneys  in  2  cases. 

Etiology. — These  tumours  of  the  kidney  may  be  congenital.  This 
was  true  of  5  cases  in  a  series  of  55  collected  by  Jacobi.  The  majority 
occur  in  early  childhood.  In  the  collection  of  130  cases  by  Longstreet 
Taylor  in  which  the  ages  are  given,  106  were  in  the  first  five  years,  and 
57  of  these  in  the  first  two  years  of  life.  The  sexes  were  about  equally 
afl^ected.    In  a  small  number  of  eases  the  history  of  a  fall  was  given. 

Symptoms. — The  principal  symptoms  are  tumour,  hsematuria,  and 
cachexia.  The  tumour  is  usually  first  noticed.  It  is  in  most  cases  dis- 
covered in  the  loin,  but  grows  forward  toward  the  median  line.  Its  sur- 
face may  be  lobulated  and  irregular  or  quite  smooth ;  and  although  solid, 
it  is  sometimes  so  soft  as  to  give  an  obscure  sensation  of  fluctuation. 
It  may  grow  to  an  enormous  size,  causing  displacement  of  the  liver, 
spleen,  intestines,  and  lungs.  The  progress  of  the  growth  is  usually 
rapid,  so  that  from  the  size  of  a  fist,  the  tumour  may  gi'ow  in  the  course 
of  five  or  six  months  so  as  to  fill  the  abdomen.  By  careful  palpation  it 
will  be  found — certainly  when  the  tumour  is  small — that  although  it 
may  be  quite  freely  movable,  its  attachment  is  near  the  lumbar  spine. 
Aspiration  may  show  blood,  but  more  frequently  the  result  is  negative. 

Hsematuria  was  observed  before  the  tumour  in  19  of  50  cases  (Sei- 
bert),  it  being  then  the  first  symptom  noticed.  The  amount  of  blood 
passed  is  sometimes  quite  large,  but  is  usually  small,  and  may  be  discov- 
ered only  by  the  microscope.  Pain  is  rare,  and  is  due  to  localized 
peritonitis.  Constitutional  symptoms  are  absent  until  the  tumour  has 
attained  a  large  size,  when  a  cachexia  develops  and  the  patient  wastes 
steadily  while  the  tumour  continues  to  grow.  The  pressure  effects  are 
dyspnoea,  from  compression  of  the  lungs;  oedema  of  the  lower  extremi- 
ties, from  pressure  upon  or  thrombosis  of  the  vena  cava;  vomiting  and 
indigestion,  from  pressure  upon  the  stomach  and  intestines.  Secondary 
deposits  very  rarely  cause  any  symptoms  except  in  the  lungs,  Avhere  they 
may  give  rise  to  cough,  and  even  to  heemoptysis. 


44 


0G9 


670  DISEASES  OP  THE  URO-GENITAL  SYSTEM. 

The  course  of  the  disease  is  steadily  from  bad  to  worse.  The  usual 
duration  of  life  in  patients  not  operated  upon,  is  from  three  to  ten 
months  after  the  tumour  is  large  enough  to  he  easily  discovered. 

Diag-nosis. — The  important  points  are,  the  position  and  attachment 
of  the  tumour,  its  steady  growth  and  solid  character,  hgematuria,  and  the 
age  of  the  patient  (under  five  years).  It  may  he  confounded  with  hydro- 
nephrosis, dermoid  cyst  of  the  ovary,  enlargement  of  the  spleen,  retro- 
peritoneal sarcoma,  tumours  of  the  liver,  or  even  of  the  abdominal  wall. 

Treatment. — Nothing  is  to  be  said  regarding  the  medical  treatment 
of  these  cases.  Unless  operated  upon,  I  believe  they  invariably  termi- 
nate fatally.  Some  of  the  results  of  operation  during  recent  years  have 
been  so  encouraging  that  no  case  should  be  abandoned,  no  matter  how 
young  the  patient.  Lewi  *  has  collected  the  results  of  60  eases  operated 
upon:  20  deaths  occurred  soon  after  operation,  from  causes  connected 
with  it;  in  20  cases  the  cause  of  death  was  recurrence  of  the  growth; 
this  raises  the  total  mortality  to  67  per  cent.  In  the  Babies'  Hospital, 
my  colleague,  Dr.  Eobert  Abbe,  operated  upon  a  nursing  child,  thirteen 
months  old,  where  the  tumour  weighed  7  pounds,  and  the  child  after  the 
operation  only  15  pounds.  This  case  made  an  uninterrupted  recovery, 
and  ten  years  after  the  operation  was  still  in  perfect  health.  The  ac- 
companying illustrations  (Figs.  119  and  120)  are  from  photographs  of 
this  patient.  A  second  child  operated  on  at  two  years  remained  well  for 
three  and  a  half  years  and  died  from  a  recurrence  in  the  opposite  kidney. 

For  a  discussion  of  the  surgical  aspects  of  this  question,  and  details 
of  the  operation,  see  the  papers  of  Abbe  f  and  Aldibert.J 

Benign  Tumours. — These  are  distinguished  by  their  slow  growth,  and 
by  the  fact  that  the  constitutional  symptoms  are  mild  or  wanting.  Of 
the  three  cases  mentioned  by  Aldibert,  one  was  adenoma,  one  fibroma, 
and  one  was  fibro-cystic. 

PYELITIS— PYELO-CYSTITIS. 

Pyelitis  is  an  inflammation  of  the  mucous  membrane  lining  the 
pelvis  of  the  kidney;  cystitis  is  an  inflammation  of  the  mucous  mem- 
brane of  the  bladder.  They  may  exist  separately  or  together.  With 
pyelitis  there  may  be  inflammation  of  the  ureter  or  of  the  kidney  itself 
(pyelo-nephritis),  and  it  may  be  acute  or  chronic.  It  may  result  in  the 
accumulation  of  pus  in  considerable  amount  in  the  pelvis  of  the  kidney 
(pyelo-nephrosis) . 

Etiology. — The  most  frequent  local  cause  of  pyelitis  is  irritation  from 
renal  calculi.  It  is  also  associated  with  congenital  malformations  of 
the  kidneys  or  ureters,  with  renal  tuberculosis  and  renal  tumours.  It 
may  result  from  an  extension  of  inflammation  from  the  tissues  surround- 

*  Archives  of  Paediatrics,  February,  1896.  f  Annals  of  Surgery,  January,  1894. 

X  Revue  Mensuelle  des  Maladies  de  I'Enfance,  November,  1893. 


PYELITIS— PYELO-CYSTITIS.  671 

ing  the  kidne}''  (perinephritis),  or  from  an  abscess  opening  into  the 
pelvis  of  tlie  Iviclney.  An  infectious  form  of  acute  pyelitis  sometimes 
occurs  as  a  complication  of  scarlet  or  typhoid  fever,  diphtheria,  malaria, 
or  pyaunia ;  but  it  is  also  seen  apart  from  these  diseases,  when  it  occurs 
apparently  as  a  primary  affection.  In  most  of  the  severe  cases  of  p3'e- 
litis  there  is  also  present  a  certain  amount  of  nephritis. 

Acute  pyelitis  may  also  be  secondary  to  acute  cystitis  even  in  in- 
fants. In  such  cases  the  inflammatory  process  travels  upward  along  the 
ureter,  which  may  or  may  not  be  involved.  These  cases  of  cystitis  occur 
chiefly  in  female  infants  and  have  been  especially  studied  by  Escherich, 
Trumpp,  and  Finkelstein,  who  found  the  characteristic  features  of  the 
disease  to  be  the  presence  of  the  colon  bacillus  in  pure  culture  in  freshly 
voided  urine;  the  term  "  eoli-cystitis  "  has  been  applied  to  them.  Of  10 
cases  observed  by  Escherich  and  7  by  Finkelstein,  all  were  girls.  I 
have  myself  seen  4  severe  cases  in  female  infants  which  corresponded 
closely  with  the  type  described  by  these  writers,  though  no  cultures 
were  made  from  the  urine.  The  infection  probably  occurs  through 
the  urethra,  and  originates  from  the  stools  through  the  napkins  or 
the  passage  of  the  stools  over  the  vulva.  This  more  frecj[uently  occurs 
in  diarrhoeal  diseases,  witli  which  the  cystitis  has  often  been  found 
associated.  It  is  surprising  that  vulvo-vaginitis-  is  seldom  present.  It 
seems  quite  possible  that  infection  may  also  occur,  especially  in  male 
infants,  by  a  direct  extension  from  the  intestine  to  the  bladder,  or 
through  the  blood.  Trumpp  examined  the  urine  in  16  cases  of  gastro- 
enteritis and  found  the  colon  bacillus  in  13,  of  whom  9  were  females. 
The  association  of  cystitis  and  gastro-enteritis  deserves  further  study. 

Lesions. — When  pyelitis  develops  from  a  local  cause  it  is  usually 
unilateral;  otherwise  both  sides  are  involved.  In  the  cases  of  acute 
cystitis  or  pyelo-cystitis  there  are  the  usual  appearances  of  an  acute 
catarrhal  inflammation  of  the  mucous  membrane,  with  congestion,  swell- 
ing, and  sometimes  minute  haemorrhages.  In  chronic  cases  there  is 
thickening  and  sometimes  a  granular  condition  of  the  lining  membrane. 
There  may  be  an  accumulation  of  pus  of  considerable  size,  distending 
the  pelvis  and  calices  (pyonephrosis).  If  the  condition  is  one  depending 
upon  a  calculus  or  congenital  deformity,  and  in  all  protracted  and 
severe  cases,  the  kidney  itself  is  involved  to  a  greater  or  less  degree ;  the 
extent  of  the  nephritis  will  depend  upon  the  nature  of  the  exciting  cause 
and  the  duralion  of  the  process. 

Symptoms. — The  history  of  the  following  case  ilhisirates  the  main 
clinical  features  of  acute  infectious  pyelitis,  in  tliis  instance  occurring 
apparently  as  a  primary  disease: 

A  previously  healthy  female  infant  of  eight  months  was  taken  sud- 
denly with  a  chill,  followed  by  a  very  high  fever.  The  child  was  ill  for 
ten  days  before  the  nature  of  tlie  disease  was  suspected.     During  this 


672  DISEASES  OF  THE   URO-GENITAL  SYSTEM, 

time  the  temperature  ranged  between  101°  and  106°  F.,  touching  105° 
nearly  every  day;  but  the  chill  was  not  repeated.  The  other  constitu- 
tional symptoms  were  not  severe.  At  the  first  examination  of  the  urine 
there  was  found  a  large  amount  of  pus,  which  on  standing  was  equal  to 
one  twelfth  of  the  volume  of  the  urine  passed ;  the  reaction  was  strongly 
acid.  There  Avere  no  signs  of  vaginitis  or  vulvitis,  no  ardor  urincB,  no 
evidence  of  local  pain  either  in  the  bladder  or  kidney,  no  abnormal  fre- 
quency of  micturition,  no  localized  tenderness,  and  no  vomiting.  At 
later  examinations  there  were  found  in  moderate  numbers  epithelial  cells 
from  the  bladder,  and  the  tubules  and  pelvis  of  the  kidney,  also  a  few 
hyaline  casts,  but  not  more  albumin  than  would  be  explained  by  the 
amount  of  pus.  Under  no  treatment  except  alkaline  diuretics,  the  tem- 
perature gradually  fell  to  normal,  and  the  pus  steadily  diminished  in 
quantity,  and  at  the  end  of  five  weeks  had  practically  disappeared  from 
the  urine.  A  report  sixteen  months  later  stated  that  the  child  had  re- 
mained well  and  entirely  free  from  urinary  symptoms. 

In  some  cases  there  are  recurring  chills,  with  wide  fluctuations  in 
temperature;  in  others  there  may  be  only  pyuria,  with  moderate  fever 
and  few  other  constitutional  symptoms.  If  the  disease  complicates  one 
of  the  acute  infectious  diseases,  pyuria  may  be  the  only  symptom.  If 
cystitis  is  also  present  micturition  is  frequent  and  ma}'  be  painful.  The 
urine  in  acute  pyelo-cystitis  is  turbid  from  the  ^^resence  of  pus,  the 
amount  of  which  may  be  from  one  to  fifty  per  cent  of  the  volume  of  the 
urine.  The  quantity  of  urine  is  generally  somewhat  diminished,  and  it 
may  be  quite  scanty.  The  reaction  is  usually  acid,  even  though  the 
amount  of  pus  is  large.  Albumin  is  present  in  proportion  to  the  amount 
of  pus  or  the  degree  of  nephritis.  Eed  blood-cells  are  found  under  the 
microscope  in  most  of  the  very  acute  cases,  and  may  be  in  sufficient  num- 
bers to  colour  the  urine.  The  pus  cells  in  recent  cases  are  usually  well 
preserved,  but  in  old  cases  they  may  be  degenerated.  There  are  many 
epithelial  cells — conical,  fusiform,  and  irregular  cells  with  long  tails. 
There  may  be  renal,  epithelium  and  hyaline,  granular,  or  epithelial  casts, 
varying  in  number  with  the  severity  of  the  nephritis.  The  colon  bacillus 
may  be  present  in  pure  culture. 

In  chronic  pyelitis  only  pyuria  may  be  present,  or  there  may  be  a 
tumour  owing  to  the  pyonephrosis.  From  time  to  time  in  the  chronic 
form  there  may  be  intermittent  attacks  of  acute  pj^elitis  resembling  those 
above  described.  In  pyelitis  depending  upon  congenital  malformations, 
pyuria  is  usually  the  only  symptom,  unless  pyonephrosis  is  present. 
With  calculi  we  may  have  acute  or  chronic  pyelitis ;  there  may  be  local- 
ized pain,  tenderness,  sometimes  a  tumour,  occasionally  hsematuria,  and 
perhaps  a  history  of  renal  colic  or  the  passage  of  gravel.  With  tuber- 
culosis we  have  chronic  pyuria  and  the  presence  of  tubercle  bacilli  in  the 
urine.     There  are  commonly  associated  the  symptoms  of  general  tuber- 


REI^AL   CALCULI.  673 

culosis.  If  associated  with  perinephritis,  the  inflammation  is  usuaJlly 
acute,  and  there  are  present  the  local  sjanptoms  of  the  original  disease. 
If  an  abscess  opens  into  the  pelvis  of  the  kidney  we  may  have  a  sudden 
discharge  of  pns  in  large  quantity  with  a  subsidence  of  previous  local 
symptoms,  including  the  tumour.  With  neoplasms  we  have  congestion 
and  haemorrhage  more  frequently  than  pus,  but  both  may  be  present. 

Diagnosis. — The  characteristic  symptoms  of  acute  pyelitis  are  chills, 
which  may  be  repeated,  high  and  fluctuating  temperature,  scanty  urine, 
frequently  pain  and  tenderness  over  the  kidneys,  and  pyuria.  The  diag- 
nosis of  pyelitis  is  made  only  by  an  examination  of  the  urine,  which 
should  never  be  omitted  in  cases  of  obscure  high  temperature,  even  in 
infancy,  particularly  if  chills  are  present.  When  cystitis  is  associated, 
the  only  additional  symptoms  may  be  pain  and  other  signs  of  vesical 
irritation.  These  symptoms,  with  an  acid  urine  containing  a  large 
amount  of  pus  and  epithelial  cells  like  those  described,  are  sufficient  to 
establish  the  diagnosis  of  pyelo-cystitis.  If  the  pus  comes  from  the 
opening  of  an  abscess  into  the  bladder,  ureter,  or  pelvis  of  the  kidne}^ 
the  local  signs  of  such  abscess  will  usually  be  present. 

Prognosis. — In  cases  apparently  primary,  and  in  those  complicating 
infectious  and  other  diseases,  the  prognosis  is  good.  The  danger  is 
chiefly  from  the  nephritis  which  follows  or  complicates  the  process.  In 
cases  depending  upon  local  conditions,  the  prognosis  will  depend  upon 
the  nature  of  the  exciting  cause.  Here,  also,  the  principal  danger  is 
from  nephritis.  If  calculi  are  present  and  if  pyonephrosis  occurs,  the 
patient  may  die  from  exhaustion  before  a  serious  degree  of  nephritis  has 
developed. 

Treatment. — Water  should  be  given  freely,  and  alkalies  up  to  the 
point  of  neutralizing  the  excessive  acidity  of  the  urine.  In  infants,  from 
twelve  to  twenty-four  grains  of  the  citrate  of  potash  are  required  daily 
for  this  purpose.  If  the  urine  is  alkaline,  benzoic  acid  may  be  used  in 
the  same  doses.  The  most  important  remedy  is  urotropin,  which  should 
be  given  in  doses  of  one  or  two  grains  every  three  hours  to  an  infant 
of  a  year,  and  proportionate  doses  to  older  children.  In  acute  cases, 
counter-irritation  over  the  kidney  by  means  of  poultices  or  dry  cups  may 
1)1'  ciiiplnycd.  If  calculi  are  present  the  same  treatment  is  indicated. 
Sui'gical  interference  is  called  for  if  pyoneplirosis  develoi)s,  or  if  the 
disease  is  evidently  unilateral  and  the  kidney  is  seriously  involved.  The 
advisability  of  surgical  interference  will  depend  ujioii  the  clearness  of 
diagnosis  and  the  severilv  of  the  syni]it()ins. 

RENAL  CALCULI 

Small  renal  calculi  are  very  common  in  infancy.  In  the  autopsy- 
I'oom  we  fre(|uently  see,  on  opening  llic  kidneys  of  young  infants,  fine 
brown  gi'anules  in  the  pelvis  and  ealici's.  and  nccasidnally  a  calculus  as 


6Y4  DISEASES  OF  THE  URO-GENITAL  SYSTEM. 

large  as  a  small  pea  is  found.  They  are  usually  composed  of  uric  acid. 
Only  once  in  over  one  thousand  autopsies  of  which  I  have  records,  was 
a  stone  of  any  considerable  size  seen  in  an  infant.  In  this  case  it  was 
an  inch  in  length  and  half  an  inch  wide.  It  is  surprising  that  these  are 
so  rare,  when  we  consider  how  very  frequently  the  minute  calculi  are 
met  with.  The  probable  explanation  is,  that  the  majority  of  them  are 
dissolved  or  washed  down  into  the  bladder  and  passed  per  wethram 
because  of  the  fluid  diet  of  the  first  two  years.  The  granular  deposits 
are  usually  lodged  in  the  pelvis  of  the  kidney,  and  are  generally  seen 
upon  both  sides.  With  the  larger  collections  there  is  often  a  slight 
catarrhal  pyelitis. 

Symptoms. — The  small  deposits  give  no  symptoms,  and  even  quite 
large  calculi  may  be  found  at  autopsy  where  no  indication  of  their  pres- 
ence had  existed  during  life,  as  in  the  case  above  mentioned.  In  some 
cases  symptoms  are  produced  which  resemble  those  of  renal  calculi  in  the 
adult.  In  infants  less  definite  symptoms  are  often  passed  over  as  merely 
intestinal  colic. 

In  well-marked  cases  in  older  children  there  is  tenderness,  pain  local- 
ized over  the  afllected  kidney,  or  radiating  to  the  bladder,  the  peringeum, 
and  even  the  opposite  kidney,  and  there  may  be  irritation  and  retraction 
of  the  testicle.  The  urine  may  show,  especially  after  exercise,  a  trace  of 
Mood;  there  may  be  the  added  sjanptoms  of  pyelitis,  with  some  fever, 
localized  tenderness,  and  the  appearance  in  the  urine  of  pus  and  epithe- 
lial cells  from  the  pelvis  of  the  kidney. 

Kenal  colic  is  produced  when  a  stone  of  any  considerable  size  passes 
from  the  kidney  to  the  bladder.  It  is  characterized  by  symptoms  similar 
to  those  seen  in  the  adult.  There  are  sudden  attacks  of  severe  sickening 
pain  in  the  loins,  shooting  down  the  thigh  or  to  the  testicle.  There  may 
be  vomiting  and  even  collapse.  The  urine  is  j)assed  frequently,  in  small 
quantities,  and  contains  blood.  The  symptoms  quickly  subside  when  the 
stone  reaches  the  bladder.  The  calculus  may  sometimes  become  im- 
pacted in  the  ureter  and  give  rise  to  hydronephrosis  or  pyonephrosis, 
which  soon  becomes  pyelo-nephritis. 

The  existence  of  small  calculi  may  be  suspected  from  the  symptoms 
above  mentioned;  the  diagnosis  is  made  positive  by  the  appearance  of 
gravel  in  the  urine.  The  use  of  the  Rontgen  rays  is  of  service  in  recog- 
nising even  small  calculi.* 

Treatment. — The  only  medical  treatment  consists  in  a  fluid  diet,  the 
free  use  of  alkaline  mineral  waters,  and  a  sufficient  quantity  of  some 
drug  to  render  the  urine  alkaline.  Such  measures  will  relieve  only  the 
milder  conditions.  With  larger  calculi  and  more  marked  symptoms,  a 
surgical  operation  should  be  considered  and  should  be  urged  in  propor- 

*  Abbe,  Annals  of  Surgery,  August,  1899. 


PERINEPHRITIS.  675 

tion  to  the  severity  of  the  symptoms  aud  the  clearness  of  the  diagnosis. 
If  calculous  pyelitis  exists,  it  is  certain  sooner  or  later  to  lead  to  serious 
nephritis,  and  it  is  only  a  question  of  time  when  the  kidney  will  be  dis- 
abled. The  same  is  true  of  hydronephrosis  from  the  impaction  of  a  cal- 
culus in  the  ureter.  Aldibert  has  collected  four  cases  of  nephrectomy  in 
children  for  renal  calculi  in  which  the  kidney  was  healthy,  with  three 
recoveries  and  one  death  from  shock.  In  nine  cases  of  operation  for  cal- 
culous pyonephrosis,  there  were  six  recoveries  and  three  deaths.  This  is 
certainly  an  encouraging  showing,  and  should  lead  one  to  consider  opera- 
tion seriously  in  many  cases  for  which  formerly  nothing  was  done.  The 
earlier  the  operation  the  greater  the  chances  of  success,  because  of  the 
better  condition  of  the  other  kidney.  Although  the  continued  use  of 
water  and  the  so-called  solvents  may  relieve  some  of  the  symptoms,  it 
is  very  questionable  whether  they  do  more. 

TRAUMA.TIC   HYDRONEPHROSIS. 

In  addition  to  the  hydronephrosis  which  results  from  congenital  mal- 
formations and  from  the  impaction  of  calculi,  a  form  is  occasionally  seen 
following  severe  injury  to  the  kidney.  The  pathology  of  hydronephrosis 
in  these  cases  is  not  well  understood.  After  the  early  symptoms  of 
traumatism  have  subsided,  there  develops  in  from  two  weeks  to  two 
months  a  tumour  in  the  region  of  the  kidney,  which  may  reach  a  consid- 
erable size  and  present  all  the  ordinary  characteristics  of  hydronephrosis 
arising  from  other  causes.  This  tumour  may  disappear  spontaneously, 
or  it  may  increase  in  size  and  demand  surgical  intervention  for  its  cure. 
In  seventeen  cases  which  Aldibert  has  collected  there  was  only  one  of 
spontaneous  recovery ;  aspiration  was  done  in  seven  cases,  with  six  cures 
and  one  death ;  incision  with  or  without  nephrectomy  was  practised  in 
nine  cases,  with  seven  recoveries  and  two  deaths. 

PERINEPHRITIS. 

This  consists  in  an  inflammation  in  the  cellular  tissue  surrounding  the 
kidney,  which  may  terminate  in  resolution  or  in  suppuration.  It  is  not 
of  very  uncommon  occurrence,  and  is  of  importance  chiefly  from  the  fre- 
quency with  which  it  is  confounded  with  disease  of  the  hip  or  spine. 
Perinephritis  may  be  secondary  to  suppurative  processes  in  the  kidney 
itself,  whether  from  calculi  or  tuberculous  deposits,  or  it  may  be  primary. 
In  cliildren  the  latter  is  the  common  form.  Primary  perinephritis  is 
attributed  to  traumatism,  cold,  or  exposure,  or  it  may  develop  without 
assignable  cause.  It  usually  runs  an  acute  or  subacute  course  ;  very  rarely 
it  may  be  chronic. 

For  the  clinical  picture  of  this  disease  I  am  chiefly  indebted  to  a 
paper  by  Gibney,  who  published  in  1880  a  report  of  twenty-eight  cases  of 


676  DISEASES   OP   THE    URO-GENITAL   SYSTEM. 

primary  perinephritis  in  children.  I  was  at  that  time  an  interne  in  the 
Hospital  for  the  Ruptured  and  Crippled,  New  York,  where  these  cases 
were  under  observation,  and  had  an  opportunity  to  see  many  of  those 
reported  in  Dr.  Gibney's  paper.* 

The  ages  of  these  patients  were  between  one  and  a  half  and  fifteen 
years,  the  majority  being  between  three  and  six  years.  The  two  sides 
and  the  two  sexes  were  about  equally  affected.  About  one  third  of  the 
cases  were  clearly  traceable  to  traumatism  ;  in  the  others  no  adequate 
exciting  cause  could  be  discovered.  The  majority  of  the  cases  were  re- 
ferred to  the  hospital  with  the  diagnosis  of  hip-joint  disease  or  caries  of 
the  spine.  Resolution  followed  in  twelve  of  these  cases,  and  sixteen  ter- 
minated in  su]3puration. 

When  abscess  forms,  it  usually  burrows  between  the  lumbar  muscles 
and  comes  to  the  surface  posteriorly  near  the  middle  of  the  ilio-costal 
space ;  it  may  burrow  forward  between  the  abdominal  muscles  and  point 
just  above  Poupart's  ligament ;  very  rarely  it  may  follow  the  psoas  muscle 
and  appear  at  the  upper  and  inner  aspect  of  the  thigh,  like  an  ordinary 
psoas  abscess ;  or  it  may  open  into  the  peritoneal  cavity. 

Symptoms. — The  onset  of  acute  perinephritis  may  be  quite  abrupt, 
with  chill,  fever,  and  localized  pain ;  or  it  may  be  gradual,  with  stiffness  of 
the  spine,  lameness  referred  to  the  hip,  and  deformity  due  to  contraction 
of  the  flexors  of  the  thigh.  The  pain  is  usually  felt  in  the  loin,  but  may 
be  referred  to  the  groin,  to  the  inner  side  of  the  thigh,  or  to  the  knee. 
It  is  often  severe,  and  increased  by  using  the  limb.  It  is  in  most  cases 
accompanied  by  localized  tenderness  in  the  neighbourhood  of  the  kidney. 
There  is  lameness  upon  the  affected  side  which  may  come  on  gradually, 
being  sometimes  referred  to  the  hip  and  sometimes  to  the  spine.  These 
symptoms  often  develop  slowly  in  the  course  of  two  or  three  weeks.  They 
are  usually  accompanied  by  a  slight  elevation  of  temperature.  In  the 
most  acute  cases  the  temperature  is  high  (102°  to  104°  F.),  and  prostration 
severe. 

As  the  disease  progresses  fever  is  a  constant  symptom,  the  temperature 
usually  varying  between  101°  and  103°  F.  There  is  in  most  cases  increas- 
ing deformity,  and  finally  the  patient  may  be  unable  to  walk  at  all.  On 
examination  at  the  height  of  the  disease  there  is  found  in  a  typical  case 
a  deviation  of  the  spine  with  the  concavity  toward  the  affected  side  ;  the 
thigh  may  be  held  flexed  to  a  right  angle ;  passive  extension  is  resisted 
and  causes  pain,  although  all  the  other  movements  at  the  hip  joint  are 
normal.  In  the  lumbar  region  there  is  tenderness,  and  there  may  be  an 
area  of  infiltration  filling  the  ilio-costal  space.  At  first  this  is  only  ap- 
preciable  by   percussion,   but  later   a   distinct   tumour   is   present.      In 


*  Chicago  Medical  Journal  and  Examiner,  1880.  where  will  be  found  a  very  full 
bibliography. 


PERINEPHRITIS.  677 

addition  to  the  tumour  in  the  usual  region,  there  is  sometimes  one  at 
the  upper  and  inner  aspect  of  the  thigh,  owing  to  a  burrowing  of  pus,  and 
the  sacs  may  communicate. 

Lameness,  pain,  deformity,  and  fever  sometimes  exist  for  two  or  three 
weeks  before  any  tumour  can  be  made  out.  The  constitutional  symp- 
toms are  often  severe,  and  symptoms  of  the  typhoid  condition  may  even 
be  present.  The  bowels  are  usually  constipated.  The  size  of  the  abscess 
is  sometimes  very  great.  In  one  case  I  have  seen  it  extend  from  the  spine 
to  the  median  line  in  front,  and  from  the  crest  of  the  ilium  nearly  to  the 
free  border  of  the  ribs.  The  amount  of  pus  varies  from  a  few  ounces  to 
two  or  three  pints.  Urinary  symptoms  are  sometimes  wanting ;  at  other 
times  there  is  increased  frequency  of  micturition,  accompanied  by  pain 
from  an  irritation  referred  to  the  bladder.  The  urine  may  contain  pus 
from  a  complicating  pyelitis.  In  only  one  of  Gibuey's  cases  was  this 
present.     It  developed  in  the  fourth  week,  and  the  case  recovered. 

The  duration  of  the  disease  in  the  acute  cases  varies  from  three  to 
eight  weeks ;  in  the  subacute  it  may  be  five  or  six  months.  When  sup- 
puration occurs  the  symptoms  subside  quite  rapidly  after  the  pus  has  been 
evacuated,  and  recovery  is  complete.  Where  resolution  takes  place,  there 
js  a  gradual  subsidence  of  the  symptoms,  and  often  some  stiffness  of  the 
thigh,  with  slight  lameness  for  several  months.  In  the  series  of  cases 
above  referred  to,  65  per  cent  recovered  comjDletely  in  three  months. 

Diagnosis. — In  many  cases  a  diagnosis  of  hip-joint  disease  is  made,  and 
they  are  reported  as  "  hip-joint  disease  cured  without  deformity,"  etc. 
The  points  of  differential  diagnosis  are  quite  distinct,  and  if  a  careful  ex- 
amination is  made  there  is  no  excuse  for  confounding  the  two  conditions. 
Hip-joint  disease  develops  more  insidiously,  is  very  much  more  chronic, 
and  rarely  produces  so  great  deformity  in  a  year  as  is  often  seen  in  peri- 
nephritis in  two  or  three  weeks ;  abscess  is  infrequent  during  the  first 
year  of  the  disease ;  on  examination,  there  is  found  limitation  of  all  the 
movements  of  the  joint,  and  not  of  extension  alone ;  atrophy  of  the  thigh 
and  joint  tenderness  are  present.  In  perinephritis,  on  the  other  hand,  we 
have  a  tolerably  acute  onset,  sometimes  with  chill,  fever,  marked  lameness, 
and  deformity,  developing  in  two  or  three  weeks ;  abscess  often  forms  in 
a  month,  and  complete  and  permanent  recovery  usually  follows  after  a 
few  months  at  most ;  the  deformity  is  due  solely  to  flexion  of  the  thigh ; 
all  other  movements  at  the  hip  may  be  free,  and  joint  tenderness  is  absent. 
Psoas  abscess  from  Pott's  disease  may  cause  deformity,  tumour,  and  lame- 
ness similar  to  that  seen  in  perinephritis,  but  on  examination  there  is 
found  the  angular  prominence  and  other  signs  of  disease  of  the  lumbar 
vertebra?. 

Prognosis. — Primary  perinephritis  in  children  almost  invariably  termi- 
nates in  complete  recovery.  Of  the  twenty-eight  cases  referred  to,  and 
eight  subsequently  observed  by  Gibney,  all  recovered  perfectly.     The  only 


^Y8  DISEASES   OP   THE   URO-GENITAL   SYSTEM. 

condition  liable  to  prove  fatal  is  rupture  of  the  abscess  into  the  peritoneal 
cavity. 

Treatment. — The  patient  should  be  put  to  bed  and  kept  as  quiet  as 
possible  throughout  the  attack.  In  the  early  stage,  a  blister,  hot  fomen- 
tations, or  an  icebag,  should  be  applied  over  the  affected  side;  heat  is 
generally  to  be  preferred.  When  suppuration  is  inevitable  and  pain  severe, 
a  poultice  may  be  used.  Abscesses  should  be  opened  early,  to  prevent 
burrowing,  and  danger  of  a  possible  rupture  into  the  peritoneal  cavity. 

GENERAL  CEDEMA  NOT  DEPENDENT  ON  RENAL  DISEASE. 

This  is  of  not  very  infrequent  occurrence  in  infants  and  young  chil- 
dren. In  the  Babies'  Hospital,  during  the  last  seven  years,  over  fifty  cases 
have  been  observed.  Nearly  all  were  in  infants  under  six  months  of  age, 
and  the  majority  have  been  under  three  months.  This  general  dropsy 
was  invariably  associated  with  extreme  malnutrition  and  ansemia.  It 
comes  on  gradually  in  the  course  of  four  or  five  days,  often  the  first  thing 
noticed  being  that  a  wasting  child,  has  unexpectedly  increased  half  a 
pound  or  a  pound  in  weight.  On  closer  inspection  there  will  be  found 
oedema  of  the  feet,  ankles,  thighs,  face,  hands,  and  sometimes  of  the 
abdominal  walls,  and  the  back.  This  may  be  quite  marked,  so  that  it 
may  be  almost  impossible  to  open  the  eyes,  and  the  extremities  may  be 
nearly  double  their  normal  size.  I  have  occasionally  seen  dropsy  in  the 
serous  cavities.  No  explanation  of  this  oedema  is  found  in  the  urine.  It 
is  not  albuminous ;  it  is  frequently  very  scanty,  but  is  sometimes  appar- 
ently normal  in  amount.  Opportunities  for  the  examination  of  the  kid- 
neys have  been  afforded  in  several  instances,  and  these  organs  have  been 
in  all  cases  normal,  even  upon  microscopical  examination. 

The  cause  of  this  oedema  was  ascribed  by  Taruier,  who  had  observed 
it  in  connection  with  premature  infants  fed  by  gavage,  to  the  giving  of 
too  much  fluid  food.  He  states  that  it  disappeared  when  the  amount  of 
food  was  reduced.  This  has  not  been  my  experience.  Many  children 
who  were  fed  by  gavage  showed  no  signs  of  it,  and  others  who  took  a 
comparatively  small  quantity  of  food  became  oedematous.  The  best  expla- 
nation seems  to  me  to  be  that  it  depends  upon  a  condition  of  hydrgemia, 
associated  with  feeble  resistance  in  the  walls  of  the  small  blood-vessels, 
through  which  a  transudation  of  serum  readily  takes  place.  The  degree 
of  anaemia  noted  in  these  patients  is  sometimes  extreme. 

The  prognosis  in  this  condition  is  extremely  bad,  as  it  rarely  occurs 
except  in  hopeless  cases  of  marasmus.  This  is  not,  however,  invariably 
the  case.  The  dropsy  may  disappear  to  return  again,  or  it  may  disappear 
permanently  and  the  case  go  on  to  recovery. 

If  the  urine  is  scanty,  such  diuretics  as  the  citrate  of  potash  and  the 
sweet  spirits  of  nitre  often  cause  a  diminution  and  sometimes  even  a 
disappearance  of  the  dropsy  in  a  short  time.     The  best  of  all  remedies, 


MALFORMATIONS   OF   THE   GENITAL   ORGANS.  679 

however,  is  digitalis.  To  an  infant  of  two  months,  rq,  ^  of  the  fluid 
extract  may  be  given  every  two  hours  for  two  or  three  days ;  and  for  a 
short  period  somewliat  larger  doses  may  be  employed. 


CHAPTER   III. 

DISEASES  OF  THE  GENITAL   ORGANS. 

MALFORMATIONS. 

Adherent  Prepuce. — This  condition  is  sometimes  called  false  phimosis. 
It  is  so  constantly  present  that  it  can  hardly  be  regarded  as  a  malforma- 
tion. It  is,  however,  a  condition  needing  attention  in  every  male  infant. 
The  prepuce  should  be  forcibly  retracted  so  as  to  expose  the  glans  com- 
pletely. The  smegma  should  then  be  washed  away,  the  glans  covered 
with  a  drop  of  oil,  and  the  skin  drawn  forward.  This  should  be  repeated 
daily  until  there  is  no  disposition  to  a  recurrence  of  the  adhesions. 

Phimosis. — This  is  such  a  narrowing  of  the  prepuce  that  it  can  not  be 
retracted  over  the  glans.  The  degree  of  phimosis  varies  greatly.  In  very 
rare  cases  there  is  no  preputial  opening.  In  other  cases  the  orifice  is  so 
small  that  no  part  of  the  glans  can  be  exposed,  and  there  is  obstruction  to 
the  outflow  of  urine ;  but  usually  a  small  part  of  the  glans  can  be  seen. 
Phimosis  may  be  complicated  by  an  elongated  prepuce  (hypertrojDhic  phi- 
mosis), and  the  elongation  may  exist  without  any  narrowing  of  the  orifice, 
although  this  is  usually  present  to  some  degree. 

The  presence  of  phimosis  makes  cleanliness  impossible  in  many  cases, 
and  want  of  cleanliness  leads  to  infection  and  to  balanitis.  This  is  quite 
frequent  even  in  infants.  It  may  be  complicated  by  urethritis,  and  even 
by  cystitis.  Another  consequence  of  the  straining  induced  by  phimosis 
is  hernia,  which  may  be  either  inguinal  or  umbilical.  To  cure  the 
hernia  is  often  impossible,  unless  the  phimosis  is  relieved.  Straining 
also  leads  to  prolapsus  ani,  and,  from  pressure  on  the  spermatic  vessels,  to 
hydrocele.  More  important  even  than  these  mechanical  results  of  phimo- 
sis are  the  reflex  conditions  resulting  from  the  irritation.  Such  symptoms 
may  come  from  preputial  adhesions  as  well  as  from  phimosis.  The 
hyperaesthetic  condition  and  the  resulting  pruritus  cause  frequent  pria- 
pism, and  are  among  the  most  common  causes  of  masturbation.  It  may 
produce  other  nervous  symptoms,  such  as  insomnia,  niglit  terrors,  etc. 
Phimosis  often  causes  frequent  micturition,  dysuria,  and,  in  fact,  most  of 
the  symptoms  of  stone  in  the  bladder.  It  sometimes  leads  to  vesical 
spasm  and  retention  of  urine,  but  more  frequently  to  nocturnal  inconti- 
nence. 


680  DISEASES  OP   THE   URO-GENITAL   SYSTEM. 

The  list  of  reflex  phenomena  which  have  been  attributed  to  phimosis 
is  a  long  one,  and  includes  most  of  the  functional  nervous  diseases  of 
childhood.  There  is  abundant  evidence  that  phimosis  may  be  a  cause, 
although  a  rare  one,  of  chorea,  convulsions,  epilepsy,  hysterical  mani- 
festations, pseudo-paralysis,  spasm  of  the  muscles  about  the  hip  causing 
symptoms  resembling  the  early  stage  of  hip-joint  disease,  strabismus, 
amaurosis,  diarrhoea,  and  many  other  nervous  conditions.  There  is,  how- 
ever, no  evidence  that  cases  of  spastic  diplegia  or  paraplegia  are  ever 
caused  by  phimosis  or  improved  by  circumcision.  There  has  been  in  the 
past  a  disposition  on  the  part  of  some  writers  to  attribute  nearly  all  the 
nervous  disturbances  of  boyhood  to  phimosis,  and  an  exaggerated  im- 
portance has  certainly  been  attached  to  this  condition.  Still,  in  a  delicate, 
anasmic  child  with  unstable  nervous  centres,  phimosis  is  capable  of  giving 
rise  to  nervous  symptoms  of  a  most  serious  and  alarming  character.  It 
is  an  important  etiological  factor  in  many  neuroses,  and  one  which 
should  not  be  overlooked.  On  the  other  hand,  a  very  marked  degree  of 
phimosis  often  exists  in  robust  children  without  producing  any  symp- 
toms whatever. 

Treatment. — Every  case  of  phimosis  should  receive  attention  in  in- 
fancy. Often  very  little  treatment  is  needed ;  but  trouble  is  likely  to 
come  sooner  or  later  if  it  is  neglected.  When  there  is  a  very  long  prepuce 
with  phimosis,  the  operation  of  circumcision  should  invariably  be  done, 
even  when  the  degree  of  phimosis  is  slight.  Many  cases  of  phimosis  in 
which  the  prepuce  is  not  long  can  be  relieved  by  stretching.  If  no  part 
of  the  glans  can  be  exposed,  the  simplest  plan  is  to  slit  up  the  dorsum 
of  the  prepuce  with  a  pair  of  scissors  and  forcibly  break  up  the  adhesions. 
The  corners  of  the  flaps  thus  made  can  then  be  snipped  off  and  one  stitch 
inserted  on  either  side.  This  is  very  easily  done,  and  gives  most  ex- 
cellent results.  In  the  case  of  obscure  nervous  symptoms  in  older  boys, 
the  condition  of  the  prepuce  should  be  examined  and  the  same  rules  of 
treatment  applied.  In  all  cases  of  hernia,  hydrocele,  or  prolapsus  ani, 
when  phimosis  is  present  it  should  be  relieved  as  the  first  step  in  the 
treatment. 

Hypospadias.- — ^In  this  condition  the  urethra  is  not  continued  to  the 
tip  of  the  penis,  but  opens  on  the  inferior  surface  some  distance  back, 
being  represented  in  front  of  this  only  by  a  shallow  furrow.  In  more 
severe  cases  there  is  a  deep  fissure  which  divides  the  scrotum,  and  some- 
times even  the  perinseum.  Into  this  fissure  the  urethra  opens.  This  is  a 
condition  likely  to  be  mistaken  for  that  of  hermaphrodism,  especially  as 
the  testicles  are  frequently  in  the  abdominal  cavity.  It  may  be  impossible 
to  decide  the  sex  of  the  child  until  puberty.  Surgical  operations  for  the 
relief  of  these  deformities  are  not  very  successful. 

Epispadias. — This  is  a  condition  in  which  the  urethra  opens  on  the 
dorsal  surface  of  the  penis.     It  is  much  less  frequent  than  hypospadias. 


MALFORMATIONS  OF  THE  GENITAL   ORGANS.  681 

There  may  be  simply  a  division  of  the  glans,  or  the  fissure  may  extend  the 
Avhole  Icnoth  of  the  organ  and  be  complicated  by  exstrophy  of  the  bladder. 

Exstrophy  of  the  Bladder. — -This  deformity  is  met  with  in  all  degrees  of 
severity.  In  the  complete  form  there  is  a  median  fissure  from  the  umbili- 
cus to  the  tip  of  the  penis.  It  includes  the  anterior  abdominal  wall,  the 
pelvic  bones,  and  the  urethra.  The  bones  are  entirely  separated  at  the 
symphysis,  or  connected  behind  the  bladder  by  a  fibrous  band.  The  hypo- 
gastric region  is  occupied  by  a  red,  mucous  surface,  slightly  corrugated, 
which  is  all  there  is  of  the  bladder.  This  is  generally  surrounded  by  a 
narrow  rim  of  integument.  In  the  lower  lateral  portions  of  the  red 
mucous  membrane  two  slightly  rounded  elevations  are  seen,  from  wdiich 
urine  oozes.  These  are  the  openings  of  the  ureters.  The  penis  is  short, 
and  presents  a  shallow  furrow  on  its  dorsal  surface.  With  this  deformity, 
also,  the  testes  are  often  in  the  abdominal  cavity. 

An  analogous  deformity  is  sometimes  seen  in  girls.  There  is  a  division 
of  the  clitoris  and  the  labia  minora  and  majora.  The  fissure  may  be  so 
deep  as  to  reach  nearly  to  the  anus.  The  vagina  is  usually  absent.  The 
rectum  may  open  into  the  prolapsed  bladder. 

All  these  deformities  are  compatible  with  long  life.  In  most  of  them 
the  individual  is  incapable  of  procreation.  In  exstrophy  of  the  bladder, 
whether  complete  or  partial,  patients  are  a  nuisance  to  themselves  and  to 
all  about  them.  It  is  almost  impossible  to  prevent  the  clothing  from 
being  soaked  with  urine,  which  gives  everything  connected  with  the  pa- 
tient a  strong  ammoniacal  odour.  The  skin  is  often  excoriated.  Opera- 
tion for  the  relief  of  these  cases  should,  I  think,  always  be  undertaken. 
Brilliant  results  have  been  obtained  even  in  some  of  the  most  severe  cases. 

Undescended  Testicle — Cryptorchidism. — In  foetal  life  the  testes  are 
situated  in  the  abdominal  cavity  below  the  kidneys.  They  usually  descend 
into  the  scrotum  during  the  ninth  month,  but  in  children  born  at  full 
term  the  testicle  may  be  in  the  inguinal  canal,  or  even  in  the  abdomen. 
The  former  condition  is  quite  a  frequent  one,  being  present,  according  to 
good  authorities,  in  fully  ten  per  cent  of  all  children.  In  the  great 
majority  of  these  the  descent  takes  place  without  difficulty  during  the 
first  weeks  of  life,  and  causes  no  symptoms.  In  others  the  condition  per- 
sists. The  testicle  may  be  found  in  the  abdominal  cavity  or  at  any  point 
in  the  canal.  If  the  latter,  it  may  be  felt  as  a  small,  hard  tumour,  slightly 
painful  upon  pressure.  Even  in  some  of  these  cases  a  natural  descent 
takes  place  about  puberty,  usually  without  symptoms.  The  testicle  occa- 
sionally makes  for  itself  a  false  passage,  and  is  found  in  the  perineum. 
When  in  the  inguinal  canal,  descent  of  the  testicle  into  the  scrotum 
may  sometimes  be  facilitated  by  manipulation.  In  other  situations  it 
had  best  be  left  alone,  unless  it  gives  rise  to  much  pain  or  tenderness, 
as  may  happen  when  a  false  passage  has  been  made.  It  should  then  be 
removed. 


682  DISEASES   OP   THE   URO-GENITAL  SYSTEM. 

With  the  exceptions  already  mentioned,  deformities  of  the  female  geni- 
tals belong  rather  to  gynaecology  than  to  psediatrics,  since  they  are  chiefly 
of  the  internal  organs,  and  do  not  usually  give  symptoms  before  puberty. 

DISEASES   OP  THE   MALE   GENITALS. 

Balanitis. — Balanitis,  or  inflammation  of  the  prepuce,  is  one  of  the 
results  of  phimosis.  It  may  follow  decomposition  of  the  smegma,  infec- 
tion of  the  mucous  membrane,  injury,  or  masturbation.  The  parts  are 
swollen,  oedematous,  red,  painful,  and  sometimes  bathed  in  pus.  Retrac- 
tion of  the  prepuce  is  impossible.  Under  proper  treatment  the  inflamma- 
tion usually  subsides  in  two  or  three  days,  but  there  may  be  some  dis- 
charge for  a  considerable  time.  Abscess  may  follow,  and  even  gangrene 
of  the  prepuce.  The  most  severe  cases  are  likely  to  be  complicated  with 
anterior  urethritis. 

The  object  of  treatment  is  to  remove  the  irritating  and  infectious 
material  lodged  beneath  the  foreskin.  This  may  be  quite  difficult.  It  is 
best  accomplished  by  syringing  with  a  l-to-5,000  bichloride  solution. 
This  should  be  repeated  several  times  a  day,  the  prepuce  being  held  in 
contact  with  the  syringe,  so  that  it  is  distended  by  the  injection.  Where 
it  is  impossible  to  do  this,  an  antiseptic  lotion  may  be  used  and  ice  applied 
until  the  oedema  has  subsided.  It  is  sometimes  necessary  to  slit  up  the 
prepuce  before  the  parts  can  be  thoroughly  cleansed,  and  in  severe  cases 
this  is  often  the  quickest  method  of  cure.  Circumcision  should  not  be 
done  during  an  attack. 

Urethritis. — This,  like  the  same  disease  in  females,  may  be  simple  or 
specific.  Both  forms  are  less  frequent  in  little  boys  than  in  the  other  sex. 
In  simple  urethritis  the  inflammation  usually  affects  only  the  anterior  part 
of  the  canal,  the  fossa  navicularis.  There  is  a  slight  discharge  of  pus,  and 
sometimes  pain  on  micturition.  The  most  frequent  cause  is  want  of 
cleanliness. 

Gonorrhoeal  inflammation  is  more  common.  This  occurs  even  in  boys 
as  young  as  eighteen  months,  but  most  of  the  cases  are  in  those  over 
seven  years  old.  The  usual  cause  is  direct  contagion.  The  symptoms  are 
more  severe  than  in  the  simple  form,  and  resemble  the  same  disease  in 
the  adult,  with  the  exception  that  constitutional  symptoms  are  usually  ab- 
sent. A  microscopical  examination  of  the  discharge  (page  686)  is  the  only 
positive  means  of  diagnosis  between  the  two  varieties.  In  these  cases  it 
reveals  the  gonococcus  in  great  numbers.  Conjunctivitis  and  arthritis 
are  seen  as  complications,  just  as  in  the  female.  Orchitis  is  very  rare, 
but  balanitis  and  bubo  are  not  infrequent.  Poynter  has  reported  a  case 
in  a  boy  of  three  years,  who,  when  five  years  old,  required  treatment  for  a 
urethral  stricture.     He  was  infected  by  a  nurse. 

The  first  thing  in  the  treatment  is  always  to  keep  the  parts  covered, 
otherwise  the  infection  is  almost  certain  to  be  carried  by  the  hands  to 


HYDROCELE.  533 

other  raucous  membranes,  usually  the  conjunctiva.     In  other  respects  the 
treatment  is  the  same  as  in  the  adult. 

Hydrocele. — Hydrocele  consists  in  an  accumulation  of  seruui  in  some 
part  of  the  serous  pouch  brought  down  by  the  testicle  in  its  descent.  In 
infants  it  is  usually  due  to  the  imperfect  closure  of  this  pouch  at  some 
point,  where  a  fluid  accumulation  occurs.  Four  varieties  of  hydrocele  are 
met  with  in  young  children  : 

1.  Congenital  hydrocele. — In  this  the  condition  is  a  congenital  one, 
although  the  tumour  is  not  necessarily  present  at  birth.  The  tunica  vagi- 
nalis communicates  with  the  general  peritoneal  cavity.  There  is  present 
an  elongated  tumour,  extending  from  the  bottom  of  the  scrotum  through- 
out the  whole  length  of  the  cord.  The  tumour  is  reducible,  sometimes 
spontaneously  by  position,  sometimes,  when  the  opening  is  smaller,  only 
by  pressure.  It  reduces  slowly,  without  gurgling,  never  going  back  eii 
masse  like  a  hernia.  The  tumour  is  translucent,  and  is  flat  on  percus- 
sion. The  testicle  is  above  and  posterior,  and  usually  indistinctly  felt. 
Congenital  hydrocele  may  be  complicated  by  hernia. 

2.  Hydrocele  of  the  tunica  vaginalis  with  the  canal  closed. — In  this 
form  the  accumulation  of  fluid  is  in  the  scrotum,  communication  with  the 
peritoneal  cavity  having  been  entirely  cut  off  by  the  complete  obliteration 
of  this  pouch  in  the  canal  in  the  normal  way.  This  is  one  of  the  most 
frequent  forms.  It  gives  rise  to  an  oval  or  pear-shaped  tumour,  quite 
tense  and  firm,  usually  about  two  inches  in  length.    The  cord  is  distinctly 

-felt  above  it,  the  testicle  is  behind  and  somewhat  above  it,  and  not  always 
felt  very  distinctly.  This  variety  gives  translucency  and  the  usual  elastic 
feeling  of  a  hydrocele. 

3.  Hydrocele  of  the  cord. — This  is  one  of  the  rare  forms.  The  serous 
pouch  which  accompanies  the  spermatic  cord  is  open  above,  and  com- 
municates with  the  peritoneal  cavity;  but  below  it  is  closed.  The  scrotum 
is  normal,  and  the  testicle  is  in  its  usual  position.  The  tumour  is  small, 
elongated,  and  reducible,  and  entirely  above  the  scrotum.  Usually  it  stops 
at  some  point  in  the  inguinal  canal.  This  hydrocele  also  may  be  compli- 
cated by  hernia.  The  diagnostic  points  are  the  same  as  in  the  form  first 
mentioned. 

4.  Encysted  hydrocele  of  the  cord. — The  peritoneal  pouch  of  the  cord 
in  this  variety  is  closed  for  some  distance  above,  and  again  below,  but 
somewhere  in  its  course  it  is  open,  and  here  the  fluid  accumulates  in 
the  form  of  a  cyst.  When  small  it  resembles  an  undescended  testicle ; 
but  on  examination  this  organ  is  found  below  and  in  its  normal  posi- 
tion. When  in  the  canal,  it  is  often  mistaken  for  a  lymph  gland,  some- 
times for  a  small  hernia.  The  tumour  is  usually  about  the  size  of  an 
almond.  It  is  clastic  and  irreducible,  and  gives  translucency  like  the 
other  varieties.  In  cases  of  doubt  it  may  be  punctured  by  a  hypodermic 
needle. 


684  DISEASES   OF   THE    URO-GENITAL  SYSTEM. 

Treatment  of  Hydrocele. — In  the  congenital  form  the  first  point  is  to 
cause  obliteration  of  the  canal,  so  as  to  shut  off  the  hydrocele  sac  from  the 
general  peritoneal  cavity.  This  is  usually  done  by  the  use  of  a  truss,  and, 
if  applied  early,  it  may  be  accomplished  in  the  course  of  a  few  months. 
It  is  subsequently  managed  like  an  ordinary  hydrocele  of  the  tunica 
vaginalis.  In  infants  and  young  children  it  is  rare  that  active  operative 
measures  are  called  for  in  any  variety  of  hydrocele,  as  these  tend,  in  a 
great  majority  of  cases  at  least,  to  disappear  spontaneously  in  the  course 
of  a  few  months.  Absorption  is  often  facilitated  by  the  application  of 
collodion.  In  many  cases  the  internal  administration  of  iodide  of  po- 
tassium, twelve  grains  a  day,  causes  a  rapid  disappearance  of  the  effusion. 
Iodine  may  be  applied  locally  over  a  hydrocele  of  the  cord,  but  should 
not  be  applied  to  the  scrotum.  In  some  cases  which  do  not  disappear 
promptly,  simple  puncture  with  the  needle,  allowing  the  fluid  to  drain  off 
into  the  cellular  tissue  of  the  scrotum  from  which  it  is  absorbed,  is  an 
excellent  means  of  treatment.  Others  are  cured  by  a  single  aspiration 
with  hypodermic  syringe.  I  have  treated  in  the  neighbourhood  of  one 
hundred  of  these  hydroceles  in  infants  and  young  children,  and  have 
never  yet  seen  one  in  which  it  was  necessary  to  resort  to  the  injection  of 
irritants  like  iodine  or  carbolic  acid. 


DISEASES  OF  THE  FE31ALE   GENITALS. 

VULVO-VAGINITIS. 

This  is  a  catarrhal  inflammation,  usually  affecting  the  mucous  mem- 
brane of  the  vulva,  vagina,  urethra,  and  often  that  of  the  cervix  uteri. 
It  may  be  simple  or  specific  (gonorrhoeal).     Neither  form  is  very  rare. 

Simple  Vulvo-vaginal  Catarrh. — This  may  be  seen  at  any  age,  even  in 
infancy.  It  is,  however,  most  frequent  after  the  second  year.  It  more 
often  occurs  in  girls  who  are  ansemic,  or  suffering  from  malnutrition, 
than  in  those  whose  general  health  is  good,  being  especially  common  in 
those  who  live  in  unhygienic  surroundings  or  where  personal  cleanliness 
is  neglected.  It  may  follow  any  of  the  infectious  diseases,  particularly 
measles.  There  seems  to  be  little  doubt  that  even  this  form  may  be 
spread  by  contagion.  It  is  common  in  children  in  institutions,  where 
small  epidemics  are  sometimes  seen.  It  may  be  communicated  by  direct 
contact,  or  by  handling  the  parts,  or  through  clothing,  diapers,  sponges, 
towels,  etc.  The  disease  may  be  traumatic,  as  from  attempted  rape,*  or 
the  introduction  of  foreign  bodies.     It  may  be  secondary  to  the  presence 

*  See  "  Twenty-one  Cases  of  Rape  in  Young  Girls,"  by  Walker,  Archives  of  Paedia- 
trics, vol.  iii,  1886,  where  the  medico-legal  points  with  reference  to  this  condition  are 
fully  discussed. 


VULVO-VAGINITIS.  685 

of  pinworms,  or  to  scabies,  and  it  is  sometimes  the  cause,  sometimes  the 
result,  of  masturbation. 

Symptoms. — The  disease  generally  begins  as  a  subacute  catarrhal  in- 
flammation, the  discharge  being  the  first  thing  noticed.  In  the  milder 
cases  this  is  thin  and  yellowish-white,  with  some  pain  on  locomotion, 
itching,  and  burning  on  micturition.  In  the  more  severe  form  it  is 
abundant  and  of  a  yellowish-green  colour,  causing  the  labia  to  adhere, 
and  the  secretion,  drying,  forms  crusts.  The  odour  is  sometimes  ex- 
tremely fetid,  and  the  skin  of  the  thighs  may  be  excoriated.  The  local 
examination  shows  the  mucous  membrane  to  be  red,  swollen,  cedematous, 
and  bathed  in  pus.  All  the  visible  parts — urethra,  hymen,  vagina,  etc. — 
are  involved.  By  using  an  ordinary  urethral  speculum  in  the  vagina, 
pus  may  be  seen  in  most  of  the  severe  cases  to  come  from  the  cervix 
uteri.  There  are  no  constitutional  symptoms.  There  may  be  swelling, 
and  even  suppuration,  of  the  inguinal  glands.  The  disease  has  no  defi- 
nite course,  but  usually  with  proper  treatment  lasts  from  one  to  three 
weeks,  when  there  may  be  complete  recovery,  or  there  may  persist  for 
a  long  time  a  leucorrhoeal  discharge.  In  children  who  are  in  poor  gen- 
eral condition,  and  where  proper  means  of  treatment  are  neglected, 
vulvo-vaginitis  may  last  for  months. 

Gonorrhoeal  Vulvo-vaginitis  (TJro-genital  Blennorrhoea). — Eecent 
studies  of  the  micro-organisms  in  the  discharge  have  shown  cases  of 
true  gonorrhoea  in  young  girls  to  be  very  much  more  numerous  than 
was  formerly  suspected.  While  indirect  infection  is  no  doubt  possible, 
and  in  certain  cases  proved,  nearly  all  writers  agree  that  this  is  very  ex- 
ceptional, and  that  the  most  common  origin  of  the  disease  is  direct  con- 
tact, either  intentional  or  accidental,  with  another  case  of  gonorrhoea, 
sometimes  sexual  and  sometimes  by  the  hands.  In  this  way  the  disease 
may  be  conveyed  from  one  child  to  another,  or  from  adults  to  children, 
very  often  from  parents  who  occupy  the  same  bed  with  the  child.  Pott 
states  that,  in  90  per  cent  of  his  forty-four  cases,  the  mothers  were  found 
to  be  suffering  from  leucorrhoea.  The  mode  of  contagion  may  be  diffi- 
cult to  trace,  but  this  fact  should  cast  no  doubt  upon  the  diagnosis  in 
tlie  case.  The  disease  occurs  in  girls  of  all  ages,  but  chiefly  between 
three  and  eight  years.  Epstein  has  reported  cases  in  the  newly  born. 
The  incubation  in  three  cases  in  which  it  could  Ije  definitely  traced,  was 
exactly  three  days  (Cahen-Brach). 

Sjimptnms. — The  disease  is  believed  to  begin  usually  in  the  urethra, 
although  this  is  in  most  cases  difficult  to  establish,  as  there  are  gener- 
ally found  on  the  first  examination  evidences  of  inflammation  of  all 
the  mucous  membranes  of  this  region.  There  is  a  copious  secretion 
of  thick,  yellow  pus.  There  may  be  erosions  of  the  vaginal  mucous 
niemljrane,  so  llial  llic  parts  bleed  readily.  Crusts  form  on  the  labia. 
When  a  view  of  the  cervix  can  be  obtained  by  means  of  a  small  specu- 
45 


686  DISEASES  OF  THE  UEO-GENITAL  SYSTEM. 

lum,  this  is  almost  invariably  seen  to  be  involved.  For  the  first  day 
or  two,  in  the  more  severe  cases,  there  may  be  slight  fever  and  general 
indisposition,  but  more  frequently — and  this  is  one  of  the  most  striking 
2Doints  of  difference  from  the  disease  as  seen  in  adults — constitutional 
symptoms  are  wanting  altogether.  Micturition  is  painful,  and  some- 
times frequent;  there  are  also  excoriations  of  the  skin,  and  difficulty 
in  walking,  all  these  symptoms  being  usually  more  severe  than  in  sim- 
ple catarrh.  The  duration  of  these  cases  is  indefinite,  being  from 
one  to  six  months.  Under  the  most  favourable  conditions  it  is  several 
weeks,  largely  owing  to  the  great  difficulties  in  the  way  of  a  thorough 
application  of  local  treatment.  It  is  always  more  obstinate  than  is  a 
simple  catarrh. 

A  positive  diagnosis  between  the  simple  and  gonorrhoeal  catarrh 
can  be  made  with  certainty  only  by  a  microscopical  examination  of 
the  discharge.  The  pus  for  examination  should  be  taken  from  as  high 
a  point  in  the  tract  as  possible,  preferably  the  orifice  of  the  urethra, 
in  order  to  avoid  contamination.  In  a  simple  catarrh  the  discharge 
is  made  up  of  epithelial  and  pus  cells,  with  quite  a  variety  of  bacterial 
forms — bacilli,  cocci,  and  diplococci.  These  bacteria  are  found  in  the 
epithelial  cells  and  in  the  pus  cells,  but  they  are  generally  associated, 
and  the  diplococci  are  few  in  number.  In  cases  of  gonorrhoeal  inflam- 
mation there  are  found  in  the  pus  cells  large  masses  of  diplococci,  these 
being  usually  the  only  bacteria  present.  It  should  then  be  emphasized 
that  the  mere  presence  of  a  few  diplococci,  even  though  found  in  the 
pus  cells,  is  not  enough  to  establish  the  diagnosis  of  gonorrhoea,  since 
there  are  varieties  of  diplococci  found  in  the  simple  catarrh,  and  even 
in  the  normal  vaginal  secretion,  whicli  morphologically  closely  resem- 
ble the  gonococcus  of  ISTeisser.  It  is  the  presence  of  these  in  large 
masses  in  the  pus  cells  which  is  the  characteristic  feature.  Accord- 
ing to  the  very  careful  observations  of  Heiman  and  others  the  two 
varieties  of  diplococci  may  be  positively  differentiated  by  staining  by 
Gram's  method.  The  gonococcus  is  decolourized,  while  the  other  form 
is  not. 

Nearly  all  the  complications  of  gonorrhoea  which  are  seen  in  the 
adult  have  been  observed  in  young  children,  but  the  majority  of  them  are 
rare.  The  most  frequent  one  is  conjunctivitis,  infection  being  carried 
by  the  hands  from  the  vaginal  discharge  to  the  eyes.  Gonorrhoeal  arthri- 
tis is  not  common,  but  may  affect  the  knee,  ankle,  wrist,  or  elbow.  The 
symptoms  of  arthritis  resemble  those  of  ordinary  rheumatism.  Cystitis 
is  extremely  rare.  Bubo  is  occasionally  seen,  and  may  be  simple  or  sup- 
purative. As  already  stated,  the  disease  in  many,  probably  in  nearly 
all  the  severe  cases,  affects  the  lining  of  the  uterus.  Infection  may 
extend  from  the  uterus  to  the  tubes  and  cause  pyosalpinx,  or  even  peri- 
tonitis.   Sanger  reports  a  case  of  pyosalpinx  from  gonorrha?al  infection 


HERPES  OF  THE  VULVA.  687 

in  a  little  girl  of  three  years,  and  Huber  a  fatal  case  of  peritonitis  of 
similar  origin  in  one  of  seven.  I  have  myself  seen  one  of  severe  pelvic 
peritonitis  in  a  girl  of  seven.  In  all  these  cases  the  diagnosis  of  the 
gouorrhoeal  origin  of  the  disease  must  rest  upon  the  presence  of  gono- 
cocci  in  the  vaginal  discharge. 

Treatment  of  Vulvo-Vaginitis. — The  first  thing  is  proper  isolation, 
and  care  to  prevent  the  spread  of  infection  by  means  of  clothing,  linen, 
etc.  In  institutions,  and  in  families  where  there  are  many  children,  the 
greatest  care  is  necessary  even  in  catarrhal  cases. 

Simple  vaginal  catarrh  requires  cleanliness,  which  is  best  secured  by 
irrigating  twice  daily  with  a  warm  saturated  solution  of  boric  acid,  or 
1  to  10,000  bichloride.  A  pad  of  sterilized  absorbent  cotton,  the  meshes 
of  which  are  filled  with  boric  acid  and  starch,  or  iodoform,  may  be  placed 
between  the  labia  in  the  most  severe  cases,  the  patients  being  kept  in 
bed.  The  skin  should  be  protected  by  ointments.  In  obstinate  cases, 
irrigation  with  astringent  solutions,  such  as  sulphate  of  zinc  or  tannic 
acid,  should  be  used  and  protargol  in  a  1-per-cent  solution  applied. 
More  radical  means  are  rarely  required.  Attention  to  the  general  con- 
dition of  the  patient  must  not  be  overlooked,  and  the  health  should 
be  built  up  by  iron,  cod-liver  oil,  and  other  tonics.  Every  young  child 
should  wear  a  napkin,  to  prevent  carrying  the  disease  to  the  eyes  by 
the  hands. 

In  the  gonorrlioeal  cases  nothing  is  so  efficient  as  the  irrigation  with 
the  solutions  above  referred  to,  and  especially  the  use  of  protargol.  They 
should,  however,  be  employed  more  frequently ;  in  the  early  stage,  where 
the  secretion  is  abundant,  as  often  as  three  or  four  times  a  day.  In  cases 
passing  to  the  chronic  stage,  a  2-per-cent  solution  of  protargol  should 
be  applied  to  the  vagina  every  second  or  third  day.  In  all  circumstances 
these  cases  are  tedious,  and  require  the  closest  attention  to  detail  to 
insure  the  best  results.  Relapses  are  not  uncommon  in  cases  which  had 
apparently  recovered. 

HERPES  OF  THE   VULVA, 

This  may  occur  on  the  cutaneous  surface  only,  or  there  may  be  a 
herpetic  condition  of  the  mucous  membrane.  The  skin  of  the  perina^um 
may  be  involved,  and  the  disease  may  extend  quite  to  the  anus.  On  the 
skin,  the  eruption  runs  the  ordinary  course  of  herpes  elsewhere.  Vesicles 
form  and  rupture  or  dry,  forming  crusts  or  leaving  small  ulcers,  which 
heal  in  a  week  or  ten  days  if  the  parts  are  simply  protected.  On  the 
mucous  membrane  i\\e  vesicles  are  succeeded  by  small  ulcers,  which  may 
coalesce  and  form  larger  ones,  tlie  appearance  resembling  the  same  con- 
dition in  the  mouth.  The  symptoms  are  itching,  burning  pain,  and  a 
slight  discharge.  The  herpetic  ulcer  may  be  confounded  with  a  mucous 
patch.    These  cases  usuiilly  recover  j)r«)inp11y  if  dusted  witli  some  absorb- 


688  DISEASES   OF   THE   URO-GENITAL  SYSTEM. 

ent  powder  like  boric  acid  and  oxide  of  zinc,  or  talcum.  In  addition, 
cleanliness  should  be  secured.  It  is  important  that  this  condition  should 
be  attended  to,  as  it  is  sometimes  followed  by  more  serious  disease. 

GANGRENOUS  VULVITIS  (NOMA). 

This  is  the  same  process  as  that  seen  in  the  mouth  and  known  as 
cancrum  oris.  It  usually  follows  one  of  the  infectious  diseases,  most  fre- 
quently measles,  occurring  in  patients  whose  general  vitality  has  been 
greatly  reduced.  The  condition  may  succeed  a  simple  catarrh  or  a  her- 
petic vaginitis.  There  is  first  noticed  a  tense,  brawny  induration,  the 
skin  being  shiny  and  swollen  over  a  circumscribed  area.  In  the  centre  of 
this  there  soon  appears,  usually  upon  one  of  the  labia  majora,  a  dark,  cir- 
cumscribed spot.  Day  by  day  the  gangrenous  area  advances,  preceded  by 
the  induration.  It  may  involve  the  whole  labium,  extending  even  to  the 
mons  veneris  and  the  perinaeum.  These  cases  are  generally  fatal.  If  re- 
covery takes  place,  it  is  with  considerable  deformity  of  the  parts  in  conse- 
quence of  the  extensive  sloughing  and  cicatrization.  As  sequelas,  there 
may  be  fistulas,  stenosis,  or  atresia  of  the  vagina.  The  prognosis  is  very 
bad.  The  only  radical  treatment  is  early  excision  of  the  gangrenous  part, 
and  the  application  of  the  actual  cautery  or  nitric  acid. 


CHAPTER   IV. 

ENURESIS. 

Synonyms:  Incontinence  of  urine;  bed-wetting. 

Enuresis  may  be  due  to  some  malformation  of  the  genital  tract,  such 
as  an  abnormal  opening  of  the  bladder  into  the  vagina,  to  extroversion  of 
the  bladder,  or  to  the  persistence  of  the  urachus ;  in  the  latter  case  the 
urine  is  discharged  from  the  umbilicus.  It  also  occurs  in  organic  dis- 
eases of  the  central  nervous  system,  such  as  idiocy,  cerebral  palsy,  acute 
meningitis,  tumours  of  the  brain,  certain  forms  of  myelitis,  and  in  in- 
juries of  the  cord.  In  many  of  these  conditions  there  is  associated  in- 
continence of  iseces.  Both  of  the  groups  of  cases  mentioned  are  quite 
distinct  from  the  ordinary  form  of  incontinence  of  urine  which  is  seen  in 
childhood.  The  latter  is  to  be  regarded  as  a  neurosis,  and  is  the  only 
variety  which  will  be  considered  here. 

In  early  infancy,  evacuation  of  the  bladder  is  purely  a  reflex  act.  An 
impulse  is  sent  from  the  nerves  of  the  bladder  to  the  spinal  centre,  and  a 
reflex  impulse  from  this  centre  produces  simultaneously  a  contraction  of 
the  detrusor  urina?  and  a  suspension  of  the  contraction  of  the  vesical 


ENURESIS.  689 

sphincter.  It  is  often  possible  to  teach  infants  to  control  the  evacuation 
of  the  bladder  before  the  end  of  the  first  year ;  usually,  however,  control 
is  not  acquired  even  during  waking  hours  until  some  time  during  the  sec- 
ond year,  and  in  some  healthy  infants  not  before  the  end  of  the  second 
year.  The  time  depends  very  much  upon  the  training.  If  a  child  during 
its  third  year  can  not  control  the  evacuation  of  the  bladder  during  its 
waking  hours,  incontinence  may  be  said  to  exist. 

Etiology. — Incontinence  of  urine  may  be  due  to  a  continuance  of  the 
infantile  condition,  to  anything  which  increases  the  irritability  of  the 
spinal  centre,  or  which  interferes  with  the  cerebral  control  over  this 
centre,  or  to  anything  which  increases  the  irritability  of  the  terminal  fila- 
ments of  the  vesical  nerves  or  of  those  in  the  neighbourhood,  in  conse- 
quence of  which  too  many  or  too  strong  impulses  are  sent  to  the  spinal 
centre.  The  causes  of  incontinence  thus  may  be  in  the  central  nervous 
system,  in  the  urine,  in  the  bladder,  or  in  any  of  the  adjacent  organs. 

The  causes  relating  to  the  central  nervous  system  are  in  the  main 
those  of  the  other  neuroses  of  childhood  ;  these  are  anemia,  malnutrition, 
an  inherited  nervous  constitution,  or  a  condition  of  extreme  nervousness 
or  neurasthenia,  the  result  of  the  child's  surroundings.  In  such  cases 
incontinence  is  often  associated  with  chorea,  epilepsy,  hysteria,  headaches, 
neuralgia,  and  other  nervous  symptoms.  In  these  conditions  there  may 
be  not  only  an  increased  irritability  of  the  nerve  centres,  but  also  of  the 
peripheral  nerves,  accompanied  by  loss  of  tone  of  the  vesical  si^hincter. 
A  similar  condition  may  exist  with  almost  any  form  of  acute  illness, 
usually,  however,  being  only  temporary. 

The  causes  referable  to  the  urine  are  chiefly  a  highly-acid  urine,  gen- 
erally associated  with  lithuria.  In  such  cases  the  incontinence  is  very 
often  due  more  to  the  constitutional  than  the  local  condition. 

In  the  bladder  itself,  cystitis  and  vesical  calculus,  although  infrequent, 
should  not  be  overlooked  as  possible  causes.  In  a  few  cases,  where  incon- 
tinence has  existed  a  long  time,  the  bladder  becomes  so  contracted  that  it 
will  hold  only  an  ounce  or  two  of  urine.  This  condition,  although  not 
the  primary  cause  of  enuresis,  may  be  enough  to  continue  it. 

Local  irritation  in  the  neighbouring  organs  may  be  due  to  adherent 
prepuce,  balanitis,  phimosis,  or  to  a  narrow  meatus.  All  of  these  condi- 
tions arc  frequently  associated  with  incontinence.  Rectal  irritation  may 
be  caused  by  pinworms,  anal  fissure,  or  rectal  polypus ;  aiid  vaginal  irrita- 
tion by  vulvo-vaginitis  or  adlicrent  clitoris,  both,  however,  being  extremely 
rare.  Often  we  have  incontinence  as  the  result  of  a  combination  of  sev- 
eral causes,  no  one  of  which  alone  would  have  been  sufficient  to  produce 
it.  Thus,  in  a  healthy  child  pliimosis  may  give  rise  to  no  symptoms,  while 
in  one  who  is  antemic  or  neurasthenic  it  may  produce  enough  local  irri- 
tation to  cause  incontinence.  In  many  cases  heredity  seems  to  be  a 
factor  of  some  importance,  parents  often  having  suffered  in  their  child- 


690  DISEASES  OF   THE  URO-GEXITAL  SYSTEM. 

hood  from  the  same  disease;  quite  frequently  two  and  sometimes  even 
three  children  in  the  same  family  are  affected.  In  many  cases  the  con- 
dition seems  to  be  mainly  the  result  of  habit,  and  in  all  cases  habit  is 
a  potent  factor  in  continuing  the  incontinence,  sometimes  after  the 
original  exciting  cause  has  been  removed.  Frequently  no  adequate  cause 
can  be  found.  Both  sexes  are  about  equally  liable  to  enuresis,  and  it 
may  be  seen  in  all  ages  up  to  puberty. 

Symptoms. — Enuresis  may  be  nocturnal  or  diurnal,  or  both.  Of  194 
cases,  T3  were  nocturnal,  9  diurnal,  and  102  were  both  nocturnal  and 
diurnal.  Cases  differ  greatly  in  severity.  Incontinence  may  be  habitual, 
occurring  every  night,  often  several  times  during  the  night,  and  frequently 
during  the  day ;  or  it  may  be  only  occasional  under  the  influence  of  some 
special  exciting  cause,  where  it  continues  a  few  days  or  weeks  until  the 
cause  is  removed.  In  a  considerable  number  of  cases,  the  condition  lasts 
from  infancy  until  the  sixth  or  seventh  year.  It  may  even  continue  until 
puberty ;  but  it  generally  ceases  at  that  period,  unless  its  cause  is  mechan- 
ical, or  depends  upon  some  organic  disease  of  the  brain  or  cord.  In  ordi- 
nary enuresis  there  is  never  dribbling  of  the  urine,  but  usually  a  contrac- 
tion of  the  walls  of  the  bladder  follows  almost  immediately  upon  the  desire, 
before  the  patient  can  make  his  wants  known  or  reach  a  convenient  place 
for  micturition.  At  night  the  same  thing  may  occur  without  wakening 
the  child,  the  contraction  being  of  purely  reflex  origin. 

Prognosis. — The  condition  is  usually  hopeless  when  it  depends  upon 
organic  disease  of  the  brain  and  cord ;  also  in  cases  due  to  malformation, 
unless  these  are  amenable  to  surgical  treatment.  In  the  ordinarv  cases 
seen,  the  prognosis  depends  ujDon  the  age  of  the  child,  the  duration  of  the 
symptom,  and  the  nature  of  the  exciting  cause.  As  a  rule,  it  is  better  in 
children  only  four  or-  five  years  old  than  in  those  of  eight  or  nine,  for  the 
obvious  reason  that  a  case  which  has  lasted  to  the  latter  age  is  usually  an 
intractable  one.  If  a  cause  can  be  discovered  and  if  this  is  one  that  can 
be  removed,  the  prognosis  is  much  better  than  if  no  cause  can  be  found. 
In  the  great  majority  of  the  cases  a  cure  is  possible,  provided  the  patient 
can  be  held  long  enough  to  a  regular  plan  of  treatment.  The  treatment 
must  in  most  cases  be  continued  from  three  months  to  a  year,  and  always 
for  several  months  after  the  incontinence  has  ceased,  on  account  of  the 
strong  tendency  to  relapses. 

Treatment. — The  first  indication  is  to  remove  the  cause,  where  one  can 
be  found.  If  there  are  preputial  adhesions,  they  should  be  broken  up 
and  irritating  smegma  removed.  If  phimosis  is  present,  it  should  be  re- 
lieved by  stretching  or  circumcision.  A  narrow  meatus  should  be  cut  to 
proper  dimensions.  If  stone  in  the  bladder  is  suspected,  as  it  should  be 
when  the  incontinence  is  worse  by  day  and  accompanied  by  straining  and 
painful  spasm  of  the  bladder,  the  patient  should  be  sounded  for  stone. 
Pinworms  in  the  rectum   should  receive  the  appropriate  treatment  by 


ENURESIS.  691 

injections.  A  concentrated  urine  of  higii  acidity,  with  deposits  of  uric 
acid,  calls  for  alkalies  and  the  free  use  of  fluids,  especially  water.  While 
the  local  conditions  mentioned  should  always  he  attended  to,  the  fact  re- 
mains that  few  cases  are  cured  simply  by  relieving  them,  except  those 
due  to  vesical  calculi.  The  explanation  of  this  is  that  habit  is  so  im- 
portant a  factor  in  keeping  up  incontinence  where  it  has  existed  a  long 
time.  In  most  cases,  therefore,  we  must  depend  upon  general  measures 
and  drugs  directed  toward  the  relief  of  the  symptom,  either  in  conjunc- 
tion with  local  treatment  or  alone. 

Care  should  be  taken  to  secure  for  the  child  a  simple,  natural  life, 
preferably  in  the  country.  There  should  be  no  overtaxing  of  the  nervous 
system  at  home  or  in  school.  Every  cause  of  unnatural  excitement  should 
be  avoided.  Early  hours  and  plenty  of  sleep  must  be  insisted  upon. 
Certain  articles  of  diet  are  to  be  avoided,  and  coffee,  tea,  and  beer 
should  be  absolutely  prohibited.  Sweets  and  all  highly  seasoned  food 
should  be  very  sparingly  allowed,  or  not  at  all.  Although  it  is  believed 
by  many  that  a  diet  into  which  meat  enters  largely  is  injurious,  from  per- 
sonal experience  I  have  not  found  the  exclusion  of  meat  to  be  of  any  ad- 
vantage ;  nor  is  anything  to  be  gained  by  limiting  the  amount  of  water 
which  the  child  takes,  except  possibly  in  cases  of  nocturnal  incontinence, 
where  it  is  well  to  restrict  the  quantity  taken  late  in  the  afternoon.  When 
incontinence  is  associated  with  highly  acid  urine,  it  is  often  aggravated 
by  cutting  down  the  fluids.  The  diet  which  succeeds  best  is  a  simple  one 
composed  of  milk,  vegetables,  fruits,  meats,  and  cereals.  Punishments, 
whether  corporal  or  otherwise,  do  no  good,  and  are  in  most  cases  abso- 
lutely harmful.  They  should  never  be  allowed.  Eewards  are  much  more 
effectual.  The  moral  treatment  of  a  case  is  important ;  it  is  well  to 
work  upon  a  child's  pride,  and  use  every  means  to  strengthen  his  will. 
Where  the  incontinence  is  solely  or  chiefly  at  night,  the  child  should  be 
taught  to  hold  his  water  as  long  as  possible  during  the  day,  in  order  to 
accustom  the  bladder  to  full  distention. 

Measures  which  are  directed  toward  the  patient's  general  condition 
are  quite  as  important  as  those  employed  for  the  control  of  the  inconti- 
nence. Anemia,  chlorosis,  malnutrition,  indigestion,  and  constipation 
should  each  receive  careful  attention.  Any  local  condition,  such  as  ade- 
noid growths  of  the  pharynx,  which  might  serve  to  increase  the  general 
nervous  irritability,  should  be  removed. 

Of  the  drugs  used  for  the  purpose  of  affecting  the  incontinence,  bella- 
donna stands  at  the  head  of  the  list ;  but  it  must  be  given  in  full  doses, 
usually  sufficient  to  produce  the  physiological  effects,  and  continued  for  a 
long  time,  in  most  cases  for  many  months.  Either  the  fluid  extract  or 
the  alkaloid,  atropine,  should  be  employed.  My  preference  is  for  the 
latter,  because  of  its  more  uniform  strength.  A  convenient  method  of 
administration  is  to  use  a  solution  of  atropine,  one  grain  to  two  ounces  of 


692  DISEASES   OF   THE    URO-GENITAL   SYSTEM. 

water,  of  which  one  drop  (y^oT  ^^  ^  grain)  may  be  given  for  each  year  of 
the  child's  age.  For  nocturnal  incontinence  this  dose  should  at  first  be 
given  at  4  and  10  p.  m.  :  after  a  few  days,  at  4,  7,  and  10  p.  ii.  Usually 
this  may  be  gradually  increased  until  double  the  quantity  is  given.  A 
child  of  five  years  would  then  be  taking  ten  drops  (y^-g-  of  a  grain)  at  each 
of  the  hours  mentioned.  I  have  rarely  found  it  advisable  to  go  above 
these  doses.  As  the  larger  doses  are  reached  the  increase  should  be  more 
gradual.  When  the  condition  is  under  control,  or  when  the  full  physio- 
logical effects  of  the  drug  are  produced,  the  same  dose  should  be  con- 
tinued for  some  time  and  then  reduced,  the  atropine  being  given  for  at 
least  two  months  in  gradually  diminishing  doses  after  the  incontinence 
has  ceased.  This  is  very  important  if  the  cure  is  to  be  permanent,  as 
there  is  so  strong  a  tendency  in  these  cases  to  relapse.* 

Strychnine  may  be  added  in  cases  not  yielding  to  the  atropine  alone. 
It  is  particularly  advantageous  when  there  is  diurnal  as  well  as  nocturnal 
incontinence,  for  under  these  conditions  there  is  usually  a  lack  of  tone  in 
the  sphincter,  as  well  as  increased  irritability  in  the  mucous  membrane  of 
the  bladder.  The  initial  dose  for  a  child  of  five  years  should  be  y-^  of  a 
grain  twice  daily  ;  this  may  be  gradually  increased  to  -^-^  of  a  grain  three 
times  a  day ;  but  there  is  rarely  any  advantage  in  pushing  it  further. 
Ergot  is  sometimes  useful,  but  rarely  gives  relief  when  both  strychnine 
and  atropine  have  failed.  Ehus  aromatica,  although  inferior  to  the 
drugs  already  mentioned,  possesses  a  certain  amount  of  value,  and  may 
be  tried  in  case  the  others  fail.  From  ten  to  thirty  drops  of  the  fluid  ex- 
tract should  be  given  three  times  a  day.  Like  strychnine,  it  is  indicated 
in  atonic  cases.  I  have  seen  some  obstinate  eases  relieved  by  faradism; 
the  positive  pole  is  attached  to  a  small  electrode  passed  into  the  rectum 
and  the  negative  pole  applied  over  the  bladder.  The  sitting  should  last 
for  ten  minutes  and  be  repeated  three  times  a  week.  If  there  is  reason 
to  suspect  a  contracted  bladder,  as  when  the  incontinence  has  lasted  for 


*  As  an  illustration  of  the  success  which  may  be  obtained  by  this  plan  of  treatment 
when  faithfully  carried  out,  our  experience  in  the  New  York  Infant  Asylum  may  be 
cited.  Twelve  obstinate  cases,  in  none  of  which  could  any  local  cause  be  found,  were 
selected  and  treated  by  Dr.  Kerley,  then  resident  physician,  in  the  manner  indicated. 
After  five  months'  treatment,  seven  of  the  cases  were  so  much  improved  that  inconti- 
nence rarely  occurred.  The  atropine  was,  however,  continued  in  smaller  doses  for  four 
months  longer,  at  the  end  of  which  time  the  cases  were  well.  In  the  remaining  five 
cases  but  little  improvement  was  seen  after  five  months'  treatment,  and  not  until  the 
end  of  ten  months  could  it  be  said  that  much  improvement  had  occurred.  In  these 
cases  the  drug  was  continued  for  two  months  longer  and  all  treatment  discontinued,  as 
the  cases  were  cured.  None  of  these  had  relapsed  six  months  afterward.  It  was  here 
of  great  advantage  that  the  children  were  under  close  observation  in  an  institution 
where  the  treatment  could  be  continued.  In  dispensary  and  private  practice  the  want 
of  early  success  would  no  doubt  have  deterred  mothers  from  continuing  the  medicine. 


VESICAL  SPASM,  693 

years  and  the  bladder  will  never  hold  more  than  an  onnce  or  two  of 
urine,  cure  is  sometimes  accomplished  by  daily  distending  the  organ 
up  to  its  normal  capacity  with  warm  water. 

Careful,  intelligent,  systematic  training  is  a  most  valuable  adjunct 
to  all  measures'  employed  for  the  relief  of  this  very  annoying  condition. 


VESICAL  SPASM. 

This  is  quite  a  common  condition,  and  often  passes  under  the  name 
of  genital  irritation.  It  is  characterized  by  frequent,  sometimes  by  diffi- 
cult and  painful,  micturition.  It  occurs  in  children  of  all  ages,  even  in 
infants,  but  is  especially  frequent  between  the  ages  of  two  and  five  years. 
This  symptom  has  already  been  referred  to  in  connection  with  uric-acid 
infarctions  in  very  young  infants. 

The  usual  cause  is  the  irritation  of  the  bladder  by  a  concentrated, 
highly  acid  urine.  It  often  results  from  cold;  it  may  accompany  acute 
febrile  processes,  and  is  sometimes  merely  a  symptom  of  nervous  irrita- 
bility. The  cause  may  thus  be  in  the  bladder  or  in  the  urine.  It  may  be 
accompanied  by  enuresis,  but  usually  occurs  without  it.  It  is  sometimes 
symptomatic  of  disease  in  adjacent  parts,  as  in  the  rectum  or  the  pelvic 
peritoneum,  or  it  may  be  associated  with  inflammation  of  the  vulva  or 
urethra.    It  is  also  one  of  the  symptoms  of  vesical  calculus. 

The  symptoms  of  vesical  spasm  are  local  only.  The  child  passes 
water  very  frequently,  often  several  times  an  hour.  The  accompanying 
pain  may  be  intense,  not  infrequently  sufficient  to  cause  the  child  to 
cry  out.  Often  there  is  pain  and  severe  vesical  tenesmus  with  the  pas- 
sage of  only  a  few  drops  of  urine  at  a  time,  but  blood  is  not  present.  If 
the  condition  depends  upon  the  character  of  the  urine,  or  is  only  an 
expression  of  an  extreme  vesical  irritability,  the  symptoms  are  generally 
of  short  duration,  possibly  a  day  or  two.  If  it  depends  upon  vesical 
calciilus,  it  may  be  intermittent.  If  it  is  associated  with  disease  of  the 
adjacent  pelvic  viscera,  it  is  inconstant,  and  may  continue  for  a  con- 
siderable period,  depending  upon  the  nature  of  the  cause. 

The  treatment,,  in  the  ordinary  cases,  consists  in  the  administration 
of  an  abundance  of  water,  with  alkaline  diuretics,  and  either  belladonna 
or  hyoscyamus.  The  following  formula  is  one  that  I  have  usually  found 
efficient : 

5     Tincture  hyoscyami 3  ss. 

Potassii  citratis 3  j 

Aqua}  (Icstillat 3  ij 

M.    Sig. :  ITalf  a  teaspoonful  in  water  every  liour  to  a  child  of  two  years. 

If  the  cause  is  outside  the  bladder,  it  should  receive  appropriate 
treatment. 


694  DISEASES  OF  THE  URO-GENITAL  SYSTEM. 


VESICAL  CALCULI. 

The  nucleus  of  a  vesical  calculus  is  usually  a  renal  calculus  which 
has  passed  the  ureter,  but  has  been  prevented  by  its  size  from  going 
farther.  Stone  in  the  bladder  is  extremely  rare  in  infancy,  probably 
owing  to  the  fluid  diet,  but  it  is  not  infrequent  in  children  from  two 
to  ten  years  of  age.  The  most  common  variety  of  calculus  at  this  time 
is  the  uric  acid.  The  other  forms,  although  occasionally  seen,  are  all 
quite  rare. 

The  symptoms  in  children  are  somewhat  different  from  those  in 
adults,  and  the  condition  is  often  overlooked.  There  is  frequently  pain 
upon  micturition,  especially  at  the  close  of  the  act,  which  may  be  felt 
at  the  end  of  the  penis  or  in  the  perinseum.  There  may  be  a  sudden 
stoppage  in  the  flow  of  urine.  The  straining  often  leads  to  rectal  tenes- 
mus and  even  to  prolapse.  This  complication  is  so  frequent  that,  in  a 
case  of  persistent  prolapse,  stone  should  always  be  suspected.  Incon- 
tinence of  urine  is  a  prominent,  and  often  the  principal  symptom;  in 
many  cases  it  is  noticed  only  during  the  day.  The  urinary  changes  are 
not  generally  marked;  hsematuria  is  rare,  and  mucus  and  pus  are  in- 
frequent and  in  small  quantity.  The  genital  irritation  may  lead  to  the 
habit  of  masturbation.  A  stone  of  any  considerable  size  may  often  be 
felt  by  a  bimanual  examination,  one  finger  being  placed  in  the  rectum 
and  the  other  hand  above  the  pubes.  This  is  easier  in  males  than  in 
females,  but  it  is  not  very  trustworthy,  and  not  conclusive  when  it  gives 
a  negative  result.  A  positive  diagnosis  is  made  only  by  exploring  the 
bladder  with  a  sound. 

The  treatment  of  calculus  is  purely  surgical.  In  young  children  the 
suprapubic  is  now  generally  preferred  by  surgeons  to  the  perineal  opera- 
tion, if  the  calculus  is  too  small  to  be  easily  removed  by  crushing. 


SECTION   VII. 

DISEASES  OF  THE  NERVOUS  SYSTEM. 

CHAPTER   I. 

INTRODUCTORY. 


The  Weight  of  the  Brain. — From  ninety-eight  observations  made  in 
the  post-mortem  room  of  the  New  York  Infant  Asylum,  the  following 
were  the  average  weights  noted  : 

At  three  months 21    oz.  (602  grammes). 

At  six  months 25^   "   (712         "       ). 

At  twelve  months 32*   "   (916         "       ). 

At  two  years 35     "   (990         "       ). 

The  following  are  the  figures  given  by  Boyd  and  Sehiifer :  * 


Age. 

Males. 

Females. 

At  birth  (full  term)    

Ounces. 

IH 

17* 

21 

27 

33 

39 

40 

46 

48* 

Grammes. 

330 

493 

602 

776 

941 
1,095 
1,138 
1,301 
1,374 

Ounces. 
10 
16 
20 
26 
30 
35 
40 
40i 
44 

Grammes. 
283 

Under  three  months 

451 

From  three  to  six  months 

560 

From  six  to  twelve  months 

From  one  to  two  vears 

727 
843 

From  two  to  four  vears 

990 

From  four  to  seven  years 

1,135 

From  seven  to  fourteen  vears 

1,154 

From  fourteen  to  twenty  vears 

1,244 

At  birth  the  weight  of  the  brain  to  that  of  the  body  is  nearly  1  :  8. 
During  infancy  and  childhood  the  following  is  the  ratio,  according  to 
Bischoff :  during  the  first  year,  1:6;  the  second  year,  1:14;  the  third 
year,  1:18;  at  the  fourteenth  year,  1 :  15  to  1 :  25  ;  in  adults,  1 :  43. 

The  Spinal  Cord. — The  weight  of  the  cord  to  the  weight  of  the  body 
at  birth  is  1  :  500  ;  in  adult  life  it  is  1 :  1500.  According  to  Kolliker,  the 
spinal  cord  and  the  vertebral  column  are  the  same  length  until  the  end  of 
the  third  month  of  foetal  life,  there  being  at  this  time  no  cauda  equina. 
At  the  ninth  month  the  lower  end  of  the  cord  is  opposite  the  third  lum- 
bar vertebra;  in  the  adult  it  is  opposite  the  first. 

*  Quoted  by  Sachs. 
695 


696  DISEASES  OP  THE  NERVOUS  SYSTEM. 

Some  Peculiarities  in  the  Diseases  of  the  Nervous  System  in  Infancy 
and  Childhood.* — The  relatively  large  size,  the  rapid  growth,  and  the  im- 
maturity of  the  brain  and  cord  during  early  life,  explain  much  that  is 
peculiar  in  the  nervous  diseases  of  this  period. 

At  this  time,  apparently  trivial  causes  are  enough  to  produce  quite  pro- 
found nervous  impressions,  because  of  the  instability  of  the  nervous  centres 
and  the  greater  irritability  of  the  motor,  sensory,  and  vaso-motor  nerves. 
These  are  conditions  which  are  very  much  increased  by  all  disturbances  of 
nutrition.  These  disturbances  may  be  manifold  in  character,  but  they  lie 
at  the  root  of  very  many  of  the  neuroses  of  early  life, — e.  g.,  extreme  nervous- 
ness, disorders  of  sleep,  stuttering,  chorea,  incontinence  of  urine,  tetany, 
and  convulsions.  The  great  liability  to  convulsions  depends  not  only 
upon  the  greater  irritability  of  the  peripheral  nerves,  but  on  the  instability 
of  the  nervous  centres  and  the  lack  of  inhibition  over  the  motor  ganglion 
cells  of  the  spinal  cord.  The  nervous  centres  are  more  easily  exhausted 
than  later  in  life.  Prolonged  or  continuous  overstrain  from  any  cause 
whatsoever,  frequently  leads  to  headache  and  chorea,  and  sometimes  even 
to  epilepsy  and  insanity. 

Another  peculiarity  is  the  serious  consequences  which  often  follow 
reflex  irritation,  although  this  is  rarely  the  only  factor  in  the  case. 
Conditions  which  in  adult  life  produce  almost  no  effect  may  in  infancy 
be  the  cause  of  most  alarming  symptoms.  As  a  few  examples  may  be 
cited,  reflex  symptoms  due  to  phimosis  or  intestinal  worms,  convulsions 
from  disturbances  of  digestion,  nervous  symptoms  due  to  eye-strain,  or  to 
adenoid  growths  of  the  pharynx.  In  the  production  of  some  of  these, 
especially  attacks  of  convulsions,  there  are  several  factors,  such  as  the 
great  irritability  of  the  peripheral  nerves,  the  instability  of  the  nervous 
centres — often  a  result  of  disturbed  nutrition,  as  in  rickets — and  the  lack 
of  inhibitory  action  of  the  cortex  of  the  brain. 

As  a  third  point  of  importance  may  be  mentioned  the  grave  permanent 
results  which  often  follow  relatively  small  organic  lesions.  A  good  illus- 
tration is  seen  in  the  lesions  which  produce  cerebral  birth-palsy.  Here 
the  damage  is  only  in  small  part  the  immediate  effect  of  the  haemorrhage, 
for  this  often  is  not  great,  but  it  is  the  interference  with  the  development 
of  certain  parts  of  the  cortex  that  makes  this  condition  so  serious. 

From  what  has  been  said,  it  follows  that  the  hygiene  of  the  nervous 
system  is  of  the  utmost  importance  in  infancy  and  childhood.  It  is 
essential  for  the  healthy  development  of  the  nervous  system  that  all 
stimulants  should  be  avoided, — not  only  tea,  coffee,  and  alcohol,  but 
undue  and  unnatural  excitement,  the  effect  of  which  in  infancy  is  almost 
as  serious.     A  normal  development  can  take  place  only  in  the  midst  of 

*  See  Rachford  ;  Some  Physiological  Factors  in  the  Neuroses  of  Childhood.  Cin- 
cinnati, 1895. 


CONVULSIONS.  697 

quiet  and  peaceful  surroundings,  with  plenty  of  time  for  rest  and  sleep. 
The  conditions  of  modern  life,  especially  in  cities,  are  such  that  these 
laws  are  almost  invariably  violated,  and  the  consequences  of  this  are  seen 
in  the  marked  and  steady  increase  in  nervous  diseases  among  children. 


CHAPTER   11. 

GENERAL  AND  FUNCTIONAL  NERVOUS  DISEASES. 
CONVULSIONS. 

UisTDER  this  head  are  included  attacks  of  acute  transient  nervous  dis- 
turbance, characterized  by  involuntary  rhythmical  spasm  of  the  muscles, 
either  of  the  face,  trunk,  or  extremities,  or  all  of  them,  usually  accom- 
panied by  loss  of  consciousness.  They  may  be  regarded  as  "  motor  dis- 
charges "  from  the  cortex  of  the  brain. 

Etiology. — The  principal  predisposing  causes  are  infancy,  conditions 
alfecting  the  nutrition  of  the  brain,  and  hereditary  influences.  Of  all  these 
factors,  the  most  important  one  is  the  instability  of  the  nerve  centres  which 
is  characteristic  of  infancy  and  is  associated  with  the  non-development  of 
the  voluntary  centres  of  the  cortex.  The  brain  grows  more  during  the 
first  year  than  in  all  later  life,  and  this  rapidity  of  growth  is  in  itself  an 
important  predisposing  cause  of  functional  derangement.  After  infancy, 
attacks  of  convulsions  are  much  less  frequent,  and  after  seven  years  they 
are  relatively  rare.  While  convulsions  occasionally  occur  in  children  pre- 
viously healthy,  the  majority  of  attacks  are  in  those  in  whom  there  is  at 
least  some  disturbance  of  the  nutrition  of  the  brain, — the  cerebral  insta- 
bility of  infancy  being  greatly  exaggerated  by  such  nutritive  disorders.  The 
most  frequent  one  is  rickets,  which  may  be  regarded  as  altogether  the  most 
important  predisposing  cause  of  infantile  convulsions.  They  are  often 
one  of  the  eai-liest  symptoms  of  that  disease,  and  where  convulsions  occur 
in  infancy  without  evident  cause,  rickets  should  always  be  looked  for. 
Any  disturbance  of  nutrition  may  predispose  to  convulsions,  such  as  ex- 
haustion, anaemia,  malnutrition,  syphilis,  and  debility  resulting  from  any 
acute  disease,  especially  those  of  the  digestive  tract.  Children  who  in- 
herit from  their  parents  a  peculiarly  nervous  temperament  are  more  liable 
to  convulsions  than  are  others.  This  predisposition  is  often  seen  in  sev- 
eral members  of  the  same  family.  Females  are  rather  more  frequently 
affected  than  males. 

The  exciting  causes  include  a  wide  variety  of  pathological  conditions, 
among  which  disturbances  of  digestion  take  tlie  first  place.  Where  the 
susceptibility  is  very  great,  the  exciting  cause  may  be  a  trivial  one.    These 


698  DISEASES  OP   THE   NERVOUS  SYSTEM. 

causes  may  be  grouped  under  three  general  heads :  (1)  direct  irritation  of 
the  cortex  of  the  brain ;  (2)  reflex  irritation ;  (3)  toxic  influences. 

Under  the  head  of  direct  irritation  may  be  included  all  convulsions 
occurring  with  the  various  forms  of  cerebral  disease ;  the  most  frequent  are 
meningitis,  meningeal  or  cerebral  haemorrhage,  tumour,  abscess,  hydro- 
cephalus, embolism,  and  thrombosis.  As  examples  of  reflex  irritation 
may  be  classed  the  convulsions  following  severe  injuries,  like  compound 
fractures  or  burns,  renal  or  intestinal  colic,  retention  of  urine,  phimosis,  a 
foreign  body  in  the  ear,  or  intestinal  strangulation.  A  case  has  been  re- 
lated to  me  in  which  the  application  of  cold  to  the  skin  repeatedly  induced 
convulsions.  Other  conditions  classed  under  this  head  are  dentition  and 
worms,  but  both  must  be  regarded  as  exceedingly  rare  causes  of  convul- 
sions. The  exciting  cause  is  very  frequently  the  presence  in  the  stomach 
or  intestines  of  undigested  food ;  such  attacks  are  sometimes  ascribed 
to  reflex  irritation,  but  the  majority  are  better  regarded  as  toxic.  Acute 
and  chronic  indigestion  are  to  be  ranked  among  the  most  frequent 
causes  of  convulsions,  both  in  infants  and  older  children.  In  either 
there  may  be  but  one  attack,  or  attacks  may  recur  at  intervals  of  a 
few  months  with  a  repetition  of  the  cause.  Of  toxic  origin  may  be 
considered  not  only  the  convulsions  resulting  from  conditions  like 
uraemia  and  asphyxia,  but  also  those  which  occur  at  the  onset  or  in  the 
course  of  various  infectious  diseases,  sometimes  classed  as  febrile  con- 
vulsions. They  are  very  frequent  at  the  onset  of  certain  diseases,  particu- 
larly pneumonia,  scarlet  fever,  malaria,  acute  indigestion,  and  gastro-enteric 
intoxication;  less  frequently  measles,  typhoid  fever,  ileo-colitis,  and 
diphtheria.  In  these  cases  the  convulsions  seem  due  partly  to  the  in- 
tensity of  the  poison  and  partly  to  the  suddenness  with  which  it  affects 
the  nervous  system.  Convulsions  occurring  late  in  the  course  of  many 
diseases  may  be  due  to  toxic  influences,  especially  when  associated  with 
exhaustion  of  the  nerve  centres,  from  the  prolonged  disturbances  of 
nutrition  accompanying  the  febrile  condition. 

In  pertussis,  which  of  all  infectious  diseases  is  the  one  in  which  con- 
vulsions are  most  frequent,  several  factors  may  be  present :  asphyxia 
due  to  a  severe  paroxysm,  cerebral  congestion  or  haemorrhage  resulting 
from  such  a  paroxysm,  or  simply  from  the  peculiar  susceptibility  of  the 
patient  brought  about  by  the  disease  itself. 

Convulsions  may  be  associated  with  enlargement  of  the  thymus 
gland.  I  have  notes  of  three  fatal  cases  of  convulsions  where  there  was 
found  at  autopsy  great  enlargement  of  the  thymus,  which  weighed  from 
one  to  one  and  a  half  ounces.  Two  of  these  infants  were  previously 
healthy;  one  was  rachitic.  The  similarity  of  all  these  cases  indicated 
that  the  convulsions  were  in  some  way  due  to  the  enlarged  thymus,  prob- 
ably from  pressure  either  upon  the  lungs,  the  large  vessels,  or  the  pneu- 
mogastric  nerves  (page  43). 


CONVULSIONS.  699 

There  are  some  cases  of  convulsions  for  which  no  cause  can  be  dis- 
covered even  at  autopsy,  and  for  the  present  we  must  be  content  to  class 
them  as  idiopathic.  One  attack  of  convulsions  renders  the  patient  more 
liable  to  a  second,  and  where  there  have  been  several,  they  occur  from 
causes  which  are  less  and  less  marked. 

Pathology. — The  "nervous  discharge "  which  occurs  in  an  attack  of 
convulsions  differs  in  no  essential  particulars  from  that  of  ordinary  epi- 
lepsy. In  the  latter  disease  there  is  seen  a  tendency  to  recurrence  with 
greater  or  less  frequency,  until  the  discharge  may  take  place  from  very 
slight  causes. 

The  part  of  the  bi*ain  most  intimately  concerned  in  the  production  of 
convulsions  is  the  cortex.  Such  attacks  may  be  regarded  as  involuntary 
discharges  of  nerve  force  from  the  cortical  motor  centres,  which  result 
from  direct  irritation  of  these  parts  by  disease ;  or  from  an  irritation  aris- 
ing in  some  other  part  of  the  brain,  as  from  the  vaso-motor  centres  of 
the  medulla ;  or  from  a  reflex  irritation  in  a  distant  part  of  the  body. 
Convulsions  may  depend  upon  the  fact  that  while  nerve  cells  may  be  able 
to  generate  nerve  force  they  can  not  control  its  discharge,  as  in  the  con- 
vulsions of  rickets.  An  important  element  in  the  convulsions  of  infancy, 
according  to  Hughlings  Jackson,  is  the  lack  of  development  of  the  higher 
cerebral  functions,  in  consequence  of  which  they  do  not  exert  the  control- 
ling influence  over  the  discharge  of  nerve  force  which  they  do  in  later  life. 

The  condition  of  the  brain  in  the  beginning  of  an  attack  of  convul- 
sions is  one  of  anaemia;  this  is  shortly  followed  by  venous  hyperemia 
which  may  be  very  intense.  In  infants  who  die  during  convulsions  the 
brain  and  its  meninges  are  usually  found  intensely  congested.  They  may 
be  the  seat  of  punctate  haemorrhages,  and  sometimes  of  more  extensive 
ones.  The  lungs  are  also  deeply  congested,  and  the  right  heart  is  generally 
distended  with  dark  clots.     The  other  lesions  found  are  accidental. 

Symptoms. — In  some  cases  prodromal  symptoms  are  present,  such  as 
extreme  restlessness,  irritability,  slight  twitchings  of  the  muscles  of  the 
face,  hands,  feet,  or  eyelids.  More  frequently,  however,  the  attack  comes 
quite  suddenly  with  but  momentary  warning.  Usually  the  first  thing 
noticed  is  that  the  face  is  pale,  the  eyes  fixed,  sometimes  rolled  up  in 
their  orbits ;  in  a  moment  or  two  convulsive  twitchings  begin  in  the 
muscles  of  the  eye  or  face,  or  in  one  of  the  extremities,  which  usually 
rapidly  extend  until  all  parts  of  the  body  particiijate.  In  most  cases  the 
convulsions  become  general,  but  they  may,  however,  remain  unilateral 
even  when  not  due  to  a  local  cause, — a  point  which  is  often  forgotten. 
The  contraction  of  the  facial  muscles  causes  a  succession  of  grimaces ;  the 
neck  is  thrown  back ;  the  hands  are  clenched ;  the  thumbs  buried  in  the 
palms;  and  a  quick  spasmodic  contraction  of  the  extremities  occurs. 
There  may  be  some  frothing  at  the  mouth,  and  in  all  true  convulsions 
there  is  loss  of  consciousness.     Respiration  is  feeble,  shallow,  and  may  be 


YOO  DISEASES   OF   THE  NERVOUS  SYSTEM. 

spasmodic.  The  pulse  is  weak ;  it  may  be  slow  or  rapid  ;  often  it  is  irreg- 
ular. The  forehead  is  covered  with  cold  perspiration.  The  face  is  first 
pale,  then  becomes  slightly  blue,  especially  about  the  lips.  Unnatural 
rattling  sounds  may  be  produced  in  the  larynx.  The  bladder  and  rec- 
tum may  be  evacuated.  The  convulsive  movements  consist  in  an  alter- 
nation of  flexion  and  extension  occurring  rhythmically.  All  varieties 
of  tonic  and  clonic  spasm  may  be  seen,  and  in  all  degrees  of  severity. 
The  contractions  of  the  two  sides  of  the  body  are  usually  synchronous. 
After  a  variable  time,  from  a  few  moments  to  half  an  hour,  the  convulsive 
movements  are  gradually  less  frequent,  and  finally  cease  altogether,  usually 
leaving  the  patient  in  a  condition  of  stupor.  They  may  recur  after  a 
short  time  or  there  may  be  but  one  attack.  A  period  of  general  relaxa- 
tion usually  follows  the  convulsive  seizures,  frequently  accompanied  by 
marked  evidences  of  prostration.  Transient  paralysis,  apparently  due  to 
exhaustion  of  the  nerve  centres,  is  not  an  uncommon  sequel. 

Death  may  take  place  from  a  single  attack ;  this,  however,  is  rare  ex- 
cept in  very  young  infants,  especially  those  who  are  rachitic.  There  may 
be  no  sequel  to  the  convulsions  if  the  cause  is  a  temporary  one,  or  they 
may  produce  some  serious  brain  lesion,  particularly  meningeal  haemor- 
rhage. Death  from  convulsions  is  generally  due  to  asphyxia,  or  to  exhaus- 
tion from  the  rapidly  recurring  attacks.  Many  cases  recover  in  which 
the  children  for  several  minutes  had  the  appearance  of  being  moribund. 

One  attack  of  convulsions  is  very  apt  to  be  followed  by  others;  for 
the  occurrence  of  the  first  one  usually  reveals  a  peculiar  susceptibility 
of  the  nervous  system,  and  each  succeeding  attack  comes  from  a  less 
powerful  exciting  cause  than  the  previous  one.  The  longer  the  interval 
which  has  passed,  the  less  likely  is  there  to  be  a  repetition,  especially  if 
the  child  has  passed  its  third  year.  The  number  of  attacks  may  be  very 
great.  In  a  case  under  the  care  of  Dr.  A.  M.  Thomas  and  mj^self  in 
1896,  an  infant  during  the  latter  part  of  its  second  year  had  during  six 
months  over  thirty-five  hundred  distinct  attacks  of  convulsions.  Eor  a 
considerable  period  they  reached  the  almost  incredible  number  of  eighty 
a  day,  and  yet  the  mental  condition  of  the  child  in  the  interval  was  ap- 
parently normal.* 

Diagnosis. — There  can  rarely  be  any  difficulty  in  recognising  an  at- 
tack of  convulsions.  The  difficulty  consists  in  determining  with  which 
of  the  many  possible  exciting  causes  we  have  to  do  in  the  case  before  us. 
Is  it  epilepsy  ?  Does  it  depend  upon  cerebral  disease  ?  Does  it  mark  the 
onset  of  some  other  acute  disease  ?    Is  it  reflex,  and  if  so  to  what  is  it 


*  The  microscopical  examination  of  the  brain  showed  only  degenerative  changes 
in  the  nerve  cells  of  the  cortex  in  the  motor  area  and  an  increase  in  the  neuroglia. 
These  changes  existed  over  quite  an  extensive  area,  and  were  more  marked  upon 
one  side. 


CONVULSIONS.  YOl 

due  ?  To  answer  these  questions  a  careful  history  must  be  obtained,  and  all 
the  circumstances  surrounding  the  patient,  the  cliaracter  of  the  convulsions, 
and  all  the  other  symptoms  present  must  be  taken  into  consideration. 

In  infancy,  epilepsy  is  certainly  the  least  probable  diagnosis.  In  older 
children  the  most  important  points  indicating  that  disease  are  :  the  pres- 
ence of  some  of  the  stigmata  of  degeneration  (page  803),  a  history  of 
previous  attacks,  a  distinct  aura  preceding  the  seizure,  or  a  sudden  onset 
with  a  cry  or  fall,  biting  of  the  tongue,  a  tonic  spasm  preceding  the  clonic, 
and,  finally,  j^erfect  recovery  in  the  course  of  a  few  hours  after  the  attack. 
Convulsions  which  come  on  with  high  fever,  even  though  a  patient  may 
have  repeated  attacks,  are  seldom  epileptic.  However,  in  some  cases  only 
prolonged  observation  can  enable  one  to  decide  positively  whether  or  not 
epilepsy  is  present. 

Convulsions  occurring  in  brain  disease,  except  acute  meningitis,  are 
not  as  a  rule  accompanied  by  any  marked  rise  in  temperature.  Focal 
symptoms  are  often  present,  such  as  localized  paralysis  or  rigidity, 
changes  in  the  pupils,  and  strabismus.  The  convulsive  movements  are  fre- 
quently limited  to  one  side  of  the  body.  It  should,  however,  be  borne  in 
mind  that  unilateral  convulsions,  even  when  repeated,  do  not  always  mean 
a  local  lesion,  as  I  have  seen  proved  by  autopsy  more  than  once.  In 
hsemorrhage  or  meningitis,  convulsions  are  likely  soon  to  recur.  In  tu- 
mour they  may  recur  after  a  longer  interval. 

Convulsions  may  be  thought  to  indicate  the  onset  of  some  acute  dis- 
ease when  they  occur  in  a  child  over  two  years  old,  and  when  they  come 
on  suddenly  or  with  only  slight  premonition  in  a  child  previously  well ; 
but  the  most  important  point  is  that  they  are  accompanied  by  a  high  tem- 
perature,— 104°  to  106°  F.  Acute  meningitis  is  the  only  other  condition 
likely  to  produce  these  symptoms.  Whether  the  convulsions  mark  the 
onset  of  lobar  pneumonia,  scarlet  fever,  malaria,  or  some  other  disease, 
can  be  determined  only  by  carefully  watching  the  patient's  symptoms  for 
twenty-four  or  thirty-six  hours. 

In  convulsions  depending  upon  some  disorder  of  the  alimentary  tract, 
one  may  get  a  history  of  chronic  constipation  or  improper  feeding,  and 
in  nursing  infants  sometimes  of  passion  or  intoxication  in  the  wet- 
nurse.  Convulsions  are  so  frequently  due  to  digestive  derangements 
that  the  condition  of  these  organs  should  be  one  of  the  first  things  to  be 
looked  into. 

Examination  of  the  urine  should  never  bo  omitted  in  any  case  of  con- 
vulsions of  doubtful  origin,  even  where  no  dropsy  is  present.  This,  both 
in  infants  and  older  children,  is  too  often  overlooked.  Asphyxia  may  be 
suspected  in  the  case  of  convulsions  occurring  in  the  newly  born,  late  in 
pneumonia,  in  some  cases  of  pertussis,  in  spasmodic  or  membranous  lar- 
yngitis, or  in  laryngismus  stridulus.  Dentition  and  worms  should  be  con- 
sidered among  the  least  probable,  never  as  the  most  probable,  causes  of 
46 


702  DISEASES  OF   THE  NERVOUS  SYSTEM. 

reflex  irritation,  and  should  not  be  so  accepted  without  positive  evidence. 
Worms  are  so  rare  in  infancy  that  at  this  period  they  may  be  practically 
ignored.  Dentition  seldom,  if  ever,  causes  convulsions  except  in  patients 
who  are  markedly  rachitic.  In  all  cases  of  convulsions  of  doubtful  or 
obscure  origin  occurring  in  infants,  rickets  should  be  suspected  as  the 
underlying  cause,  and  the  child  carefully  examined  for  other  evidences  of 
that  disease. 

Prognosis. — This  depends  upon  the  age  of  the  patient  and  the  cause 
of  the  convulsions.  Idiopathic  or  reflex  convulsions  are  rarely  dangerous 
to  life  except  in  very  young  or  in  rachitic  infants.  In  such  patients  death 
from  convulsions  is  not  at  all  uncommon.  Convulsions  occurring  at  the 
onset  of  acute  febrile  diseases  are  seldom  fatal,  and  not  often  serious ; 
they  may  not  even  indicate  an  unusually  severe  type  of  the  disease.  Espe- 
cially fatal  are  the  convulsions  of  pertussis  and  of  asphyxia  when  they 
occur  late  in  any  form  of  laryngeal  or  pulmonary  disease.  In  nephritis, 
while  always  serious,  convulsions  are  by  no  means  invariably  fatal.  The 
conditions  during  an  attack  which  should  lead  one  to  make  a  bad  prognosis 
are  when  the  convulsions  are  prolonged  or  recur  frequently ;  also  the  pres- 
ence of  very  great  prostration,  a  feeble  pulse  with  cyanosis,  or  deep  stupor. 

In  the  prognosis  one  must  take  into  account  not  only  the  immediate 
result  of  the  attack,  but  its  possible  outcome.  Except  where  convulsions 
mark  the  beginning  of  epilepsy,  they  are  much  less  serious  than  they  are 
generally  supposed  to  be  by  the  laity.  In  a  highly  nervous  or  susceptible 
child  a  convulsion  may  often  mean  no  more  than  does  an  attack  of  severe 
migraine  in  an  older  person.  Such  are  undoubtedly  most  of  the  attacks 
seen  in  practice.  Permanent  injury  to  the  brain,  simply  as  a  result  of 
an  attack,  although  possible,  is  still  rare.  But  when  convulsions  are  re- 
peated the  development  of  epilepsy  is  to  be  feared.  There  is  little  doubt 
that  some  cases  of  epilepsy  have  their  origin  in  attacks  of  convulsions, 
which  in  the  beginning  were  the  result  simply  of  digestive  derangements ; 
by  a  constant  repetition  of  the  exciting  cause  the  convulsive  habit  finally 
becomes  established.  This  possibility  is  therefore  to  be  borne  in  mind  in 
all  cases  where  children  have  had  several  convulsions,  although  it  is  un- 
usual that  this  result  is  seen.  The  farther  apart  the  attacks  are  and  the 
more  definite  tlie  exciting  cause,  the  less  likely  is  this  to  be  the  case. 

Treatment. — Summoned  to  a  child  in  convulsions,  a  physician  should 
go  at  once  and  remain  until  the  attack  has  subsided.  He  should  take 
with  him  chloroform,  a  hypodermic  syringe  with  morphine,  a  soft  cath- 
eter or  rectal  tube,  and  a  solution  of  chloral.  In  order  to  treat  convul- 
sions intelligently  one  must  have  in  mind  the  prominent  pathological 
conditions.  These  are  acute  cerebral  hyperemia,  a  more  or  less  severe 
asphyxia  with  pulmonary  congestion,  an  overtaxed  right  heart,  and  in 
fact  a  tendency  to  congestion  of  all  the  internal  organs.  The  nervous 
centres  are  in  a  condition  of  such  unnatural  excitabilitv  that  the  slight- 


CONVULSIONS.  703 

est  irritation  iiuiy  bring  on  convulsive  movements  when  the}^  have  tempo- 
rarily subsided.  The  patient  should  therefore  be  kept  perfectl}-  quiet, 
and  every  unnecessary  disturbance  avoided.  Cold  should  be  applied  to 
the  head — best  by  means  of  an  ice  cap  or  cold  cloths — and  dry  heat  and 
counter-irritation  to  the  surface  of  the  body  and  extremities.  The  time- 
honoured  mustard  bath  causes  so  much  disturbance  of  the  patient  that  it 
can  usually  be  dispensed  with  and  the  mustard  pack  (page  52)  substituted. 
The  feet  may  be  placed  in  mustard  water  while  the  child  lies  in  its  crib. 
The  mustard  pack  and  footbath  should  be  continued  until  the  skin  is  well 
reddened.  The  degree  to  which  counter-irritation  of  the  skin  should  be 
carried  will  depend  upon  the  condition  of  the  pulse  and  the  cyanosis. 

Tn  controlling  convulsions  the  three  remedies  which  may  be  depended 
upon  are  the  inhalation  of  chloroform,  morphine  hypodermically,  and 
chloral.  Chloroform  is  undoubtedly  the  most  reliable  remedy  for  an 
immediate  effect,  and  should  be  used  even  in  the  youngest  infant.  At 
the  same  time  that  it  is  being  administered,  chloral  should  be  given 
per  rectum.  The  initial  dose  should  be,  at  six  months,  four  grains ;  at 
one  3'ear,  six  grains;  at  two  years,  eight  grains,  dissolved  in  one  ounce 
of  warm  milk.  It  should  be  injected  high  into  the  bowel  through  a 
catheter,  and  prevented  from  escaping  by  pressing  the  buttocks  together. 
It  may  be  repeated  in  an  hour  if  necessary.  The  effect  of  the  drug  is 
generally  obtained  in  twenty  minutes.  If,  in  spite  of  the  chloral,  the 
convulsions  show  a  marked  tendency  to  continue  as  soon  as  the  chloro- 
form is  withdrawn,  or  if  the  enema  of  chloral  has  been  expelled,  morphine 
should  be  given  hypodermically.  Where  the  heart's  action  is  weak,  this 
is  probably  the  best  of  all  remedies.  Objections  are  urged  against  it  only 
by  those  who  have  had  no  experience  with  its  use.  To  a  well-grown  child 
two  years  old,  -^  of  a  grain  may  be  given ;  one  year  old,  -^  of  a  grain ; 
six  months  old,  ^^g-  of  a  grain.  This  dose  may  be  repeated  in  half  an 
hour  if  no  effect  is  seen.  The  tolerance  of  opium  in  cases  of  convulsions 
is  very  marked,  and  sometimes  double  the  doses  mentioned  may  be  re- 
quired. The  only  other  agent  of  much  value  is  oxygen.  I  have  seen  con- 
vulsions which  continued  in  spite  of  all  other  means,  yield  immediately 
to  oxygen.  This  is  most  likely  to  be  valuable  in  cases  of  convulsions  due 
to  asphyxia. 

When  once  under  control,  the  recurrence  of  the  convulsions  may  be 
prevented  by  keeping  the  patient  for  two  or  three  days  under  the  influ- 
ence of  chloral  with  bromide  of  sodium,  the  amount  of  cldoral  being 
gradually  reduced.  If  it  is  badly  borne  by  the  stomach  and  not  easily  re- 
tained by  the  rectum,  either  antipyrine  or  phenacetine  may  be  used  with 
the  bromide.  Where  there  is  a  strong  tendency  to  recurrence  of  the  con- 
vulsions, larethan  is  sometimes  even  more  efficient  than  chloral.  It  may 
be  given  in  the  same  or  in  slightly  larger  doses. 

As  soon  as  the  convulsions  have  ceased,  the  cause  should  be  sought 


7-04:  DISEASES   OF   THE   NERVOUS   SYSTEM. 

and  treated.  In  infancy  it  is  wise  in  every  case  to  irrigate  the  colon  thor- 
oughly with  warm  water,  to  remove  any  possible  source  of  irritation.  If 
there  is  reason  to  suspect  the  presence  of  indigestible  food  in  the  stom- 
ach, this  maybe  washed  out.  Much  more  frequently  it  is  in  the  intestines, 
and  free  purgation  by  calomel  is  advisable.  If  there  is  high  temperature, 
this  should  be  reduced  by  the  cold  bath  or  pack.  Secondary  attacks  are 
to  be  prevented  by  careful  feeding,  by  improving  the  general  nutrition 
by  means  of  fresh  air,  iron,  cod -liver  oil,  and  phosphorus.  The  last  two 
are  especially  valuable  in  cases  due  to  rickets. 

EPILEPSY. 

Epilepsy  may  be  defined  as  a  disease  in  which  there  is  an  established 
disposition  to  convulsions  of  a  certain  type,  with  loss  of  consciousness, 
which  have  recurred  until  a  habit  of  convulsions  has  become  fixed. 

A  distinction  must  be  made  between  cases  of  so-called  "  idiopathic  " 
epilepsy  and  those  which  are  secondary  to  a  definite  lesion  of  the  brain, 
such  as  tumour,  sclreosis,  or  abscess.  Convulsions  of  the  latter  character 
are  designated  as  "  symptomatic  "  epilepsy,  and  are  discussed  in  connection 
with  the  various  diseases  in  which  they  occur.  The  nature  of  the  attack 
may,  however,  be  identical  in  both  varieties,  and  may  not  differ  from  an 
ordinary  attack  of  convulsions  or  eclampsia. 

The  proportion  of  idiopathic  cases  in  children  is  not  so  large  as  was 
formerly  supposed ;  for  many  of  these  have  been  shown  to  depend  upon 
lesions  once  overlooked,  particularly  infantile  cerebral  paralyses  of  a  mild 
type. 

Etiology. — From  a  consideration  of  1,450  cases  of  epilepsy.  Growers 
states  that  12  per  cent  begin  in  the  first  three  years  of  life,  and  46  per  cent 
between  ten  and  twenty  years.  The  greatest  tendency  to  the  development 
of  the  disease  is  shown  about  the  time  of  puberty.  Females  are  rather 
more  liable  to  be  affected  than  males,  although  the  difference  in  sex  is 
slight.  Heredity  plays  an  impoi'tant  role  in  the  production  of  the  disease. 
In  one  third  of  the  cases,  according  to  Gowers,  there  is  a  family  history 
either  of  epilepsy  or  insanity.  Not  infrequently  more  than  one  child  in 
the  family  is  affected.  All  hereditary  nervous  diseases  predispose  to  epi- 
lepsy, but  it  is  a  question  whether  other  hereditary  diseases  have  any 
special  influence. 

Not  very  infrequently  epilepsy  may  be  traced  to  convulsions  occurring 
during  infancy.  In  what  proportioii  of  the  cases  this  is  true  it  is  impossible 
•to  state  with  accuracy.  Infantile  convulsions  are  very  common,  and  usu- 
ally the  cause  which  produces  them  is  a  transient  one.  The  proportion  of 
such  cases  Avhich  develop  epilepsy  later  in  life  is  certainly  small.  In  the 
second  and  third  years,  however,  the  occurrence  of  convulsions  not  infre- 
quently marks  the  beginning  of  true  epile2Dsy.  Given  a  strong  predispo- 
sition to  epilepsy,  it  is  easy  to  see  how  early  infantile  convulsions  so  often 


EPILEPSY.  Y05 

associated  with  rickets  may  have  been  the  first  of  the  epileptic  series. 
The  first  seizure  is  sometimes  traceable  to  fright,  great  excitement, 
heat-stroke,  or  blows  or  falls  upon  the  head  even  without  any  gross 
lesion.  It  may  follow  any  of  the  acute  diseases  of  childhood,  particu- 
larly scarlet  fever,  rarely  measles  or  typhoid.  In  none  of  these,  however, 
is  it  often  seen.  As  reflex  causes  may  be  mentioned  intestinal  worms, 
phimosis,  adenoid  vegetations  of  the  pharynx,  delayed  or  difficult  men- 
struation, and  masturbation.  Most  of  these  are  rare  causes,  but  they  may 
be  sufficient  to  produce  the  disease  where  a  strong  predisposition  exists. 
Syphilis  may  be  the  cause  of  ej^ilepsy  even  when  there  is  no  local  disease 
of  the  brain. 

Among  the  most  important  factors  in  producing  a  paroxysm,  i>  in- 
testinal putrefaction  associated  with  chronic  constipation  and  chronic 
intestinal  indigestion.  This  subject  has  been  investigated  with  great 
care  by  Herter  and  Smith,*  who  studied  238  specimens  of  urine  from  31 
epileptics.  In  72  per  cent  of  their  observations  there  was  unmistakable 
evidence  of  excessive  intestinal  putrefaction,  as  shown  by  the  presence 
of  ethereal  sulphates  in  the  urine  in  large  amount,  just  before  the  occur- 
rence of  the  paroxysm.  The  inference  seems  warranted  that  this  intestinal 
condition  was  closely  connected  with  the  epileptic  seizures.  The  state- 
ment of  Haig,  that  there  is  an  excessive  elimination  of  uric  acid  preceding 
the  paroxysm,  was  not  borne  out  by  the  observations  of  Herter  and  Smith. 
The  association  of  intestinal  putrefaction  with  seizures  of  epilepsy  is  very 
important  as  furnishing  a  clew  to  the  management  of  many  of  these 
cases.  I  believe  it  to  be  one  of  the  most  important  etiological  factors  in 
cases  occurring  in  children,  particularly  as  an  exciting  cause  of  the  first 
attacks. 

Pathology. — It  is  not  within  the  scope  of  this  work  to  discuss  the 
various  theories  which  have  been  advanced.  The  following  are  the  con- 
clusions reached  by  Gowers :  f 

"  The  muscular  spasm  is  to  be  regarded  as  the  result  of  the  sudden 
overaction  (discharge)  of  nerve  cells,  the  violent  liberation  of  nerve  force, 
and  the  sensations  which  the  patient  experiences  before  losing  conscious- 
ness must  be  due  directly  or  indirectly  to  the  same  cause.  The  disease 
which  excites  convulsions  is  most  frequently  at  the  cortex,  and  when 
organic  disease  causes  convulsions  that  begin  locally,  the  disease  is  almost 
invariably  at  the  cortex.  In  idiopathic  epilepsy  the  convulsions  some- 
times begin  in  this  way,  and  this  suggests  very  strongly  that  in  such  cases 
the  change  occurs  in  the  cortex.  Epilepsy  must  then  be  regarded  as  a 
disease  of  the  gray  matter,  most  frequently  of  the  gray  matter  of  the 
cortex." 

*  New  York  Medical  Journal,  August  and  September,  1892. 
f  Diseases  of  the  Nervous  System,  American  ed.  1888,  p.  1098. 


ijQQ  DISEASES   OF   THE   NERVOUS  SYSTEM. 

While  there  is  pretty  general  agreement  that  the  seat  of  the  morbid 
changes  in  true  epilepsy  are  in  the  cortex,  but  little  is  yet  definitely 
known  as  to  the  nature  of  these  changes.  Van  Gieson  has  published  * 
some  very  careful  observations  made  upon  portions  of  the  cortex  removed 
at  surgical  operations  from  two  epileptic  patients.  In  one  of  these  the 
disease  was  primarily  due  to  a  foreign  body  ;  in  the  other,  to  an  old  cica- 
trix. The  conditions  found  represent  the  earlier  changes  of  the  disease, 
and  were  essentially  the  same  in  both  cases.  There  were  degenerative 
changes  in  certain  of  the  ganglion  cells,  which  in  places  had  resulted  in 
almost  complete  dissolution  of  these  cells.  In  addition  there  was  a  distinct 
hyperplasia  of  the  neuroglia  tissue.  Diffuse  neuroglia  sclerosis  starting 
from  the  focus  of  disease  has  been  reported  by  certain  French  writers — 
Marie,  Fere,  and  Chaslin. 

Symptoms.^Two  distinct  types  of  epileptic  seizures  are  met  with  :  the 
major  attacks,  or  grand  nial,  in  which  there  are  severe  convulsions  lasting 
from  two  to  ten  minutes,  with  loss  of  consciousness,  etc. ;  and  minor 
attacks,  or  petit  mat,  in  which  the  convulsive  movements  are  slight  and 
may  be  absent,  and  in  which  the  loss  of  consciousness  is  often  but  mo- 
mentary.    Between  these  two  extremes  all  gradations  are  seen. 

Grand  mat — The  onset  may  be  sudden,  without  premonition,  or  it 
may  be  preceded  by  certain  prodromal  symptoms  known  as  the  aura. 
The  aura  may  be  motor,  such  as  a  local  spasm  of  the  hand,  face,  or  leg ;  or 
sensory,  such  as  numbness  and  tingling  in  any  part  of  the  body,  or  some 
abnormal  sensation  rising  gradually  to  the  head,  at  which  time  loss  of 
consciousness  occurs.  The  variety  of  sensations  described  by  patients  as 
indicating  an  attack  is  endless.  There  may  be  a  sensation  in  one  finger, 
in  the  face,  tongue,  eye,  or  in  any  part  of  the  body ;  or  the  warning  may 
be  of  a  general  character,  like  a  tremor  or  a  shivering  sensation,  or  a  feeling 
of  faintness.  There  has  also  been  described  a  visceral  or  pneumogastric 
aura,  in  which  there  is  epigastric  pain,  sometimes  nausea,  and  a  sensation 
of  a  ball  in  the  throat;  or  there  may  be  pal^jitation,  or  cardiac  distress. 
There  may  be  general  giddiness  or  vertigo,  or  a  sensation  of  fulness  in 
the  head ;  or  feelings  of  strangeness,  or  a  dreamy,  dazed  condition  ;  and, 
finally,  the  aura  may  have  reference  to  any  of  the  special  senses,  most 
frequently  to  sight.  Sparks  may  appear  before  the  eyes,  or  flashes  of  light 
or  colour,  or  strange  objects  may  be  seen  ;  or  there  may  be  a  momentary 
loss  of  hearing ;  or  strange  sounds  may  be  heard.  In  most  cases  the  aura 
is  peculiar  to  the  individual,  whose  attacks  are  likely  to  be  preceded  by 
the  same  symptoms. 

At  the  beginning  of  the  seizure  the  face  becomes  pale,  the  pupils 
widely  dilated,  the  eyes  rolled  up  in  their  orbits  and  fixed.  Speedily  there 
is  loss  of  consciousness.     Simultaneously  with  these  symptoms,  or  imme- 

*  New  York  Medical  Record,  April  24,  1893. 


EPILEPSY.  707 

diately  following  tlieni,  there  occurs  a  \iolent  tonic  muscular  spasm  to 
which  are  due  the  characteristic  symptoms  of  the  early  part  of  the  seiz- 
ure— viz..  the  fall,  cry,  biting  of  the  tongue,  cyanosis,  and  evacuation  of 
the  bladder  or  rectum.  The  fall  is  forcible,  violent;  in  fact,  the  patient  is 
precipitated  usually  forward,  and  frecjuently  suffers  injury,  never  sinking 
down  as  in  a  faint.  The  head  is  often  strongly  rotated  to  one  side.  The 
position  of  the"hands  is  often  that  assumed  in  tetany.  The  cry  is  a  hoarse, 
inarticulate  sound,  not  very  loud,  and  is  due  to  forcible  expiration,  owing 
to  spasm  of  the  muscles  of  respiration  with  the  glottis  partially  closed. 
The  cyanosis  is  the  result  of  tonic  spasm  of  the  muscles  of  respiration ;  it 
may  be  quite  intense,  so  that  the  face  is  livid,  bloated,  and  the  features 
distorted.  The  spasm  of  the  muscles  of  mastication  causes  the  biting  of 
the  tongue.  Evacuation  of  the  bladder  and  rectum  may  result  from  con- 
traction of  their  walls,  or  from  spasm  of  the  abdominal  muscles.  The  vio- 
lence of  the  muscular  spasm  in  this  stage  may  be  very  great ;  it  has  caused 
fracture  of  bones,  rupture  of  muscles,  and  even  dislocation  of  joints. 

The  stage  of  tonic  spasm  may  be  only  momentary,  the  patient  passing 
almost  at  once  into  the  stage  of  clonic  convulsions.  The  usual  duration 
is  from  ten  seconds  to  half  a  minute.  In  the  stage  of  clonic  spasm  which 
follows,  the  symptoms  are  those  of  an  ordinary  attack  of  convulsions. 
The  muscular  contractions  are  violent,  and  there  is  often  frothing  at  the 
mouth.  Gradually  the  muscles  of  respiration  relax,  air  enters  the  lungs, 
and  the  cyanosis  passes  off.  After  the  clonic  spasm  has  continued  for  a 
variable  time — from  two  or  three  minutes  to  half  an  hour — the  muscular 
contractions  become  less  and  less  frequent,  and  finally  cease  altogether. 
In  a  few  minutes  the  patient  may  regain  consciousness,  look  vacantly 
around,  and  in  a  dazed  way  pei'haps  ask  what  has  happened,  he  being  com- 
pletely oblivious  to  all  that  has  occurred.  More  frequently,  however,  he 
passes  at  once  into  a  deep  sleep,  which  continues  for  an  hour  or  more, 
but  from  which  he  can  be  aroused.  From  this  he  usually  wakens  with  a 
severe  headache,  which  may  continue  for  several  hours.  After  this  he  often 
feels  better  than  for  several  days  preceding  the  attack.  During  the  seizure 
the  temperature  may  be  elevated  one  or  two  degrees,  but  rarely  more. 
The  attack  may  be  followed  by  a  slight  temporary  paresis,  or  aphasia, 
hysterical  phenomena,  vomiting,  and  intense  hunger.  In  very  rare  cases 
the  urine  may  contain  a  trace  of  sugar. 

Petit  mal. — The  minor  attacks  of  epilepsy  may  present  a  very  great 
variety  of  symptoms,  and  at  times  it  is  almost  impossible  to  decide  that 
these  are  epileptic,  except  from  their  periodical  occurrence.  They  pass 
under  the  names  of  "spells,"  "  attacks  of  dizziness,"  "  fainting  turns,"  etc. 
The  most  striking  thing  which  stamps  them  as  epileptic  is  the  loss  of  con- 
sciousness, and  this  may  be  of  short  duration,  sometimes  only  momentary, 
and  so  pass  unnoticed.  In  some  cases  it  is  absent  altogether.  There  is 
no  fall,  but  there  may  be  a  slight  dropping  of  the  head,  a  fixed  stare  for  a 


^^08  DISEASES  OF  THE   NERVOUS  SYSTEM. 

moment  or  two,  and  that  is  all.  This  may  or  may  not  be  preceded  by  an 
aura.  After  such  a  mild  attack  the  patient's  mind  may  be  somewhat 
confused,  and  he  may  do  or  say  strange  things.  All  sorts  of  curious  acts 
have  been  performed  in  an  automatic  way  by  patients  in  the  condition 
which  follows  an  attack  of  epilepsy,  which  may  perhaps  be  regarded  as 
part  of  the  attack.     In  rare  instances  even  acts  of  violence  may  be  done. 

The  mental  condition  of  epileptics. — In  this  connection  a  careful  dis- 
tinction must  be  made  between  cases  in  which  epilepsy  is  secondary  to 
some  organic  brain  disease,  such  as  infantile  cerebral  palsy,  which  may 
itself  be  a  cause  of  mental  impairment,  and  the  mental  disturbances  seen 
in  cases  of  idiopathic  epilepsy.  The  children  who  are  the  subjects  of  the 
latter  disease,  and  who  are  perfectly  normal  mentally,  are  certainly  few. 
All  degrees  of  disturbance  may  be  seen,  from  those  who  are  simply  dull, 
apathetic,  backward  in  development,  and  uncontrollable  in  temper,  to 
those  who  are  melancholic,  idiotic,  and  even  maniacal.  The  earlier  in 
childhood  epilepsy  develops,  the  greater  is  usually  the  mental  disturbance 
seen,  because  of  the  effect  of  the  seizures  upon  the  brain  during  its  period 
of  active  growth.  Speech  and  all  mental  development  may  be  greatly  re- 
tarded. The  more  frequent  and  more  severe  are  the  attacks,  the  more 
marked  are  the  mental  symptoms  present. 

Symptomatic  epilepsy. — This  occurs  most  frequently  in  children  as  a 
sequel  of  cerebral  palsy,  usually  with  hemiplegia,  and  it  may  follow  either 
the  congenital  or  acquired  form.  Epilepsy  may  come  on  at  any  time  after 
the  onset  of  the  paralysis — from  a  few  months  to  five  or  six  years.  At 
first  the  attacks  may  be  separated  by  long  intervals,  but  they  gradually 
become  more  frequent  as  time  passes.  The  convulsions  in  post-hemiplegic 
epilepsy  begin,  as  a  rule,  on  the  paralyzed  side,  and  for  a  long  time  they 
mav  be  confined  to  that  side ;  but  later  they  may  become  general,  in  which 
cases  they  are  indistinguishable  from  attacks  of  idiopathic  epilepsy.  Se- 
vere seizures  are  more  likely  to  be  seen  than  are  the  mild  ones. 

Coui'se  of  the  disease. — This  is  extremely  irregular.  In  most  cases 
seizures  at  first  occur  at  long  intervals,  of  perhaps  a  year,  but  later  they 
become  more  and  more  frequent.  Either  the  mild  or  the  severe  attacks 
may  be  first  seen,  and  may  remain  throughout  as  the  only  type  present,  or 
they  may  be  associated  in  the  same  case.  There  are  most  frequently  seen, 
occasional  major  attacks  with  a  large  number  of  minor  ones.  The  inter- 
val between  the  epileptic  seizures  in  most  cases  is  from  two  to  four  weeks, 
although  they  may  be  of  daily  occurrence.  Sometimes  three  or  four 
seizures  will  follow  one  another  closely,  and  then  there  will  occur  a  long 
interval  of  immunity.  The  seizures  may  come  on  either  during  sleep  or 
in  the  waking  hours,  and  in  some  cases  for  a  long  time  they  may  occur 
only  in  sleep.  Such  cases  present  peculiar  difficulties  in  diagnosis,  and 
are  often  long  unrecognised  as  epileptic.  The  general  health  of  patients 
may  be  quite  normal. 


EPILEPSY.  709 

Death  rarely,  if  ever,  results  from  epilepsy,  except  from  some  acci- 
dent at  the  time  of  the  seizures,  or  from  the  condition  known  as  the 
stahis  epilejiticus ;  in  this  the  attacks  come  on  with  great  frequency  and 
severity,  the  patient  at  times  passing  rapidly  from  one  convulsion  into 
another,  the  temperature  rising  to  105°  or  106°  F.,  and  death  occurring 
either  from  exhaustion,  owing  to  the  severity  of  the  convulsions,  or  from 
coma. 

Diagnosis. — In  most  cases  there  is  little  difficulty  in  recognising  the 
major  attacks  when  they  occur  by  day.  Nocturnal  attacks  may  be  diag- 
nosticated by  the  cry,  the  biting  of  the  tongue,  blood  upon  the  pillow, 
sub-conjunctival  extravasation,  evacuation  of  the  bladder  or  rectum,  and 
the  severe  headache.  Minor  attacks  present  the  greatest  difficulties,  and 
a  positive  diagnosis  is  often  impossible  until  the  patient  has  been  watched 
for  a  long  time.  The  most  important  points  to  be  noted  are  sudden 
pallor,  dilatation  of  the  pupils,  temporary  loss  of  consciousness,  or  sim- 
ply mental  confusion,  and  sometimes  the  evacuation  of  the  bladder. 
The  duration  of  the  attack  is  shorter  than  is  usual  in  an  ordinary  faint. 
The  difficulty  of  distinguishing  epilepsy  from  hysteria  rarely  occurs  in 
childhood. 

It  is  not  always  possible  to  distinguish  between  secondary  or  symp- 
tomatic epilepsy  and  the  idiopathic  or  hereditary  form,  particularly  if  the 
case  comes  under  observation  late  in  the  course  of  the  disease.  The  points 
which  go  to  establish  the  first  form  are  :  that  the  convulsive  movements  are 
partial,  or  limited  to  one  side ;  that  when  they  are  general,  they  always 
begin  in  the  same  part  of  the  body ;  or  that  there  is  a  history  of  partial  or 
unilateral  attacks  for  some  time  before  the  occurrence  of  any  general 
convulsions.  It  is  important  in  all  cases  to  examine  the  patient  care- 
fully for  signs  of  an  old  hemiplegia,  the  symptoms  of  which  may  be  so 
slight  as  to  be  readily  overlooked.  A  marked  increase  in  the  reflexes  of 
one  side  is,  according  to  Sachs,  quite  as  conclusive  evidence  as  a  distinct 
weakness  of  the  arm  or  leg.  In  idiopathic  epilepsy  some  of  the  stigmata 
of  degeneration  (page  803)  are  usually  present.  The  sudden  development 
of  epileptic  seizures  in  a  child  previously  healthy,  and  iu  whom  there  is 
no  hereditary  history  of  the  disease,  should  always  arouse  the  suspicion  of 
organic  brain  disease,  especially  tumour ;  and  if  there  are  besides,  severe 
headache,  vomiting,  and  optic  neuritis,  the  existence  of  tumour  is  reason- 
ably certain. 

Prognosis. — The  danger  to  life  in  epilepsy  is  very  slight.  Death  is 
generally  due  to  some  accident,  particularly  drowning,  at  the  time  of  a 
seizure.  The  tendency  to  spontaneous  cessation  of  the  attacks  is  small, 
while  the  tendency  to  recurrence  is  very  great. 

The  prognosis  in  any  given  case  depends  upon  the  cause  of  the  disease 
and  the  duration  of  the  symptoms.  Where  the  cause  can  be  removed, 
and  where  the  symptoms  have  lasted  less  than  a  year,  the  prospects  of  per- 


YIO  DISEASES  OP   THE   NERVOUS   SYSTEM. 

manent  cure  are  fairly  good.  This  is  particularly  true  of  cases  in  which 
the  epilepsy  clearly  depends  upon  gross  errors  in  diet,  with  chronic  intes- 
tinal indigestion.  In  such  cases,  if  the  patient  can  be  placed  under  proper 
control  and  dietetic  measures  well  carried  out,  the  development  of  chronic 
epilepsy  can  be  arrested  in  a  considerable  number  of  cases.  If,  on  the 
contrary,  the  hereditary  tendency  to  the  disease  is  marked,  if  the  epileptic 
seizures  have  developed  apart  from  any  adequate  exciting  cause,  and  if 
they  have  continued  untreated  or  in  spite  of  treatment  for  two  or  three 
years,  the  symptoms  may  perhaps  be  relieved,  but  there  is  no  prospect 
whatever  of  permanent  cure.  In  the  cases  also  which  are  due  to  local  irri- 
tation, like  that  resulting  from  an  old  meningeal  haemorrhage,  the  prog- 
nosis is  invariably  bad,  and  only  temporary  relief  is  to  be  expected.  A 
few  cases  of  traumatic  epilepsy  have  been  cured  and  many  have  been 
greatly  improved  by  a  surgical  operation. 

Treatment. — The  first  indication  is  to  remove  the  cause  where  one  can 
be  found.  If  in  the  male  phimosis  exists,  or  other  evidence  of  genital 
irritation,  circumcision  should  be  done,  or  the  prepuce  retracted  and  ad- 
hesions broken  up.  Adenoid  growths  of  the  pharynx  should  be  removed, 
and  likewise  every  other  cause  of  reflex  irritation.  Particular  attention 
should  be  given  to  the  digestive  organs.  The  most  hopeful  cases  are  those 
associated  with  acute  and  chronic  disturbances  of  digestion,  especially 
chronic  intestinal  indigestion  with  constipation.  These  cases  are  to  be 
managed  like  others  of  the  same  sort  in  which  epileptic  attacks  are  not 
present  (page  414).  Meat  should  be  allowed  once  a  day  and  in  mod- 
erate quantity.  Milk  should  be  given,  diluted  if  necessary,  also  kumyss 
and  matzoon.  Green  vegetables,  except  peas  and  beans,  may  be  given 
freely ;  also  all  fresh  fruits.  Tea,  coffee,  and  alcohol  in  every  form  must 
be  absolutely  prohibited ;  also  potatoes  and  oatmeal.  The  most  careful 
attention  should  be  given  to  the  bowels.  Under  no  circumstances  should 
a  condition  of  chronic  constipation  be  neglected.  A  dose  of  calomel 
once  a  week  and  intestinal  irrigation  two  or  three  times  a  week  are  of 
great  value  in  many  cases.  Where  the  symptoms  of  intestinal  putrefac- 
tion are  marked,  borax  is  at  times  of  decided  value — two  grains  three 
times  a  day  to  a  child  of  five  years — or  salicylate  of  sodium,  salol,  or  the 
benzoate  of  sodium  may  be  given ;  the  dose  of  each  being  from  two  to 
ten  grains,  according  to  the  age  of  the  child,  after  each  meal.  The  gen- 
eral hygiene  of  the  patient  must  receive  careful  attention.  He  should 
lead  a  simple,  regular  life,  as  miich  as  possible  out  of  doors,  away  from 
the  excitements  of  a  large  city,  or  from  association  with  many  children, 
and  in  short  the  nervous  system  should  be  kept  as  quiet  as  possible. 

All  the  foregoing  means  of  treatment  are  of  equal  importance  with 
the  use  of  special  drugs.  The  most  common  mistake  is  to  rely  only  upon 
drugs,  ignoring  the  other  measures  mentioned.  It  not  infrequently  hap- 
pens that  drugs  are  without  any  effect  when  they  are  the  only  means  of 


EPILEPSY.  Yll 

treatment  employed,  whereas  in  conjunction  with  other  measures  marked 
improvement  is  seen. 

The  bromides  are  unquestionably  the  best  means  of  combating  the  epi- 
leptic habit.  Either  the  sodium  salt  alone  or  a  combination  of  the  sodium 
and  ammonium  bromides  is  to  be  preferred.  The  purpose  should  be  to 
give  the  smallest  doses  which  will  control  the  seizures.  Children  require 
proportionately  larger  doses  than  adults,  and  in  most  cases  a  child  of  five 
years  will  need  from  twenty-five  to  fifty  grains  a  day.  Seguin's*  method  of 
administering  the  bromides  is  largely  followed  in  New  York,  and  is  of  great 
value.  It  is  to  give  the  larger  part  of  the  quantity  for  twenty-four  hours, 
shortly  before  the  time  when  the  seizures  have  usually  occurred ;  in  the  inter- 
val to  give  much  smaller  doses,  and  in  all  cases  to  give  the  dose  largely  di- 
luted,— in  from  six  to  eight  ounces  of  water.  He  gives  a  full  dose  early  in  the 
morning,  and,  where  the  seizures  are  apt  to  come  at  night,  one  at  bedtime. 

Cases  ot  jjetit  mal  are  especially  difficult  to  control.  For  such  there  is 
often  an  advantage  in  combining  belladonna  with  the  bromides.  In  all 
cases  the  treatment  must  be  continued  for  a  long  time  if  anything  is  ac- 
complished. The  bromide  should  be  gradually  reduced  after  the  attacks 
are  controlled,  but  must  be  given  in  moderately  large  doses  for  at  least 
two  years  after  the  seizures  have  ceased.  The  addition  of  borax  seems 
occasionally  better  than  the  bromides  alone  in  cases  where  there  is  ex- 
cessive intestinal  putrefaction.  Sometimes  the  combination  of  chloral  or 
antipyrine  with  bromides  is  advantageous,  particularly  if  the  latter  are 
badly  borne  or  cause  an  annoying  amount  of  acne.  Seguin  states  that  he 
has  been  able  to  control  the  acne  in  many  cases  by  giving  at  the  same 
time  moderate  doses  of  arsenic.  Other  drugs  occasionally  useful  as  adju- 
vants to  the  bromides  are  strychnine  and  digitalis. 

The  surgical  treatment  of  epilepsy  has  of  late  attracted  much  atten- 
tion. An  operation  is  to  be  considered  in  cases  in  which  the  paroxysms 
are  very  frequent  and  severe,  and  when  there  is  present  a  definite  local 
cause,  such  as  an  old  fracture  of  the  skull,  or  where  epilepsy  has  followed 
an  injury  to  the  head  even  without  fracture.  Sachs  sums  up  the  present 
status  of  this  question  as  follows  :  "  In  a  case  due  to  a  traumatic  or  organic 
lesion  an  early  operation  may  prevent  the  development  of  cerebral  sclerosis. 
If  early  operation  is  not  done,  the  occurrence  of  epilepsy  is  a  warning  that 
secondary  sclerosis  has  been  established  and  an  operation  may  prevent  it 
from  increasing.  Operation  must  include  the  removal  of  the  diseased 
area ;  here,  if  all  other  parts  are  normal,  a  cure  may  result.  Under  favour- 
able conditions  a  few  cases  of  epilepsy  may  be  cured  by  surgery  and  many 
more  improved." 

The  education  of  epileptic  children  is  a  subject  of  great  difficulty  and 
is  often  neglected.     There  are  many  reasons  why  it  is  impracticable  to 

*  New  York  Medical  Journal,  March  29,  1890. 


712  DISEASES   OF   THE   NERVOUS   SYSTEM. 

send  them  to  ordinary  schools,  and  it  is  very  desirable  that  special  schools 
and  colonies  for  them  should  be  established. 

The  mafiagement  of  the  attack. — Abortive  measures  are  sometimes 
successful  in  cases  with  a  distinct  aura,  the  most  reliable  being  the  inha- 
lation of  nitrite  of  amyl.  While  the  seizure  lasts,  the  patient  should  be 
prevented  from  injuring  himself.  The  clothing  should  be  loosened,  a 
spool  or  cork  should  be  placed  between  his  teeth  to  protect  the  tongue, 
but  no  effort  made  to  restrain  his  movements  unless  he  is  liable  to  do  vio- 
lence to  himself.  An  epileptic  child  should  never  be  withoiit  some  com- 
panion. 

TETANY. 

Tetany  is  a  condition  characterized  by  tonic  muscular  spasm,  which 
may  be  intermittent  or  continuous.  It  usually  affects  the  muscles  of  the 
extremities,  especially  the  hands  and  feet,  more  rarely  the  neck,  face,  and 
trunk.  When  limited  to  the  hands  and  feet  it  is  known  as  carpo-pedal 
spasm  or  arthrogryposis ;  and  although  sometimes  classed  separately, 
this  seems  to  be  really  only  one  manifestation  of  the  same  general  condi- 
tion. In  infants,  tetany  is  very  frequently  associated  with  laryngismus 
stridulus,  this  being  present  in  fully  two  thirds  of  the  cases ;  but  in  older 
children  this  association  is  quite  rare.  G-eneral  convulsions  occur  in  from 
twenty  to  thirty  per  cent  of  the  cases.  Tetany  is  not  a  frequent  disease 
in  America.  In  a  pretty  large  hospital  service  I  seldom  see  more  than 
four  or  five  eases  a  year,  while  in  some  European  cities  tetany  is  re- 
ported to  be  very  common  and  at  times  to  occur  epidemically.  It  is 
probable  that  more  than  one  pathological  condition  has  been  included 
under  this  term. 

Etiology. — While  tetany  may  occur  at  any  age,  it  is  most  frequent  in 
infancy.  Of  eighty-seven  cases  reported  by  Barthez  and  Sanne,  fifty  per 
cent  were  observed  in  the  first  two  years,  twenty  per  cent  from  three  to 
six  years,  and  twenty-five  per  cent  from  twelve  to  fifteen  years.  Of  thir- 
ty-eight cases  in  children  collected  by  Griffith,  sixty-six  per  cent  were 
under  two  years  of  age.  In  infancy  males  are  much  more  frequently 
affected;  but  when  the  disease  occurs  in  older  children,  females  appear 
more  liable  to  it.  Tetany  rarely  occurs  as  a  primary  disease.  It  is  most 
frequently  associated  with  rickets ;  in  fact,  rickets  is  almost  invariably 
found  in  the  infantile  cases.  It  sometimes  occurs  with  chronic  diarrhoea 
and  with  marasmus.  It  has  been  known  to  follow  broncho-pneumonia, 
pertussis,  typhoid  fever,  rheumatism,  and  measles.  Of  the  exciting 
causes,  the  most  frequent  one  is  some  irritation  in  the  gastro-enteric 
tract.  This  may  be  the  products  of  chronic  indigestion,  or  acute  intoxi- 
cation, Avorms,  and  sometimes  even  intussusception.  Attacks  in  older 
children  are  frequently  ascribed  to  cold.  In  girls,  tetany  may  occur  at 
the  time  of  puberty,  especially  where  menstruation  is  delayed ;  it  has  fol- 
lowed removal  of  the  thyroid  gland. 


.     TETANY.  Y13 

Pathology. — Up  to  the  present  time  no  constant  anatomical  lesions 
have  been  demonstrated  in  tetany.  The  circumstances  in  which  it  oc- 
curs, its  symptoms  and  course,  all  indicate  that  it  is  a  neurosis  probably 
depending  upon  disturbances  of  nutrition  in  the  nerve  cells  of  the  spinal 
cord  and  medulla. 

Symptoms. — The  spasm  may  develop  abruptl}',  or  it  may  be  preceded 
by  sensory  disturbances,  such  as  jjain,  numbness,  or  tingling.  The  up- 
per extremities  are  usually  first  affected,  the  spasm  gradually  becoming 
more  severe  and  finally  involving  the  lower  extremities.  Both  sides  of 
the  body  are  equally  affected.  The  position  assumed  by  the  hands  is 
very  characteristic:  The  fingers  are  flexed  at  the  metacarpo-phalangeal 
joint  and  the  phalanges  extended;  the  thumbs  are  adducted  almost  to 
the  little  finger;  the  wrist  is  flexed  at  an  acute  angle,  and  the  whole  hand 
drawn  somewhat  to  the  ulnar  side  (Fig.  121).  No  motion  is  allowed 
at  the  wrist,  but  movements  at  the  elbow  and  shoulder  are  usually  nor- 
mal. The  feet  are  strongly  extended,  sometimes  in  the  position  of  typi- 
cal equino-varus.  The  first  phalanges  of  the  toes  are  flexed,  and  the 
second  and  third  rows  extended;  the  plantar  surface  is  strongly  arched, 
and  the  dorsum  of  the  foot  is  very  prominent,  standing  out  like  a  cush- 
ion. The  typical  position  of  the  feet  is  well  shown  in  Fig.  121.  The 
tendo-Achillis  stands  out  prominently.  Motion  at  the  hip  and  knee  is 
generally  free.  The  spasm  in  many  cases  is  limited  to  the  hands  and 
feet;  more  rarely  the  muscles  of  the  thigh,  usually  the  adductors,  may 
be  involved.  In  very  rare  cases  the  muscles  of  the  trunk,  the  face,  or 
the  eye  may  be  involved. 

The  knee-jerk  and  the  cutaneous  reflexes  are  exaggerated,  and  there 
is  abnormal  excitability  both  to  the  galvanic  and  faradic  currents  and  to 
mechanical  irritation.  Light  percussion  upon  the  nerve  trunk  often  in- 
duces marked  contraction  of  the  muscles  supplied  by  the  nerve.  This 
is  particularly  striking  in  the  face.  The  contraction  of  the  facial  mus- 
cles following  such  irritation  is  known  as  "  Chvostek's  symptom"  or  the 
facial  phenomenon.  Spasm  may  also  be  excited  by  pressure  upon  the 
large  nerve  trunks  and  arteries  of  the  parts  affected.  This  is  known  as 
*'  Trousseau's  symptom." 

Pain  owing  to  the  spasm  is  frequently  present.  It  is  usually  sharp 
and  lancinating,  and  may  be  so  severe  as  to  cause  children  to  cry  out. 
Pain  is  induced  by  any  attempt  to  overcome  the  spasm,  and  sometimes 
it  is  constant.  Other  disturbances  of  sensibility  are  even  more  common 
than  pain.  There  is  no  loss  of  consciousness  and  no  fever.  The  spasm 
is  generally  continuous,  although  there  may  be  periods  of  remission  or 
even  of  intermission.  When  associated  with  laryngismus  stridulus,  the 
spasm  is  much  increased  during  these  attacks. 

The  duration  of  the  disease  is  from  a  few  days  to  several  weeks.  The 
mild  form,  which  is  usually  seen  in  infants,  in  most  cases  passes  away 
spontaneously  in  one  or  two  weeks,  although  there  may  be  relapses  and 


7iA 


DISEASES   OP   THE   NERVOUS  SYSTEM. 


second  attacks  at  variable  intervals.     The  most  important  complication 
is  general  convulsions.     These  may  come  on  at  any  time  in  the  course  of 


Fig.  121..— Tetany,  showing  the  characteristic  position  of  the  hands  and  feet,  in  a  child  two 

years  old. 

the  disease.  Spasm  of  the  glottis  may  either  precede  or  follow  tetany. 
When  associated  they  generally  cease  at  the  same  time.  Slight  paralysis 
may  follow  or  alternate  with  the  spasm. 

Diagnosis. — The  diagnostic  features  of  the  disease  are  bilateral  spasm — 
in  infants  usually  limited  to  the  hands  and  feet — without  loss  of  conscious- 
ness, the  spasm  being  increased  or  excited  by  pressure  upon  the  nerves, 
exaggerated  reflexes,  and  the  presence  of  some  previous  disease,  especially 


LARYNGISMUS  STRIDULUS.  715 

rickets  or  some  disorder  of  the  intestines.  The  severe  form  may  be  mis- 
taken for  tetanus;  but  this  is  very  rare  except  in  the  newly  born;  and 
trismus  is  the  rule,  and  generally  it  is  the  first  symptom.  Trismus  is 
extremely  rare  in  tetany.  From  meningitis,  tetany  is  distinguished  by 
the  absence  of  cerebral  symptoms  ;  from  cerebral  tumour,  by  the  bilateral 
character  of  the  spasm,  the  absence  of  headache  and  focal  brain  symp- 
toms ;  from  haemorrhage,  by  the  absence  of  cerebral  symptoms ;  from 
malarial  spasm,  by  the  fact  that  it  is  constant,  not  intermittent. 

Prognosis.— Tetany  per  se  is  not  fatal,  but  death  may  result  from  the 
development  of  general  convulsions  or  from  the  original  disease  which 
tetany  complicates.  Eecovery  is  usually  perfect,  although  Gowers  states 
that  in  rare  cases  it  is  followed  by  mnscular  atrophy. 

Treatment. — The  first  indication  is  to  remove  the  cause,  and  this  in 
most  cases  is  found  in  the  digestive  tract.  If  rickets  is  present  it  should 
receive  the  usual  treatment,  both  dietetic  and  medicinal.  If  worms  are 
suspected  a  vermifuge  should  be  given.  For  the  relief  of  the  spasm,  the 
hot  bath  is  a  most  valuable  remedy ;  friction  may  also  be  employed.  Drugs 
which  have  the  power  of  allaying  spasm  should  be  given, — chloral,  bromides, 
and  antipyrine.  In  the  event  of  failure  by  these  methods  galvanism  mav  be 
tried.  After  the  attack  the  child's  general  nutrition  should  receive  careful 
attention,  to  prevent  relapses. 

LARYNGISMUS   STRIDULUS— SPASM  OF   THE  GLOTTIS. 

Idiopathic  spasm  of  the  glottis,  or  laryngismus  stridulus,  is  a  rather  rare 
disease,  and  belongs  especially  to  infancy.  It  is  a  pure  neurosis,  not  often 
seen  except  in  children  who  are  rachitic.  It  is  frequently  associated  with 
carpo-pedal  spasm  and  with  general  convulsions.  The  disease  is  not  to  be 
confounded  with  ordinary  spasmodic  croup  or  catarrhal  spasm  of  the 
larynx,  which  is  of  very  frequent  occurrence. 

Spasm  of  the  larynx  may  be  seen  in  several  conditions  quite  different 
from  laryngismus  stridulus.  It  forms  one  of  the  essential  features  of  per- 
tussis. It  occurs  both  in  infants  and  in  older  children  from  pressure  upon, 
or  irritation  of,  the  pneumogastric  or  recurrent  laryngeal  nerve  by  a  tumour 
in  the  mediastinum, — usually  a  tuberculous  lymph  node,  or  re tro-cesophageal 
abscess.  Reflex  spasm  of  the  larynx  is  also  associated  with  enlarged  ton- 
sils, adenoid  growths  of  the  pharynx,  and  elongated  uvula.  There  is 
a  form  of  reflex  spasm  which  occurs  in  the  newly-born  accompanied  by 
crowing  inspiration  ;  this  is  not  frequent,  and  is  rarely  serious. 

Idiopathic  spasm  of  the  larynx  is  quite  difl^orent  from  any  of  these 
conditions.  It  is  peculiar  to  infancy,  the  great  proportion  of  cases  oc- 
curring between  the  sixth  and  eighteenth  months.  Males  appear  to  be 
more  susceptible  than  females.  The  constitutional  condition  with  which 
it  is  usually  associated  is  rickets.  In  a  large  number  of  cases,  but  not  in 
all,  there  is  cranio-tabes.     Many  writers  believe  that  laryngismus  is  in- 


Y16  DISEASES   OP  THE   XERVOTS  SYSTEM. 

variabl}^  of  rachitic  origin.  Of  fift}'  cases  observed  by  Gee,  there  were 
found  in  all  but  two  unmistakable  evidences  of  rickets.  The  disease 
occurs  in  delicate  infants  who  have  been  closely  confined  in  warm  rooms, 
and  it  is  probably  on  this  account  that  it  is  more  often  seen  in  the  winter 
and  spring  than  at  other  seasons.  The  exciting  causes  of  this  spasm 
may  be  a  breath  of  cold  air,  or  any  form  of  nervous  excitement,  such  as 
passion,  fright,  or  crying. 

Pathology. — There  are  no  anatomical  changes  in  this  disease.  It  is 
a  pure  neurosis,  and  it  is  generally  believed  to  be  of  central  origin,  de- 
pending essentially  upon  imperfect  nutrition  of  the  motor  centres  of  the 
spinal  cord  and  medulla. 

Symptoms. — The  disease  is  often  unnoticed  by  the  parents  until  the 
attacks  have  become  quite  frequent,  the  first  ones  being  mild,  and  the 
later  ones  more  and  more  severe.  Occasionally  the  very  first  paroxysms 
may  be  severe.  The  attack  comes  on  suddenly.  The  child  throws  back 
his  head,  the  face  becomes  pale,  then  livid,  and  for  the  time  there  is  com- 
plete arrest  of  respiration.  This  continues  for  a  few  moments,  during 
which  the  cyanosis  deepens,  and  the  child  seems  in  great  distress,  making 
violent  efforts  to  breathe.  If  the  parox3'sm  is  a  severe  one,  the  asphyxia 
may  be  so  great  as  to  lead  to  loss  of  consciousness,  and  it  ma}"  even  be 
fatal,  or  the  attack  ma}^  terminate  in  general  convulsions.  In  milder  at- 
tacks, after  fifteen  or  twent}^  seconds  the  muscular  spasm  relaxes,  the 
glottis  opens,  and  a  long,  deep  inspiration  occurs,  with  the  production  of 
a  crowing  sound.  The  so-called  "  holding-breath  spells "  and  the 
"  crowing  attacks  "  of  infants  are  usually  of  this  nature.  Such  forms 
of  spasm  are  often  brought  on  by  passion  or  any  excitement,  and  may 
occur  from  two  or  three  to  twenty  times  a  day.  Between  them  the 
condition  of  the  child  may  be  normal,  or  carpo-pedal  spasm  may  be 
present.  It  is  important  to  note  that  in  this  disease  there  is  not  a 
stridor  due  to  narrowing  of  the  glottis,  as  in  ordinary  croup,  but  a 
condition  of  apnoea  from  its  complete  closure.  Not  all  the  paroxysms 
in  the  same  case  are  equally  severe.  A  child  may  have  in  the  course 
of  a  day  a  great  many  mild  attacks,  but  only  a  few  severe  ones.  Gen- 
eral convulsions  are  seen  in  over  one  third  of  the  cases,  and  carpo-pedal 
spasm  or  tetany  complicates  a  still  larger  proportion.  If  tetany  is  pres- 
ent in  the  interval,  it  is  always  increased  during  the  attacks. 

The  duration  of  the  disease  varies  from  a  few  days  to  several  weeks, 
or  even  months.  In  cases  which  terminate  in  recovery  there  is  a  gradual 
diminution  in  the  frequency  and  severity  of  the  paroxysms,  until  the}' 
finally  cease  altogether. 

Prognosis. — This  is  good,  except  when  there  are  general  convulsions. 
The  cases  in  which  fatal  asphyxia  occurs  are  very  rare.  Usually  with 
proper  treatment  marked  improvement  begins  in  the  course  of  a  fewdays. 

Diagnosis. — This  is  to  be  made  from  catarrhal  spasm  of  the  larynx. 
The  differential  points  have  been  mentioned  under  the  latter  disease 


CHOREA.  717 

(page  486).  Owing  to  the  occurrence  of  paroxysms  and  the  crowing 
sounds,  the  disease  may  be  mistaken  for  whooping-cough,  and  in  fact 
this  diagnosis  is  not  infrequently  made  by  parents.  A  careful  examina- 
tion of  the  patient  during  the  attacks,  the  absence  of  cough,  and  the 
frequent  association  of  tetan}^,  are  sufficient  to  differentiate  this  from 
pertussis. 

Treatment. — During  the  attack  the  object  is  to  break  the  spasm.  In 
mild  cases  this  may  be  done  by  sprinkling  water  in  the  face.  In  severe 
cases  inhalations  of  chloroform  may  be  required,  and  even  intubation. 
Between  the  attacks  the  patient  should  be  given  either  bromide  and 
chloral,  or  antipyrine.  Sodium  bromide,  gr.  v,  and  chloral,  gr.  ij,  may  be 
given  every  three  or  four  hours  to  a  child  a  year  old  until  the  frequency 
and  severity  of  the  attacks  are  controlled ;  afterward  three  times  a  day. 
My  own  experience  with  antipyrine  in  this  disease  leads  me  to  the  belief 
that  it  is  more  effective  than  bromide  and  chloral.  When  the  sj-mptoms 
are  severe,  two  grains  of  antipyrine  may  be  given  every  four  hours  to  a 
child  a  year  old,  the  dose  being  gradually  diminished  as  the  symptoms 
improve. 

The  general  treatment  of  the  child  is  quite  as  important  as  drugs  di- 
rected toward  relieving  the  spasm.  Cold  sponging  should  be  used  in 
every  case  unless  it  occasions  so  much  fright  as  to  increase  the  number  of 
paroxysms.  Careful  attention  should  be  given  to  the  diet.  Children 
should  be  kept  in  the  open  air  as  much  as  possible.  Cod-liver  oil  is 
.needed  in  most  cases,  and  rachitic  cases  are  sometimes  much  benefited 
by  phosphorus.  Any  source  of  local  irritation,  such  as  enlarged  tonsils, 
elongated  uvula,  or  adenoid  growths,  should  be  removed ;  for,  if  not  the 
actual  cause  of  the  attack,  they  may  be  the  means  of  aggravating  the 
symptoms.  In  all  cases  the  treatment  should  be  continued  for  several 
weeks  after  the  paroxysms  have  subsided. 

CHOREA— SAINT  VITUS'S   DANCE. 

Chorea  is  a  functional  nervous  disease  characterized  by  aimless,  irreg- 
ular movements  of  any  or  all  the  voluntary  muscles.  Choreic  move- 
ments are  of  a  somewhat  spasmodic  character,  often  accompanied  l)y  an 
apparent  or  real  loss  of  power  in  the  groups  of  muscles  affected,  and  by 
a  mental  condition  of  extreme  irritability. 

Etiology. — Chorea  is  most  frequently  seen  between  the  ages  of  seven 
and  fourteen  years.  Of  146  cases,  6  were  under  five  years,  72  between  five 
and  nine  years,  and  68  between  ten  and  fourteen  years.  The  youngest 
case  of  which  I  have  record  was  that  of  a  child  four  years  old.  It  is  ex- 
tremely rare  before  the  third  year,  although  it  may  occur  even  in  infancy, 
and  in  a  few  recorded  cases  it  was  undoubtedly  congenital.  My  own  obser- 
vations coincide  with  those  of  nearly  all  writers,  that  the  disease  is  more 
than  twice  as  frequent  in  females  as  in  males.  While  chorea  may  be  seen 
47 


718  DISEASES   OF   THE   NERVOUS   SYSTEM. 

at  all  seasons,  it  is  much  more  frequent  in  the  spring  months.  Of  717  at- 
tacks studied  by  Lewis  (Philadelphia),  the  largest  number  began  in  March, 
and  the  next  largest  number  in  Ma}';  in  my  own  cases  May  stood  first. 

The  relation  of  chorea  to  rheumatism  is  of  much  importance,  and  has 
during  late  years  attracted  a  great  deal  of  attention.  Thus  far  the  inves- 
tigations of  different  writers  have  given  results  which  are  somewhat  con- 
tradictory. Some  have  found  evidences  of  rheumatism  in  but  a  small 
proportion  of  the  cases — in  not  more  than  5  or  10  per  cent — while  the 
statistics  of  others  have  placed  the  percentage  of  rheumatism  as  high  as 
50  or  even  60  per  cent.  It  is  rather  striking  that  the  statistics  of  neu- 
rologists, almost  without  exception,  have  given  a  very  much  smaller  per- 
centage of  rheumatism  in  choreic  cases  than  those  taken  from  children's 
clinics  and  hospitals.  The  question  hinges  largely  upon  what  is  to  be 
admitted  as  evidence  of  rheumatism  in  a  child;  if  cases  of  acute  articular 
inflammation  only,  then  the  number  will  be  very  small;  if  subacute  cases 
with  Joint  swellings  are  included,  the  proportion  will  be  considerably 
larger;  while  if  we  admit  cases  of  acute  endocarditis  without  articular 
symptoms,  and  those  of  articular  pains  and  joint  stiffness  but  without 
swelling,  the  proportion  will  be  very  much  increased.  My  own  belief  is 
that  there  is  a  very  close  connection  between  chorea  and  the  rheumatic 
diathesis  as  manifested  by  all  the  symptoms  above  noted,  and  accom- 
panied by  a  family  history  of  rheumatism.  On  careful  scrutiny,  the 
number  of  cases  of  chorea  in  which  unmistakable  evidence  of  this  di- 
athesis is  found,  is  very  large,  including  in  my  own  observations  over  one 
half  the  cases.  There  seems,  then,  to  be  a  large  group  of  cases  which 
may  be  classed  distinctly  as  rheumatic  chorea.  There  are,  however,  many 
others  in  which  no  such  element  can  be  found. 

My  former  associate.  Dr.  F.  M.  Crandall,  has  analyzed  116  cases  of 
chorea  treated  by  us  at  the  jS^ew  York  Polyclinic  and  elsewhere,  with  the 
following  results:  Of  111  cases  in  which  the  question  of  rheumatism  was 
investigated  there  was  a  definite  history  of  it  in  63.  In  41,  rheumatism 
occurred  before  the  chorea;  in  13,  the  first  evidence  of  rheumatism  was 
coincident  with  the  chorea;  and  in  9  it  first  occurred  subsequently  to  the 
chorea,  usually  within  three  months.  In  about  one  third  of  the  cases,  at- 
tacks or  rheumatism  occurred  during  or  subsequent  to  the  chorea  as  well 
as  before  it.  It  may  then  be  stated  that  previous  rheumatism  was  evi- 
dent in  37  per  cent,  concurrent  rheumatism  in  24  per  cent,  and  subse- 
quent rheumatism  in  15  per  cent  of  the  cases.  Excluding  cases  men- 
tioned twice,  and  also  all  those  in  which  there  was  a  history  only  of 
"'  growing  pains,"  there  was  evidence  of  articular  rheumatism  in  56.7  per 
cent  of  the  cases.  Many  of  these  patients  have  now  been  under  obser- 
vation for  several  years,  and  it  has  l)een  interesting  to  see,  as  time  has 
passed,  how  the  evidences  of  the  rheumatic  diathesis  have  multiplied  the 
longer  the  cases  have  been  followed. 

In  the  above  statistics  only  articular  symptoms  have  been  accepted  as 


CHOREA. 


719 


evidence  of  rheumatism.  If  the  cases  of  endocarditis  without  articular 
symptoms  were  included,  as  I  think  they  might  fairly  be,  it  would  raise 
the  proportion  of  rheumatic  cases  still  higher.  The  great  proportion 
of  cardiac  murmurs  persisting  after  chorea,  if  not  all  of  them,  should,  I 
believe,  be  classed  as  rheumatic,  even  if  no  articular  symptoms  have  been 
present. 

Overpressure  in  school  is  often  an  important  factor  in  the  production 
of  chorea,  as  has  been  shown  by  Sturges  (London).  Anaemia,  if  not  an 
essential  factor,  is  certainly  a  very  important  one,  and  the  great  propor- 
tion of  cases  present  very  distinct  evidences  of  it.  Chorea  may  develop  as 
a  sequel  of  any  of  the  infectious  diseases,  more  particularly  scarlet  and 
typhoid  fevers.  It  is  seen  quite  often  in  cases  of  chronic  malarial  poi- 
soning. Among  the  reflex  causes  may  be  mentioned  phimosis,  either 
lumbricoids  or  pinworms,  delayed  menstruation,  and  ocular  defects, — 
although  the  latter  more  frequently  cause  a  local  spasm  of  the  muscles  of 
the  eyes,  which  can  hardly  be  considered  choreic.  It  has  been  claimed 
that  chorea  may  result  from  the  reflex  irritation  arising  from  adenoids  of 
the  pharynx  and  enlarged  tonsils.  Whether  this  is  directly  or  only  indi- 
rectly a  cause  is  not  evident.  The  association  of  the  two  conditions  is  not 
very  infrequent. 

Hereditary  influence  is  of  considerable  importance  in  the  production 
of  chorea.  It  is  much  more  frequent  in  children  of  neurotic  families,  and 
very  often  several  successive  generations,  or  several  children  in  the  same 
family,  may  suffer  from  the  disease. 

The  exciting  cause  of  chorea  in  a  certain  proportion  of  cases  is  fright ; 
occasionally  it  arises  from  imitation,  and  the  disease  has  been  known  to 
occur  epidemically  in  institutions.  Choreiform  movements  may  follow 
hemiplegia.  Chorea  and  epilepsy  may  be  associated  in  the  same  patient, 
or  one  disease  may  follow  the  other. 

The  causes  which  underlie  the  occurrence  of  chorea  therefore,  seem  to 
be  a  rheumatic  diathesis,  a  neurotic  constitution,  aneemia,  and  some  severe 
disturbance  of  general  nutrition.  When  these  predisposing  factors  are 
present,  an  attack  may  be  induced  by  many  things.  The  greater  the  j)re- 
disposition  the  less  important  may  be  the  exciting  cause.  A  very  large 
number  of  the  cases  of  chorea  are  in  children  who  present  distinct  evi- 
dences of  rheumatism,  although  the  explanation  of  this  relationship  is  not 
yet  understood.  In  another  group  the  neurotic  element  predominates,  and 
in  these  there  may  be  no  connection  whatever  with  rheumatism. 

Pathology. — The  exact  pathology  of  chorea  is  at  the  present  time  not 
settled.  The  seat  of  the  morbid  process  is  undoubtedly  the  central  nerv- 
ous system,  ]irobably  the  motor  areas  of  the  cortex.  Like  epilepsy, 
chorea  may  follow  organic  brain  disease,  especially  hemiplegia  from  cor- 
tical lesions.  In  some  severe  cases  which  were  fatal,  owing  to  associa- 
tion with  acute  endocarditis,  capillary  emboli  have   been  found   in  the 


Y20  DISEASES  OF  THE  XERVOUS  SYSTEM. 

brain.  They  have,  however,  often  been  absent,  and  probably  explain  but 
a  small  number  of  cases,  if,  indeed,  they  explain  any.  The  fact  that  in 
the  great  majority  of  the  cases  of  ordinary  chorea,  complete  recovery 
occurs  in  the  course  of  a  few  weeks  or  months,  speaks  strongly  against 
any  important  structural  change  in  the  nervous  centres.  It  seems  much 
more  in  harmony  with  what  we  know  of  the  disease  clinically,  to  seek  an 
explanation  of  the  symptoms  in  vascular  changes  in  these  parts,  having 
their  origin  in  disturbances  of  nutrition. 

Symptoms. — An  attack  of  chorea  generally  comes  on  gradually.  At 
first  the  child  may  be  considered  simply  as  unusually  nervous ;  if  at  school, 
there  may  be  noticed  a  difficulty  in  writing,  drawing,  or  in  using  the 
hands  for  other  delicate  operations.  At  home,  the  child  is  continually 
dropping  things,  has  difficulty  in  feeding  himself,  sometimes  in  buttoning 
his  clothes,  and  very  frequently  he  is  not  brought  to  the  physician  until 
the  symptoms  have  lasted  a  week  or  two.  Sometimes  the  legs  are  first 
affected,  and  a  history  is  given  of  frequent  falls,  a  stumbling  gait,  diffi- 
culty in  going  upstairs,  etc.  At  other  times  the  spasm  is  first  seen  in  the 
facial  muscles,  with  disturbance  of  articulation,  twitchiugs  of  the  eye 
muscles,  and  the  child  may  be  punished  for  making  grimaces.  In  most 
cases  the  spasmodic  movements  soon  extend  to  all  parts  of  the  body. 
According  to  Starr,  they  remain  limited  to  one  side  of  the  body  (hemi- 
chorea)  in  about  one  third  of  the  cases.  "When  fully  developed,  the  move- 
ments of  chorea  are  quite  unmistakable.  They  are  irregular,  jerking, 
spasmodic,  never  rhythmical,  rarely  symmetrical,  and  vary  in  intensity 
from  an  occasional  muscular  contraction  to  almost  constant  motion.  The 
movements  are  not  under  the  control  of  the  patient's  will,  and  are  usually 
intensified  by  efforts  to  suppress  them.  They  are  increased  by  excitement, 
embarrassment,  or  fatigue,  but  do  not  as  a  rule  continue  during  sleep. 

Very  often  there  is  some  weakness  of  the  affected  muscles,  which  may 
be  so  great  as  to  lead  to  the  suspicion  that  actual  paralysis  exists,  l^ot  in- 
frequently I  have  had  patients  brought  to  the  clinic  for  supposed  paralysis, 
either  of  one  extremity  or  of  one  side  of  the  body,  where  the  choreic  move- 
ments have  not  been  severe  enough  to  attract  the  attention  of  the  mother. 
This  paralysis  usually  disappears  in  the  course  of  a  few  weeks. 

In  severe  forms  of  chorea  the  patient  may  be  unable  to  help  himself 
or  even  to  walk,  from  the  inability  to  co-ordinate  muscular  movements. 
The  symptoms  may  be  so  intense  as  even  to  endanger  life.  Such  cases, 
however,  are  dangerous,  not  from  the  choreic  movements,  but  from  the 
acute  endocarditis  with  which  they  are  frequently  associated. 

The  mental  condition  of  choreic  patients  is  one  of  marked  irritability. 
They  are  fretful,  emotional,  easily  provoked  to  tears  or  laughter,  and 
often  very  difficult  to  control.  In  extreme  cases  a  mental  disturbance 
bordering  upon  acute  mania  has  been  observed.  All  degrees  of  speech 
disturbances  may  be  met  with,  from  the  slight  difficulty  in  articulation 


CHOREA.  721 

due  to  inability  properly  to  control  the  movements  of  the  tongue  and  lips, 
to  a  condition  in  which  speech  is  almost  impossible.  In  rare  cases  speech 
has  been  temporarily  lost.  Heart  murmurs  are  frequent  in  chorea.  Some 
of  these  are  of  anaemic  origin,  some  possibly  are  due  to  chorea  of  the  heart- 
muscle  itself — although  this  is  a  matter  of  some  uncertainty — but  a  large 
number,  probably  the  majority,  are  due  to  concurrent  endocarditis,  as  is 
shown  by  the  fact  that  they  are  permanent,  and  are  followed  by  all  the 
signs  of  organic  heart  disease.  During  every  attack  the  heart  should  be 
closely  watched,  especially  in  children  in  whom  there  is  a  strong  predis- 
position to  rheumatism. 

The  urine  in  chorea  has  recently  been  studied  with  care  by  Herter  and 
Smith,  who  have  shown  that  in  very  many  cases  there  is  an  excessive 
elimination  of  uric  acid.  This  is  neither  the  cause  nor  the  effect  of  the 
chorea,  but  is  to  be  regarded  as  evidence  of  a  profound  disturbance  of 
nutrition,  of  which  the  choreic  movements  are  but  another  manifestation.* 
The  general  condition  of  choreic  patients  is  usually  much  below  normal. 
They  are  angemic  ;  the  appetite  is  poor,  often  capricious ;  they  sleep  very 
badly ;  they  suffer  frequently  from  headaches  ;  they  are  easily  fatigued  by 
slight  muscular  exertion ;  and  in  short  they  have  all  the  symptoms  of  a 
greatly  disturbed  nutrition. 

Course  and  Duration. — The  ordinary  form  of  chorea  tends  to  spon- 
taneous recovery  in  from  six  to  ten  weeks.  Exceptionally  it  may  last  for 
three  or  four  months.  In  a  small  number  of  cases  the  disease  may  be- 
come chronic  and  continue  indefinitely.  Certain  forms  of  local  spasm, 
particularly  choreiform  movements  of  the  muscles  of  the  face,  eyes,  or 
neck,  may  be  permanent.  In  any  case  of  chorea  which  lasts  longer  than 
the  usual  time,  the  patient  should  be  carefully  examined  for  some  cause  of 
peripheral  irritation.  The  tendency  to  relapses  and  second  attacks  is  very- 
marked.  Later  attacks  are  likely  to  occur  in  the  spring  succeeding  the 
first  illness,  and  in  a  small  number  of  patients  attacks  may  come  every 
year  for  four  or  five  years. 

Diagnosis. — There  is  little  difficulty  in  recognising  chorea  from  the 
sudden,  irregular,  spasmodic  contraction  of  the  muscles  coming  on  under 
the  circumstances  indicated.  No  other  movements  of  childhood  are 
likely  to  be  confounded  with  it.  The  form  of  chorea  following  hemi- 
plegia is  usually  more  athetoid  than  choreic,  yet  at  times  it  closely  simu- 
lates ordinary  chorea.  The  difficulty  in  distinguishing  between  the  two  is 
often  increased  by  the  fact  that  the  weakness  of  simple  chorea  may,  if  uni- 
lateral, closely  simulate  hemiplegia.    The  existence  of  rigidity,  contractions. 


*  Dr.  rierter  has  called  my  attention  to  the  fact  that  in  many  eases  of  well-marked 
chorea  the  urine  contains  a  peculiar  reddish  colouring  matter  called  hiemato-porphyrin. 
This  is  also  found  in  many  cases  of  rheumatism,  another  evidence  of  the  close  relation- 
ship existing  between  these  two  diseases. 


Y22  DISEASES  OF  THE  NERVOUS  SYSTEM. 

and  increased  reflexes  belongs  exclusively  to  hemiplegic  cases,  and  these 
will  usually  suffice  to  clear  up  all  doubt  with  reference  to  the  diagnosis. 

Prognosis. — As  a  rule  this  is  favourable,  and  complete  recovery  can  be 
predicted,  the  exceptions  being  few  in  number.  Parents  should  always 
be  warned  of  the  tendency  of  the  disease  to  return  in  succeeding  years, 
and  the  fact  should  be  stated  that  in  a  certain  proportion  of  eases  the 
disease  may  be  permanent.  The  prognosis  of  the  cardiac  murmurs  oc- 
curring in  chorea  should  always  be  guarded,  although  some  of  these  are 
functional  and  disappear  with  recovery  from  the  chorea ;  but  the  number 
of  those  which  do  not  disappear  is  sufficiently  large  to  make  one  always 
apprehensive  as  to  the  ultimate  result.  Acute  chorea  accompanied  with 
endocarditis  may  be  fatal ;  a  number  of  such  cases  are  on  record  in  which 
there  was  no  other  evidence  of  rheumatism. 

Treatment. — The  general  management  of  the  case  is  equally  impor- 
tant with  the  administration  of  drugs.  A  child  with  chorea  should  at 
once  be  taken  from  school,  and  should  never  be  subjected  to  punishment 
or  to  ridicule  on  account  of  the  movements.  Special  attention  should 
be  given  to  the  patient's  diet  and  general  nutrition.  Tonics,  especially 
iron,  are  indicated  in  most  cases.  The  food  should  be  simple  and  nutri- 
tious, and  all  stimulants,  particularly  tea  and  coffee,  should  be  absolutely 
prohibited.  While  fresh  air  is  desirable,  exercise  should  be  prescribed 
with  great  caution  and  its  effect  should  be  carefully  watched.  It  should 
never  be  carried  beyond  the  point  of  slight  fatigue.  A  certain  amount  of 
moral  restraint  is  absolutely  necessary;  thus  it  often  happens  that 
choreic  patients  do  very  badly  at  home  where  they  are  indulged  and  re- 
ceive sympathy,  while  in  a  hospital,  where  they  are  under  restraint  and 
made  to  control  themselves,  they  begin  to  improve  immediately.  Gjir- 
nastics,  although  useful  in  some  of  the  milder  cases,  may  do  positive 
harm  in  those  which  are  severe.  They  should  be  regularly  and  systemat- 
ically practised  twice  a  day,  but  not  continued  too  long.  In  all  severe 
cases  the  "  rest  treatment "  should  be  employed,  whicli  is  equally  bene- 
ficial in  the  milder  ones ;  the  patient  is  put  to  bed,  and  complete  mental 
and  physical  rest  secured.  This  may  be  combined  with  gentle  massage 
for  fifteen  or  twenty  minutes  a  da3\  The  daily  use  of  warm  baths,  either 
alone  or  in  conjunction  Avith  massage,  is  decidedlj'  beneficial.  In  other 
cases  the  regular  use  of  cold  sponging  is  of  the  greatest  value. 

With  reference  to  the  use  of  drugs,  it  is  advisable  to  separate  from 
other  cases  those  in  which  the  connection  with  rheumatism  is  very  close. 
In  the  rheumatic  cases,  salicylate  of  soda  is  often  efficient,  while  the  drugs 
usually  employed  may  be  absolutely  Avithout  effect.  In  a  case  recently 
under  observation,  arsenic  had  been  continued  for  two  weeks  without  the 
slightest  improvement,  when  the  patient  had  an  intercurrent  attack  of 
subacute  rheumatism  for  which  salicylate  of  soda  in  full  doses  was  giA^n, 
Avith  the  effect  of  controlling  the  choreic  symptoms  promptly  and  perma- 


HABIT  SPASM.  723 

nently.  In  the  non-rheumatic  cases,  arsenic  is  almost  universally  ad- 
mitted to  be  the  most  valuable  remedy  we  possess.  The  method  of 
administration  is  important;  failure  most  frequently  results  from  the 
use  of  too  small  doses.  Beginning  with  four  drops  of  Fowler's  solution 
three  times  a  day  for  a  child  of  eight  years,  the  daily  quantity  may  be 
increased  by  two  drops  each  day  until  a  disturbance  of  the  stomach  or 
bowels  is  produced,  with  puffiness  under  the  eyes.  The  drug  should  now 
be  stopped  for  two  or  three  days,  and  then  the  same  doses  resumed  and 
gradually  increased,  usually  up  to  twelve  drops  three  times  a  day,  some- 
times to  fifteen,  and  even  twenty  drops,  unless  the  movements  cease 
before  that  time;  but  when  this  occurs  the  drug  should  be  stopped. 
Arsenic  should  always  be  given  after  meals,  and  largely  diluted,  the  dose 
being  taken  in  a  full  glass  of  water,  but  not  necessarily  drunk  at  one 
time.  The  possibility  of  arsenical  poisoning  should  be  remembered,  al- 
though it  is  extremely  rare.  Semple  has  reported  a  case  in  which  mul- 
tij)le  neuritis  and  general  pigmentation  of  the  skin  occurred  after  four 
weeks'  administration  of  the  drug. 

In  the  event  of  the  failure  of  arsenic  alone,  it  should  be  combined  with 
the  rest  treatment.  Drugs  which  sometimes  succeed  where  arsenic  fails 
are  antipyrine  and  strychnine.  From  twenty  to  thirty  grains  of  antipyrine 
should  be  given  daily  in  divided  doses  to  a  child  of  eight  years.  There 
are  a  certain  number  of  cases  in  which  striking  improvement  follows  the 
use  of  this  drug  if  given  in  the  full  doses  mentioned.  To  a  child  of  eight 
years  strychnine  should  be  given  in  doses  of  -^  of  a  grain  three  times  a 
day,  the  dose  being  gradually  increased  until  double  this  quantity  is 
given;  sometimes  even  larger  doses  than  these  are  well  borne.  Galvanism 
is  of  some  value  in  cases  not  relieved  by  drugs.  Acute  chorea  of  great 
severity  may  require  opium,  bromide  and  chloral,  or  even  chloroform. 

In  estimating  the  value  of  drugs  in  the  treatment  of  chorea,  the  natu- 
ral course  of  the  disease  should  be  kept  in  mind,  since  those  drugs  which 
are  taken  after  the  third  or  fourth  week  are  much  more  likely  to  be 
thought  beneficial  than  those  used  in  the  early  period  of  the  attack. 

There  is  no  doubt  that  chorea  may  be  dependent  upon  some  ocular  de- 
fect, and  a  correction  of  this  will  then  form  an  essential  part  of  the  treat- 
ment, although  few,  if  any,  cases  are  cured  by  attention  to  the  eyes  alone. 

Chorea  has  a  strong  tendency  to  recur,  especially  in  the  spring  of  the 
year.  Children  who  have  had  one  attack  should  be  closely  watched,  par- 
ticularly with  reference  to  their  work  in  school.  They  should  not  be 
crowded  in  their  studies,  they  should  have  long  vacations,  and  the  nerv- 
ous system  should  not  be  put  upon  any  severe  tension  for  a  long  time. 

OTHER  SPASMODIC   AFFECTIONS. 

Habit  Spasm. — This  term  was,  I  think,  first  suggested  by  Gowers,  to 
•describe  certain  muscular  movements  of  a  spasmodic  character  which  at 


Y24  DISEASES   OP   THE   NERVOUS  SYSTEM. 

first  are  only  occasionally  noticed,  but  which  sometimes  persist  until  they 
become  habitual  and  almost  entirely  involuntary.  The  condition  was  pre- 
viously called  "  habit  chorea  "  by  Weir  Mitchell.  The  movements  usually 
affect  the  muscles  of  the  face,  but  they  may  be  seen  in  almost  any  part  of 
the  body.  The  most  frequent  varieties  consist  of  blinking  or  sudden 
frowning,  raising  the  eyebrows,  or  some  peculiar  grimace.  At  other  times 
there  is  sudden  twisting  of  the  head,  shrugging  of  the  shoulders,  or  jerk- 
ing of  the  hands.  It  is  not  often  seen  in  the  leg,  but  the  muscles  of 
respiration  are  quite  frequently  affected.  There  may  be  a  half-sigh,  a 
sort  of  sob,  or  a  peculiar  dry,  laryngeal  cough. 

These  movements  are  at  first  only  occasional ;  but  as  the  habit  becomes 
more  firmly  fixed  the  spasm  recurs  every  few  minutes,  and  in  severe  cases 
it  may  be  almost  continuous.  In  nearly  all  cases  it  increases  by  observa- 
tion. The  same  form  of  spasm  does  not  always  continue,  but  after  a  time 
one  may  subside  and  another  take  its  place.  The  condition  may  last  for 
months  or  years,  and  it  may  even  be  permanent. 

The  causes  are  those  of  neuroses  in  general.  In  the  beginning,  at 
least,  there  is  usually  a  somewhat  depreciated  general  health.  The  patients 
are  nervous  children  of  neurotic  antecedents.  There  may  be  a  history  of 
some  definite  exciting  cause,  such  as  illness  or  overwork  in  school.  The 
spasm  of  the  muscles  about  the  eyes  may  be  associated  with  pathological 
conditions  of  these  organs.  This  may  be  enough  to  start  the  spasm,  if  not 
to  continue  it.  Both  sexes  are  affected.  In  boys,  masturbation  may  some- 
times be  an  exciting  cause. 

Habit  spasm  is  to  be  differentiated  from  chorea :  this  is  usually  easy, 
from  the  limitation  of  the  movements  to  one  part  or  group  of  muscles  and 
from  the  duration  of  the  disease. 

Treatment  is  quite  unsatisfactory  after  the  habit  has  become  fixed, 
hence  it  is  of  the  utmost  importance  that  it  should  be  arrested  at  the 
earliest  possible  age.  Punishments  are  of  no  avail,  and  usually  aggravate 
the  condition.  Ee wards  are  much  more  effectual.  The  general  health 
should  receive  attention  and  nerve  tonics  should  be  given,  especially 
strychnine. 

Athetosis  and  Athetoid  Movements.— This  term,  introduced  by  Ham- 
mond, is  used  to  describe  a  chronic  form  of  spasm  usually  seen  in  the 
hand,  but  sometimes  also  in  the  foot,  and  even  the  face.  It  may  affect 
both  sides,  but  in  most  cases  it  is  unilateral.  The  movement  is  slow, 
irregular,  and  inco-ordinate — a  sort  of  "mobile  spasm,"  as  it  has  been 
called — and  there  may  be  associated  a  certain  amount  of  muscular  rigidity. 
Such  movements  may  occur  in  persons  otherwise  healthy,  but  are  usually 
seen  as  a  sequel  of  cerebral  palsies,  generally  hemiplegia.  Eecovery  from 
the  hemiplegia  may  be  so  nearly  complete  that  the  athetoid  movements 
are  looked  upon  as  primary.  In  some  cases  the  movements  are  more 
rapid   and   somewhat   resemble  those   of   chorea,   the    condition   being 


NYSTAGMUS.  Y25 

sometimes  classed  as  post-hemiphgic  chorea.     Athetosis  is  not  influ- 
enced by  treatment. 

Rotary  and  Nodding  Spasm  of  the  Head. — These  are  rare  forms  of 
irregular  movements  usually  observed  in  infancy.  The  condition  was 
described  long  ago  by  Henoch,  and  since  then  cases  have  been  reported  by 
Hadden,*  Peterson,  and  others.  The  most  frequent  is  the  rotary  spasm, 
which  consists  in  a  side-to-side  oscillation  of  the  head,  which  may  be  slow 
or  rapid,  and  in  some  cases  is  almost  continuous.  Some  children  have  at 
times  the  nodding  spasm  also,  and  in  others  this  is  the  only  movement 
seen.  Nystagmus  is  frequently  associated,  and  may  affect  one  or  both 
eyes.  In  a  few  of  the  reported  cases  convergent  strabismus  was  present. 
The  causes  of  the  condition  are  extremely  obscure.  It  is  usually  seen 
in  infancy  between  the  third  and  eighteenth  months,  and,  like  most  nerv- 
ous symptoms  of  this  period,  has  been  ascribed  to  dentition,  but  without 
any  special  reason.  In  three  of  the  cases  reported  by  Hadden,  it  followed 
an  injury  to  the  head,  and  might  perhaps  be  regarded  as  a  result  of  cere- 
bral concussion. 

As  a  rule,  the  condition  lasts  for  several  months  and  improves,  recov- 
ery generally  taking  place.  The  prognosis  is  therefore  usually  favour- 
able. In  most  of  the  reported  cases  improvement  has  followed  the  use 
of  bromides ;  from  ten  to  twelve  grains  daily  should  be  given. 

Nystagmus. — This  term  is  applied  to  rhythmical,  involuntary,  oscillatory 
movements  usually  of  both  eyes.  They  are  caused  by  the  alternate  con- 
traction of  opposing  muscles.  Nystagmus  may  be  either  vertical  or  hori- 
zontal. It  is  most  often  seen  in  infants  a  few  months  old,  and  is  a 
symptom  of  irritation  which  may  be  general  or  local.  In  some  cases  the 
movement  is  almost  continuous,  occurring  even  in  sleep ;  in  others,  it  is 
only  noticed  at  times  of  special  excitement. 

The  etiology  of  nystagmus  is  obscure,  and  it  may  occur  in  quite  a 
variety  of  conditions, — sometimes  referable  to  the  eye,  at  other  times  to 
the  central  nervous  system.  On  the  part  of  the  eye,  nystagmus  may  be 
due  to  blindness  from  any  cause,  to  congenital  cataract,  corneal  opacity, 
disease  of  the  choroid  or  retina,  or  to  errors  of  refraction.  It  may  be 
seen  in  almost  any  organic  disease  of  the  nervous  system,  both  with  focal 
and  diffuse  lesions,  especially  in  chronic  hydrocephalus,  insular  sclerosis, 
tuberculous  meningitis,  and  in  diseases  in  which  sight  is  impaired.  Nystag- 
mus may  be  of  reflex  origin,  as  in  a  case  recently  occurring  in  the  Babies' 
Hospital,  where  an  infant  with  a  severe  diarrhoea  had  repeated  attacks, 
which  disap^Dcared  each  time  after  intestinal  irrigation.  "While  it  is  of  no 
importance  as  a  localizing  symptom,  nystagmus  usually  indicates  some- 
thing more  than  functional  disturbance.  An  exception  to  this  may  per- 
haps be  made  when  it  follows  cerebral  concussion.     In  such  cases  it  is 

*  Lancet,  June  14,  1890. 


^12Q  DISEASES   OF   THE   XERVOUS  SYSTEM. 

usually  temporary,  disa^Dpearing  in  a  few  days  or  weeks.  Under  most 
other  conditions  it  may  continue  indefinitely. 

The  condition  of  the  eyes  should  be  investigated  in  every  case  of 
nystagmus ;  it  is  only  when  the  cause  is  here,  and  can  be  removed,  that 
habitual  nystagmus  is  amenable  to  treatment. 

Hiccough  (Singultus). — This  is  a  S23asm  of  the  diaphragm  which  is 
usually  seen  in  young  infants.  In  them  it  is  in  most  cases  due  to  some 
irritation  in  the  stomach.  It  is  seen  after  eating,  and  may  depend  upon 
overfilling  of  the  stomach  by  food,  swallowing  of  air,  etc.  In  other 
cases  it  has  no  rfelation  to  the  taking  of  food,  and  is  to  be  regarded  as 
a  form  of  reflex  spasm,  which  may  occur  from  a  variety  of  causes,  such  as 
cold  feet,  chilling  of  the  surface  during  bath,  or  suddenly  taking  an  in- 
fant from  a  warm  bed  into  a  cold  room.  In  cases  like  the  above,  hic- 
cough, though  sometimes  annoying,  is  of  little  importance.  It  may  be 
associated  with  gastric  indigestion,  with  intestinal  flatulence  or  inflamma- 
tion, with  peritonitis  or  intestinal  obstruction.  With  the  last  two  condi- 
tions it  is  always  an  unfavourable  symptom.  In  older  children  hiccough 
sometimes  occurs  as  a  pure  neurosis. 

The  object  of  treatment  is  to  remove  the  cause.  In  infants  this  is  to 
aid  in  the  expulsion  of  the  gas  from  the  stomachby  manipulation,  position, 
or  the  other  means  useful  in  gastric  colic.  Wliere  it  is  a  nervous  symptom 
only,  it  may  be  arrested  by  holding  the  breath,  by  prolonged  forced  ex- 
piration, as  in  blowing  a  trumpet,  and  sometimes  it  may  be  relieved  by 
drugs  which  control  muscular  spasm — e.  g.,  antipyrine  or  chloral. 

Thomsen's  Disease  (Congenital  Myotonia). — This  rare  disease  is  usually 
congenital.  It  may  occur  in  several  members  of  the  same  family,  and  is 
often  hereditary.  The  characteristic  symptoms  are  a  peculiar  rigidity  of 
the  muscles  which  is  observed  when  they  are  first  brought  into  action  after 
repose.  This  rigidity  is  spasmodic,  and  usually  continues  but  a  few 
moments.  It  may  recur  when  voluntary  movements  are  again  attemj)ted. 
If,  however,  muscular  effort  is  persisted  in,  it  soon  passes  off.  It  is  in- 
creased by  apprehension,  excitement,  or  cold,  and  by  observation.  The 
legs  are  most  frequently  afiected,  the  condition  being  often  noticed  when 
the  patient  starts  to  walk ;  any  of  the  voluntary  muscles,  however,  may 
be  involved.  It  may  be  greater  upon  one  side  of  the  body  than  upon  the 
other.  The  muscles  are  abnormally  sensitive  to  mechanical  stimulation, 
and  often  to  galvanism.  They  are  above  normal  size,  and  the  fibres  them- 
selves are  enlarged. 

The  pathology  of  this  disease  is,  according  to  Gowers,  an  altered  func- 
tional condition  of  the  muscle  fibres,  and  an  abnormal  functional  state  of 
the  nerve  cells  of  the  cord  and  the  cortex.  It  is  incurable,  although  the 
symptoms  n-:ay  be  improved  by  active  muscular  exercise. 

Cervical  Opisthotonus. — This  is  usually  a  symptom  of  disease  at  the 
base  of  the  brain,  occurring  with  simple,  tuberculous,  and  chronic  basilar 


TORTICOLLIS. 


727 


meningitis,  sometimes  with  tumours  of  the  posterior  fossa  of  the  skull. 
However,  in  certain  cases  it  occurs  as  a  form  of  reflex  spasm,  particu- 
larly in  young  infants  who  are  suffering  from  diarrhoeal  diseases  or  maras- 
mus. In  these  cases  it  may  last  for  days  or  weeks.  The  deformity  is 
produced  by  a  contraction  of  the  superior  fibres  of  the  trapezius  and  by  the 
posterior  group  of  cervical  muscles. 

Torticollis — Wry-Neck. — Torticollis  is  usually  produced  by  a  tonic 
spasm  of  one  sterno-mastoid  muscle,  with  which  may  be  associated  spasm 
of  the  posterior  cervical  muscles, 
including  the  trapezius.  In  re- 
cent cases  there  is  simply  a  con- 
dition of  muscular  spasm ;  in  those 
of  long  standing  there  may  be 
permanent  shortening  of  the  af- 
fected muscle,  atrophy,  and  par- 
tial paralysis.  A  somewhat  simi- 
lar deformity  may  be  caused  by 
cicatricial  contraction  of  the  tis- 
sues of  the  neck  following  burns. 

The  deformity  varies  some- 
what according  as  the  sterno-mas- 
toid muscle  is  alone  affected,  or 
the  posterior  muscles  also,  and  as 
to  which  predominates.  In  sim- 
ple sterno-mastoid  spasm  the  head 
is  inclined  to  the  affected  side  and 
rotated  toward  the  opposite  side ; 
the  chin  is  raised,  and  the  ear 
approaches  the  clavicle.  "When 
other   muscles  are    involved   the 

deformity  is  modified.  If  the  trapezius  is  affected  (Fig.  122)  there  is  less 
rotation  of  the  head,  but  it  is  drawn  to  the  affected  side  and  somewhat 
backward,  while  the  shoulder  is  raised  and  the  spine  curved.  Both  of 
these  symptoms  may  be  seen  to  a  slight  degree  in  almost  any  marked  case 
of  sterno-mastoid  spasm.  Sometimes  the  spasm  of  the  posterior  muscles 
affects  both  sides ;  the  head  is  then  drawn  backward  and  held  rigidly  but 
without  rotation.  In  most  of  the  recent  cases  the  deformity  can  be 
partially  or  entirely  overcome  by  passive  force ;  but  after  a  time  this  is 
impossible,  owing  to  muscular  shortening.  In  recent  cases  also  localized 
pain  and  tenderness  are  frequently  present,  and  sometimes  they  are  severe. 

Etiology. — Spasmodic  torticollis  may  be  produced  by  anything  causing 
irritation  of  the  trunk  or  the  branches  of  the  spinal  accessory  nerve  ;  the 
source  may  be  in  the  spinal  canal,  in  the  cranium,  along  the  course  of  the 
nerve  trunk,  or  of  any  of  its  peripheral  fibres. 


Fig.  122. — Spasmodic  torticollis  from  malaria. 
Trapezius  and  sterno-mastoid  of  the  left 
side  are  affected. 


728  DISEASES   OF   THE  XERVOUS   SYSTEM. 

Cases  are  usually  divided  into  congenital  and  acquired.  Whitman,* 
from  the  records  of  the  Hospital  for  the  Ruptured  and  Crippled,  ISTew 
York,  for  nineteen  years,  gives  the  following  statistics  of  264  cases, — torti- 
collis from  Pott's  disease  not  being  included  :  Males,  109  ;  females,  155  ; 
congenital,  32  ;  under  two  years,  33  ;  from  two  to  ten  years,  153 ;  over 
ten  years,  46  ;  acute  (i.  e.,  of  less  than  two  months'  duration),  77 ;  chronic, 
60,  of  which  number  22  had  lasted  two  years  or  longer. 

Regarding  the  cause  of  congenital  torticollis  there  is  some  dispute. 
Such  cases  have  often  been  attributed  to  the  contraction  resulting  from 
haematoma  of  the  sterno-mastoid  (page  94).  My  own  experience  coin- 
cides with  Whitman's,  that  this  is  rarely  if  ever  the  case.  While  it  is  pos- 
sible that  the  deformity  is  sometimes  the  consequence  of  injury  received 
during  delivery,  the  cause  of  most  of  the  congenital  cases  goes  back  to  con- 
ditions existing  before  birth.  It  may  be  compared  to  club-foot,  and 
may  be  due  to  a  faulty  position  of  the  child  in  utero,  or  it  may  come 
from  more  serious  conditions,  such  as  malformations,  or  unequal  develop- 
ment of  the  two  sides  of  the  body. 

One  of  the  most  frequent  causes  in  the  acquired  cases,  is  irritation  of 
the  spinal  accessory  nerve  by  an  enlarged  cervical  lymph  gland ;  this  was 
the  cause  assigned  in  nearly  half  of  Whitman's  cases  ;  such  is  the  usual 
etiology  of  torticollis  following  scarlet  fever,  measles,  or  diphtheria.  I 
have  seen  it  in  the  early  stage  of  quinsy,  and  it  may  occur  in  cellulitis  of  the 
neck.  A  cause  which  the  physician  should  always  have  in  mind  is  cervical 
Pott's  disease ;  torticollis  may  be  the  earliest,  and  for  several  weeks  some- 
times almost  the  only,  objective  symptom  of  this  disease.  Torticollis 
coming  on  acutely  is  most  frequently  due  to  cold  (rheumatism?)  or 
malaria.  I  have  notes  of  eight  cases  clearly  traceable  to  malaria,  and  have 
seen  at  least  a  dozen  others.  In  several  of  these  there  was  a  distinct  perio- 
dicity in  the  spasm,  it  recurring  regularly  at  about  the  same  time  each 
day  until  quinine  was  given  ;  in  some  cases  it  was  accompanied  by  fever, 
in  others  not.  In  the  so-called  rheumatic  torticollis,  muscular  pain  and 
soreness  are  rather  more  prominent  than  in  the  other  forms.  In  fourteen 
of  Whitman's  cases  the  spasm  was  attributed  to  injuries  other  than  burns  \ 
and  in  only  nine  was  it  associated  with  some  other  disease  of  the  nervous 
system,  most  frequently  with  chorea. 

Prognosis. — The  result  in  a  case  of  torticollis  depends  upon  the  cause, 
the  severity,  and  the  duration  of  the  deformity.  Most  of  the  acute  cases 
from  malaria,  rheumatism,  etc.,  recover,  under  appropriate  treatment,  in 
the  course  of  a  few  weeks,  sometimes  in  a  few  days,  and  not  a  few  re- 
cover spontaneously.  The  congenital  cases  with  slight  deformity  are 
usually  amenable  to  mechanical  or  postural  treatment  if  begun  early. 
There  is,  however,  in  most  of  the  other  varieties  a  disposition  of  the  de- 

*  Observations  upon  Torticollis,  Medical  News,  October  24,  1891. 


HYSTERIA.  729 

formity,  if  untreated,  to  persist,  aud  even  to  increase.  If  it  has  lasted 
several  months  the  probabilities  of  spontaneous  recovery  or  even  of  im- 
provement are  small. 

Treatment. — The  first  indication  is  to  remove  or  treat  the  cause  where 
one  can  be  found.  Malarial  cases  require  quinine  ;  rheumatic  cases  are 
benefited  by  rest  in  bed,  hot  applications,  counter-irritation,  friction,  and 
sometimes  by  anti-rheumatic  remedies.  Cases  which  have  lasted  a  month 
usually  require  some  orthopaedic  head-support,  and  those  which  have 
lasted  six  months  or  more  are  rarely  cured  without  a  surgical  operation. 
This  may  be  either  a  subcutaneous  tenotomy  or  myotomy  of  the  sterno- 
mastoid,  or  an  open  incision.  Whitman  gives  the  result  of  thirty-two  cases 
admitted  for  treatment  to  the  hospital  mentioned,  as  follows  :  In  17  in 
which  the  deformity  had  lasted  less  than  six  months,  10  were  cured,  the 
average  duration  of  treatment  being  three  months;  4  were  improved,  and 
3  not  improved,  the  average  duration  of  treatment  in  these  cases  being 
eleven  months.  Of  15  cases  in  which  the  deformity  had  lasted  over  six 
months,  none  were  cured  and  only  6  improved,  after  an  average  of  about 
eight  months'  treatment.  In  the  foregoing  series  of  cases  the  treatment 
consisted  mainly  in  the  use  of  orthopaedic  apparatus  ;  later  results  from 
incision  have  been  considerably  more  favourable.  But  these  figures  show 
how  serious  a  matter  is  an  old  case  of  torticollis,  and  emphasize  the  im- 
portance of  resorting  to  radical  measures  early  in  the  disease. 

HYSTERIA. 

This  is  not  a  disease  of  childhood,  but  one  which  is  occasionally  seen 
in  early  life.  All  that  will  be  attempted  in  this  chapter  is  to  point  out  the 
most  common  manifestations  of  hysteria  when  it  occurs  in  young  children. 
After  puberty  it  is  essentially  the  same  as  in  adults.* 

Etiology. — Hysteria  is  very  rare  before  the  seventh  or  eighth  year,  and 
most  of  the  cases  seen  in  children  occur  after  the  tenth  year.  As  to  sex, 
there  is  no  such  predominance  of  females  as  in  later  life,  although  even  in 
childhood  they  are  more  frequently  affected  than  males.  Hereditary 
influences  play  an  important  part  in  the  production  of  this  disease.  It  is 
seen  in  children  who  inherit  a  nervous  constitution,  or  in  whose  parents 
nervous  diseases,  such  as  insanity,  or  hysteria,  or  alcoholism  have  been 
present.  Of  the  other  etiological  factors  the  most  imjjortant  are  a  dis- 
ordered nutrition,  frequently  with  ansemia  or  chlorosis,  and  overpressure 
in  schools.  Masturbation  or  phimosis  may  act  as  an  exciting  cause,  or, 
indeed,  anything  which  leads  to  an  exalted  nervous  irritability  aud  depre- 
ciation of  the  general  health.     It  is  occasionally  associated  with  tuber- 

*  For  a  fuller  discussion  of  this  subject,  and  references  to  recent  literature,  see 
Mills,  in  Keating's  Cyclopasdia,  vol.  iv. 


730  DISEASES  OF  THE  NERVOUS  SYSTEM. 

culosis ;  it  may  follow  any  of  the  acute  infectious  diseases ;  or  it  may  be 
excited  by  injury,  fright,  or  imitation. 

Symptoms. — There  is  scarcely  any  disease  in  which  the  clinical  picture 
presented  is  so  varied  as  in  hysteria.  It  may  simulate  almost  any  form  of 
organic  disease  of  the  brain,  lungs,  digestive  organs,  bones,  or  joints.  The 
most  common  symptoms  may  be  grouped  under  four  general  heads.  These 
are,  however,  seen  in  almost  every  conceivable  combination. 

1 .  Psychical  symptoms. — Where  these  predominate  there  may  be  seen 
periods  of  mental  depression  of  longer  or  shorter  duration,  a  change  in 
disposition,  an  indifference  to  surroundings,  a  capricious  humour,  or  a  nerv- 
ous condition  of  extreme  irritability  with  irregular  paroxysms  of  laugh- 
ter or  weeping  without  cause.  There  may  be  great  excitability  of  temper, 
and  fits  of  passion  almost  maniacal  in  their  severity.  There  may  be  vari- 
ous hallucinations.  Sleep  is  frequently  disturbed,  sometimes  by  attacks 
resembling  ordinary  night-terrors ;  sometimes  somnambulism  is  present. 
There  is  often  a  disposition  to  deception  about  the  most  trivial  matters, 
which  may  last  for  weeks.  There  is  a  tendency  to  imifate  the  symptoms 
of  various  diseases,  which  the  patients  may  have  witnessed  in  others  or 
about  which  they  have  read. 

2.  Sensory  symptoms. — These  are  the  most  frequent  manifestations  o\ 
hysteria  in  early  life.  There  is  often  general  or  local  hypersesthesiaj 
which  may  be  so  great  as  to  simulate  inflammation  of  the  various  internal 
organs.  Anaesthesia  is  much  less  common,  although  it  may  be  seen  in 
children  as  young  as  eight  or  nine.  Headache  is  an  occasional  symptom, 
and  is  sometimes  associated  with  great  tenderness  of  the  scalp.  There 
may  be  neuralgias  in  the  different  parts  of  the  body,  or  sharp  epigastric 
pain,  sometimes  accompanied  by  vomiting.  Sometimes  the  special  senses 
are  affected,  giving  rise  to  hysterical  blindness  or  deafness,  usually  of  short 
duration. 

3.  Joint  symptoms. — These  are  really  a  variety  of  sensory  disturbances. 
They  are  not  uncommon,  and  are  often  most  puzzling.  The  symptoms 
may  be  referable  to  the  spine,  or  to  any  of  the  large  joints,  particularly 
those  of  the  lower  extremity.  All  forms  of  organic  disease  of  these  joints 
may  be  simulated,  and  these  patients  are  often  treated  for  months  with 
orthopaedic  apparatus,  with  the  belief  that  they  are  suffering  from  Pott's 
disease,  lateral  curvature  of  the  spine,  club-foot,  or  ostitis  of  the  hip,  knee, 
or  ankle.  Cases  of  this  sort  have  been  very  fully  described  by  Gibney,* 
and  by  Shaffer,  whose  articles  should  be  consulted  for  fuller  details.  They 
are  usually  seen  between  the  ages  of  ten  and  fourteen  years,  and  occur  in 
both  sexes.  There  may  be  lameness  referred  to  one  of  the  large  joints, 
curvature  of  the  spine,  or  torticollis.     The  symptoms  are  most  frequently 

*  Gribney,  Transactions  of  the  American  Neurological  Association,  1877.     Shaffer^ 
Archives  of  Medicine,  New  York,  December,  1879,  February  and  April,  1880. 


HYSTERIA.  731 

referred  to  the  hip,  and  next  to  the  knee,  the  ankle,  or  the  spine.  The 
pain  is  often  acute.  It  is  increased  by  motion,  and  by  attempts  at  over- 
coming the  deformity,  if  any  is  present.  There  is  a  marked  hyperaesthesia 
of  the  whole  limb,  and  sometimes  of  the  body.  In  nearly  every  case  there 
is  marked  tenderness  of  the  spine  upon  pressure,  especially  in  the  dorsal 
region.  The  deformity  may  be  very  slight  from  spasm  of  the  flexors 
only,  or  it  may  be  severe,  and  followed  by  contracture,  so  that  the  thighs 
may  be  flexed  tightly  against  the  abdomen  with  the  heels  against  the 
buttocks.  Such  deformities  may  last  for  months.  There  may  be  con- 
siderable muscular  atrophy,  but  only  that  which  comes  from  disuse.  A 
special  diflficulty  in  diagnosis  arises  from  the  circumstance  that  these 
symptoms  occasionally  follow  an  injury. 

Organic  disease  of  bones  and  joints  may  usually  be  excluded  by  atten- 
tion to  the  following  points :  The  mode  of  onset  is  more  abrupt  than  is 
seen  in  bone  disease,  and  the  course  of  the  disease  is  quite  irregular.  The 
degree  of  deformity  is  greater  than  is  seen  in  bone  disease  of  the  same 
duration.  There  are  general  hyperesthesia  of  the  limb,  acute  tenderness  of 
the  spine  upon  pressure,  and  undue  sensitiveness  to  heat  or  cold.  The  de- 
formity varies  from  time  to  time,  being  always  more  marked  when  examina- 
tion is  attempted.  If  the  patients  are  closely  watched,  other  evidences  of 
hysteria  may  be  seen.  Under  complete  anesthesia  the  contractures  may 
disappear  entirely.  There  is  no  enlargement  of  the  articular  ends  of  the 
bones,  no  swelling  of  the  soft  parts,  and  no  evidence  of  active  inflammation 
or  of  suppuration.  All  the  symptoms  except  the  deformity  are  subjective. 
Under  proper  treatment  there  is  in  most  cases  perfect  recovery,  often  in  a 
surprisingly  short  time. 

4.  Motor  and  convulsive  symptoms. — In  the  milder  forms  we  may 
see  many  varieties  of  tonic  or  clonic  spasm.  There  may  be  seen  local 
spasm  of  the  eyes,  face,  or  mouth,  spasm  of  the  muscles  of  the  neck  pro- 
ducing torticollis,  of  the  muscles  of  respiration  causing  dyspnoea,  which 
may  be  constant  or  paroxysmal.  There  may  be  hiccough,  or  spasm  of  the 
larynx  causing  hysterical  aphonia.  A  very  common  symptom  is  hysterical 
cough,  which  may  be  so  frequent  and  so  severe — even  accompanied  by 
haemoptysis — that  grave  disease  of  the  lungs  is  suspected  ;  the  chest, 
however,  is  free  from  the  physical  signs  of  disease.  There  may  be  fre- 
quent attacks  of  vomiting  with  eructations;  these  maybe  continued  some- 
times even  for  months,  and  in  rare  instances  blood  has  been  vomited. 
There  may  be  dysphagia  from  spasm  of  the  oesophagus,  or  regurgitation 
of  food  on  attempts  at  swallowing.  In  more  severe  cases  we  may  have  the 
symptoms  of  chorea  major  and  attacks  of  hystero-epilepsy.  The  latter  are 
rare  in  children  and  do  not  differ  essentially  from  such  attacks  in  older 
patients.  There  are  usually  prodromal  symptoms.  The  convulsive  move- 
ments are  exceedingly  varied  in  type.  There  are  painful  sensations  and 
sensitive  areas,  by  pressure  upon  which  hysterical  symptoms  may  be  in- 


732  DISEASES   OF  THE   XERVOUS  SYSTEM. 

creased  or  even  convulsions  excited.  The  respiration  may  be  rapid  or 
irregular.  All  variations  in  tonic  and  clonic  spasm  may  be  seen.  Opis- 
thotonus is  frequent.  Consciousness  is  not  fully  lost,  but  is  disturbed,  and 
hallucinations  are  present.     The  temperature  is  normal. 

Hysterical  paralysis  is  not  common  in  children,  but  it  may  be  seen 
even  in  the  very  young.  Gillette  has  reported  the  case  of  a  child  eighteen 
months  old  who  exhibited  the  symptoms  of  hysterical  palsy  of  one  arm. 
Other  symptoms  occasionally  seen  in  hysteria,  are  persistent  anorexia,  poly- 
uria, sometimes  incontinence  of  urine,  disturbance  of  the  secretion  of 
saliva  or  perspiration,  and  very  rarely  hysterical  fever. 

The  general  condition  of  hysterical  patients  is  usually  below  the  nor- 
mal. They  are  poorly  nourished  and  anemic ;  they  sleep  badly ;  they  have 
capricious  appetites,  feeble  digestion,  and  faulty  assimilation. 

Diagnosis. — Hysteria  is  apt  to  be  overlooked  because  its  occurrence  in 
children  is  not  considered  as  often  as  it  should  be.  In  most  cases  the 
diagnosis  is  easy  if  hysteria  is  suspected.  A  combination  of  vague  discon- 
nected symptoms  is  usually  present  which  admits  of  no  other  explanation. 
Organic  disease  can  be  excluded  only  by  careful  and  repeated  examinations. 
It  is  to  be  borne  in  mind,  however,  that  hysteria  not  infrequently  compli- 
cates organic  or  constitutional  disease.  Much  importance  is  to  be  attached 
to  a  family  history  of  hysteria  or  of  other  neuroses.  From  poliomyelitis, 
hysterical  paralysis  is  differentiated  by  the  presence  of  faradic  contractility 
even  though  atrophy  exists.  Hysterical  convulsions  are  differentiated  from 
true  epilepsy  by  the  absence  of  any  elevation  of  temperature,  of  biting  of 
the  tongue,  evacuation  of  the  viscera,  of  a  violent  fall,  and  often  by  the 
rapid  disappearance  of  the  symptoms  under  appropriate  treatment. 

Prognosis. — This  is  better  than  in  adults,  especially  if  the  cases  are 
taken  in  hand  early,  before  the  disease  has  become  deeply  seated.  Very 
much  depends  upon  how  well  the  directions  for  treatment  can  be  carried 
out.  The  prognosis  is  less  favourable  where  the  hereditary  tendency  is 
strongly  marked.     In  many  cases  there  are  relapses  later  in  life. 

Treatment. — Prophylaxis  is  of  much  importance.  When  a  hereditary 
tendency  to  nervous  diseases  exists  in  a  family,  or  whenever  very  nervous 
children  are  placed  under  the  physician's  care,  every  means  should  be  taken 
toward  muscular  development,  keeping  the  nervous  system  in  the  back- 
ground. Such  children  should  lead  an  out-of-door  life  as  much  as  possi- 
ble, preferably  in  the  country  ;  they  should  keep  early  hours,  have  regular 
exercise,  and  their  education  should  be  directed  with  moderation  and  judg- 
ment ;  special  attention  being  paid  to  regularity  of  work,  and  the  preven- 
tion of  overpressure  in  schools.  Theatres  and  exciting  books  should  be 
avoided.  All  stimulants,  including  tea  and  coffee,  should  be  absolutely 
forbidden.  The  diet  should  be  plain  and  nutritious.  It  is  highly  impor- 
tant that  such  children  should  be  removed  from  association  with  a  hysteri- 
cal mother,  when  this  is  possible. 


HEADACHES.  733 

In  the  g-eneral  management  of  a  case  of  hysteria,  it  is  of  the  first  im- 
portance that  the  child  shonld  be  cared  for  by  a  person  of  firmness,  who 
can  exercise  proper  control.  Hj'sterical  children  are  always  managed 
more  easily  when  they  are  removed  from  their  homes  and  placed  under  the 
charge  of  a  good  trained-nurse.  Isolation  is  absolutely  essential  in  many 
cases.  The  general  health  should  be  carefully  looked  after,  and  arsenic, 
iron,  cod-liver  oil,  and  other  tonics  given  according  to  indications.  Horse- 
back exercise  and  other  out-of-door  sports  should  be  encouraged,  and  every 
means  taken  to  interest  the  child  in  something  which  requires  j)hysical 
exercise.  In  cases  of  simulated  disease,  the  child  should  be  put  to  bed,  no 
books  or  toys  allowed,  and  no  effort  made  toward  his  amusement.  Xo 
sympathy  should  be  exliibited,  but  the  child  should  be  treated  ^vith  kind- 
ness and  firmness.  This  moral  treatment  is  quite  as  important  as  any 
other  part  of  the  therapeutics.  In  cases  with  hysterical  joint  symptoms 
the  most  valuable  thing  is  counter-irritation  to  the  spine,  preferably  by 
the  Paquelin  cautery.  Some  cases  are  benefitted  by  galvanism.  The 
moral  eff'ect  of  hypodermics,  even  of  cold  water,  is  sometimes  striking. 
Under  no  circumstances  should  mechanical  force  be  used  to  overcome 
deformity.  Many  cases  of  hysteria  improve  under  hydrotherapy;  the 
cold  douche,  the  cold  pack,  or  the  shower  bath  may  be  used.  This  is 
valuable  in  conjunction  with  massage  and  the  "  rest  treatment.'"' 

In  attacks  of  hystero-epilepsy  the  cold  douche  may  be  used,  or  pres- 
sure made  upon  the  testicle  or  ovary.  In  severe  eases  ether  may  be  given. 
In  all  hysterical  cases  the  condition  of  the  bowels  should  receive  careful 
attention,  as  these  patients  are  very  prone  to  obstinate  constipation. 

HEADACHES. 

Headaches  are  not  common  in  little  children  except  in  connection 
with  disease  of  the  brain  or  meninges ;  in  older  children  they  occur  from 
causes  similar  to  those  seen  in  adult  life.  The  most  frequent  headaches 
may  be  grouped  in  the  following  classes  : 

1.  Toxic  headaches. — Such  are  the  headaches  resulting  from  ura?mia, 
from  carbonic  acid  in  poorly  ventilated  rooms,  and  from  malaria.  But 
the  largest  number  are  due  to  absorption  of  toxines  from  the  intestines, 
and  are  associated  with  chronic  indigestion  and  constipation. 

2.  Headaches  from  aniemia  and  malnutrition. — These  are  most  fre- 
quently seen  in  girls  from  ten  to  fourteen  years  old.  Some  are  intellec- 
tually bright,  and  have  been  crowded  in  tlieir  school  work  ;  others  are  dull 
and  learn  only  with  difficulty,  and  in  consequence  worry  over  their  work 
until  tlieir  health  becomes  undermined.  They  sleep  badly,  lose  appetite, 
and  often  become  choreic.  The  ausemia  may  be  either  the  cause  or  the 
result  of  these  symptoms.  The  urine  in  these  cases  often  contains  a  large 
excess  of  uric  acid. 

48 


Y34  DISEASES  OF  THE  NERVOUS  SYSTEM. 

3.  Headaches  of  nervous  origiii. — These  may  occur  in  children  who 
are  highly  neurotic,  either  from  their  inheritance  or  surroundings,  and  in 
those  who  are  the  subjects  of  epilepsy  or  hysteria,  and  they  may  be  symp- 
tomatic of  organic  disease  of  the  brain,  such  as  tumour  or  tuberculous  or 
syphilitic  meningitis.  True  facial  neuralgia  is  rare  in  childhood  except 
from  carious  teeth ;  from  this  cause,  however,  it  is  not  infrequent. 

4.  Headaches  due  to  disease  of  some  of  the  organs  of  special  sense. — In 
connection  with  the  eyes  there  may  be  conjunctivitis,  keratitis,  iritis,  errors 
of  refraction,  or  strabismus ;  connected  with  the  nose  there  may  be  polypi, 
hypertrophic  rhinitis,  or  adenoid  vegetations  of  the  pharynx ;  connected 
with  the  ears  there  may  be  otitis  or  foreign  bodies  in  the  canal.  Each  one 
of  these  conditions  requires  special  treatment. 

5.  Headaches  due  to  inherited  gout  or  rheumatism. — These  are  not 
very  frequent,  but  they  may  be  severe,  and  may  at  times  simulate  the  onset 
of  meningitis.  They  are  often  accompanied  by  pains  in  the  joints,  mus- 
cles, or  nerve  trunks ;  they  may  be  associated  with  a  urine  which  is  highly- 
acid  and  contains  deposits  of  oxalates  or  of  free  uric  acid. 

6.  Disturhances  of  the  genital  tract  are  rarely  a  cause  of  headaches  in 
children,  although  this  may  be  the  case  in  girls  about  the  time  of  puberty,, 
especially  where  menstruation  is  delayed  or  difficult. 

Diagnosis. — The  diagnosis  of  headaches  includes  the  discovery  of  the 
cause,  and  this  is  often  difficult.  In  an  infant  or  a  young  child,  organic 
disease  of  the  nervous  system  should  always  be  suspected  as  a  cause  of  se- 
vere headaches.  In  older  children  the  important  things  to  be  considered,, 
because  the  most  frequent,  are  digestive  disturbances,  nervous  exhaustion,, 
malnutrition,  and  visual  disorders.  An  absolute  diagnosis  in  a  case  of 
persistent  headache  can  be  made  only  by  a  careful  physical  examination,, 
not  omitting  a  study  of  the  urine ;  often  there  must  be  a  close  observation 
of  the  patient  for  some  time. 

Treatment. — The  only  successful  treatment  is  that  which  is  directed 
toward  a  removal  of  the  cause.  Each  one  of  the  different  groups  above- 
mentioned  is  to  be  managed  differently,  according  to  the  principles  else- 
where laid  down  regarding  the  treatment  of  these  conditions.  For  the- 
relief  of  the  symptom,  cold  to  the  head,  a  hot  foot-bath,  and  phenacetine- 
in  moderate  doses  are  perhaps  the  most  certain  of  all  remedies. 

DISORDERS  OF  SPEECH. 

In  this  chapter  will  be  discussed  only  functional  speech  defects,* 
those  depending  upon  organic  conditions  being  considered  in  connection 
with  diseases  of  the  brain.  The  most  common  varieties  are  stuttering,, 
stammering,  lisping,  alalia,  backwardness,  and  functional  aphasia.     All 

*  See  Wyllie,  Edinburgh  Medical  Journa],  October,  1891. 


DISORDERS   OF   SPEECH.  735 

forms  are  much  more  frequent  in  boys  than  in  girls,  the  proportion  being 
more  than  four  to  one. 

Stuttering. — This  is  the  most  common  form  of  speech  disturbance. 
Articuhition  is  distinct  and  the  separate  sounds  are  properl}^  produced, 
but  there  is  a  difficulty  in  connecting  the  consonant  with  the  succeeding 
vowel ;  this  seems  like  an  obstacle  to  be  overcome.  Stuttering  is  occa- 
sionally seen  in  most  children.  It  is  more  frequent  in  the  third  and 
fourth  years,  before  speech  is  thoroughly  mastered.  At  this  age  it  is 
aggravated  or  produced  by  disturbances  of  nutrition,  but  is  usually  of 
temporary  duration,  lasting  for  a  few  weeks  or  months.  Only  recently  a 
little  boy  of  four  was  under  my  care,  who  became  very  anaemic,  slept 
poorly,  and  suffered  from  malnutrition  as  a  result  of  the  confinement  inci- 
dent to  a  home  in  the  city.  He  soon  began  to  stutter,  and  in  a  short 
time  it  became  painfully  marked.  After  a  few  weeks  in  the  country  he 
improved  very  much  in  his  general  condition,  gained  four  or  five  pounds 
in  weight,  and  his  stuttering  completely,  and  I  think  permanently,  disap- 
peared. Such  disturbances  as  this  are  analogous  to  chorea.  In  other  cases 
stuttering  follows  some  acute  illness,  and  under  such  conditions  also  it  is 
usually  of  short  duration. 

Most  children  who  become  habitual  stutterers  do  not  begin  until  they 
are  six  or  seven  years  old,  and  sometimes  even  later.  Stuttering  may  arise 
from  imitation,  and  probably  inheritance  is  an  occasional  factor.  It  is 
frequently  a  mark  of  degeneration. 

It  is  important  that  all  such  cases  receive  early  treatment  before 
the  habit  becomes  firmly  fixed.  The  prognosis  is  good  for  sponta- 
neous recovery  in  nearly  all  the  cases  seen  in  very  young  children, 
and  also  in  those  coming  on  after  acute  illness.  Other  cases  in  which 
the  condition  has  become  habitual,  should  have  the  benefit  of  syste- 
matic training  under  a  competent  teacher  in  breathing,  vocal  and  speech 
gymnastics. 

Stammering. — This  term  is  sometimes  used  synonymously  with  stut- 
tering. Kussmaul  makes  the  distinction  between  them  that,  in  stammer- 
ing, individual  sounds  are  difficult  of  production,  while  in  stuttering  it  is 
syllabic  combinations.  Stammering  is  often  accompanied  by  some  defect 
in  the  organs  of  articulation — the  teeth,  lips,  tongue,  or  palate — which 
is  not  present  in  stuttering. 

The  treatment  consists  in  careful  training  and  in  the  correction  of 
whatever  abnormal  local  conditions  may  exist. 

Lisping. — In  this  there  is  imperfect  production  of  certain  sounds, 
owing  usually  to  a  faulty  position  of  the  organs  of  articulation.  The 
sounds  may  be  so  indistinct  that  they  can  not  be  understood.  In  this 
condition  also  there  may  be  defective  formation  of  some  of  the  organs  of 
articulation,  although  in  the  milder  forms  tliis  is  not  the  case.  The  treat- 
ment is  similar  to  that  of  stammering. 


Y36  DISEASES  OF  THE  NERVOUS   SYSTEM. 

Alalia. — This  consists  in  a  total  inability  to  articulate.  It  is  seen  in 
all  young  infants  during  their  earliest  attempts  at  talking.  In  older 
children  it  is  usually  associated  with  some  mental  defect. 

Backwardness. — Backwardness  is  carefully  to  be  distinguished  from  a 
late  development  of  speech  due  to  idiocy.  At  two  years  old  children  not 
deaf  are  almost  invariably  able  to  speak.  Speech  may  be  late  in  conse- 
quence of  prolonged  or  very  severe  illness,  and  where  it  has  been  acquired 
it  may  be  lost  from  similar  causes. 

Functional  Aphasia. — The  term  has  been  applied  to  a  temporary  loss 
of  speech  which  sometimes  occurs  in  chorea,  and  sometimes  from  severe 
fright  or  anything  else  which  has  produced  a  marked  nervous  im- 
pression. West  records  an  instance  in  a  girl  of  eight  years,  who  was 
suffering  from  an  attack  of  chorea  induced  by  fright.  Speech  first  be- 
came difficult  and  then  was  lost  altogether.  For  a  month  the  child  could 
say  only  "  Yes  "  and  "  ISTo."  The  case  improved  very  slowly,  but  at  the 
end  of  nine  weeks  had  recovered  completely. 

Loss  of  speech  sometimes  follows  the  acute  infectious  diseases,  espe- 
cially typhoid  fever. 

In  all  disorders  of  speech,  the  functional  cases  are  to  be  distinguished 
from  those  which  depend  upon  deafness  and  mental  deficiency.  The 
frequency  with  which  these  disorders  are  due  to  disturbances  of  general 
nutrition,  and  to  local  causes  in  the  mouth  and  throat,  should  be  borne 
in  mind,  and  these  conditions  should  receive  their  appropriate  treatment 
early,  before  the  habit  of  defective  speech  becomes  firmly  established. 
For  the  latter  class  of  unfortunates,  special  training  at  the  hands  of  a 
competent  teacher  should  be  advised,  preferably  in  an  institution. 

DISORDERS  OF  SLEEP.* 

Disturbed  Sleep,  Sleeplessness. — Disturbed  or  restless  sleep  is  much 
more  common  in  infancy  and  childhood  than  is  true  insomnia,  although 
the  causes  of  the  two  conditions  may  be  the  same. 

Etiology. — In  infancy  these  symptoms  are  most  frequently  due  to 
hunger  or  to  indigestion  resulting  from  overfeeding  or  improper  feeding. 
Very  often  disturbed  sleep  is  the  result  of  bad  habits,  such  as  rocking 
during  sleep  or  night-feeding.  Sometimes  it  arises  from  dentition,  or  the 
pain  of  colic  or  otitis ;  at  other  times  it  may  be  simply  the  expression  of  a 
condition  of  nervous  irritability,  the  result  of  inheritance  or  of  the  child's 
surroundings. 

In  later  childhood  the  first  thing  to  be  suspected  when  sleep  is  much 
disturbed  is  some  derangement  of  the  digestive  organs ;  in  this  will  be 
found  the  explanation  of  fully  half  the  cases.     The  most  frequent  type, 

*  For  the  characteristics  of  the  sleep  of  infancy,  and  the  average  amount  taken  at 
the  different  ages,  see  pages  5  and  6. 


DISORDERS   OF   SLEEP.  737 

where  the  symptom  is  of  long  duration,  is  elirouic  intestinal  indigestion, 
often  associated  with  indicanuria,  a  condition  in  which  the  diagnosis  of 
the  mother  is  nsnally  worms.  Other  cases  are  due  to  obstructed  respira- 
tion from  adenoid  growths  of  the  pharynx  or  enlarged  tonsils,  sometimes 
to  nocturnal  attacks  of  asthma.  A  lack  of  fresh  air  in  the  sleeping  room, 
excessive  or  insufficient  bedclothing,  and  cold  feet,  are  other  frequent 
causes.  Disturbed  sleep  with  "  starting  pains "  is  one  of  the  earliest 
symptoms  of  hip-joint  disease.  In  the  nervous  exhaustion  resulting 
from  overpressure  in  schools,  and  in  malnutrition  and  anaemia,  dis- 
turbances of  sleep  are  well-nigh  constant.  They  are  also  seen  in  organic 
cardiac  disease  and  in  all  pulmonary  conditions  accompanied  by  dysp- 
noea or  cough.  Sleep  may  be  disturbed  in  consequence  of  bad  dreams 
which  have  their  origin  in  exciting  stories  heard  or  read  just  before  bed- 
time, or  in  too  violent  or  exciting  play.  To  discover  the  cause  in  almost 
any  case  it  is  necessary  to  investigate  carefully  the  whole  routine  of  the 
child's  life. 

Symptoms. — The  condition  may  be  one  of  real  insomnia  which  may 
last  for  weeks  or  months ;  or  the  sleep  may  be  simply  disturbed  and  rest- 
less, the  child  waking  many  times  during  the  night,  and  when  asleep  will 
not  lie  quietly,  but  constantly  changes  his  position.  Sometimes  children 
wake  suddenly  with  a  scream,  but  immediately  drop  off  to  sleep  again. 

Treatment. — The  essential  treatment  consists  in  the  discovery  and  re- 
moval of  the  cause  of  the  disturbance.  This  will  often  involve  a  radical 
change  in  the  manner  of  feeding,  in  the  hygiene  of  the  nursery,  and  in 
all  the  surroundings  of  the  child ;  but  in  this  way  only  should  these  cases 
be  managed.  Under  no  circumstances  should  the  physician  countenance 
the  use  of  drugs  to  promote  sleep  in  children,  except  in  the  case  of  severe 
acute  disease.  Soothing  syrups  and  all  nostrums  for  "  teething  "  should 
be  absolutely  forbidden.  Mothers  and  nurses  are  only  too  ready  to  fall 
into  the  habit  of  using  them,  because  the  injurious  effects  are  not  appre- 
ciated. When  the  cause  of  sleeplessness  is  found  and  removed  the  child 
will  sleep,  but  compulsory  sleep  obtained  under  other  conditions  is  always 
productive  of  more  harm  than  good.  If  food,  diet,  and  all  bad  habits 
have  been  corrected,  nervous  causes  should  be  investigated.  ^A"lu■n  no 
cause  can  be  discovered  the  treatment  should  consist  in  putting  the 
child  upon  the  simplest  possible  diet,  and  in  attention  to  such  genornl 
conditions  as  anaemia,  malnutrition,  and  neurasthenia,  some  of  which 
are  almost  certain  to  be  present.  In  many  cases  a  warm  bath  at  bed- 
time will  be  found  beneficial.  A  quiet,  darkened  room,  plenty  of  fresh 
air,  and  the  stopping  of  both  cnliiig  and  di'iiiking  during  the  niglit,  arc 
essential  to  a  cure  in  most  cases.  When  the  condition  aecomjianics  some 
acute  disease,  the  drugs  which  are  most  useful  are  codeine  and  trional. 
A  child  of  two  years  may  take  -^V  of  a  giain  of  codeine  or  two  grains  of 
trional  as  an  initial  dose,  to  be  increased  if  necessary. 


738  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Night  Terrors — Pavor  Nocturnus. — Two  classes  of  cases  have  been 
grouped  under  this  head,  both  having  this  in  common,  that  sleep  is  dis- 
turbed by  fright.  In  an  excellent  article  upon  this  subject,*  Coutts  calls 
attention  to  the  necessity  of  sharply  distinguishing  between  them. 

The  condition  in  the  first  group  partakes  of  the  nature  of  nightmare. 
It  may  be  due  to  partial  asphyxia  from  adenoid  growths  of  the  pharynx, 
or  to  other  causes  mentioned  under  disturbed  sleep,  or  it  may  be  gastric 
or  intestinal  in  its  origin.  These  cases  are  quite  frequent.  Sleep  may 
be  disturbed  from  the  outset,  and  the  attack  may  be  merely  the  culmina- 
tion of  such  disturbance.  The  child  wakes  in  a  state  of  fright  and  ex- 
citement, and  often  sa3^s  he  has  had  a  bad  dream.  His  mind  is  clear,  he 
recognises  those  about  him,  but  it  may  be  a  long  time  before  he  is  suffi- 
ciently calm  to  sleep  again.  The  attack  may  be  remembered  perfectly 
the  next  day.  Cases  like  this  are  to  be  managed  in  the  same  general  way 
as  those  of  disturbed  sleep  above  mentioned. 

In  the  second  group  are  the  only  cases  to  which  the  term  "  night  ter- 
rors "  should  really  be  applied.  These  are  relatively  rare,  but  the  condi- 
tion is  a  much  more  serious  one.  The  symptom  is  due  to  some  disturb- 
ance of  the  central  nervous  system.  According  to  Coutts,  it  occurs  espe- 
cially in  those  of  neurotic  antecedents,  or  those  who  have  previously  suf- 
fered from  infantile  convulsions,  and  it  is  often  the  precursor  of  other 
nervous  attacks — migraine,  hysteria,  epilepsy,  and  even  insanity.  The 
attack  usually  comes  suddenly  where  a  child  has  previously  been  sleep- 
ing quietly,  and  more  frequently  in  the  early  part  of  the  night  than  later. 
He  is  generally  found  sitting  upright  in  his  bed  in  a  bewilderment  of 
terror,  being  "  afraid  of  the  dog,"  or  "  the  bear,"  or  there  is  some  other 
vision  or  hallucination  which  has  produced  the  fright.  Often  this  is  asso- 
ciated with  something  of  a  red  colour.  The  child  does  not  recognise 
those  about  him,  does  not  know  where  he  is,  and  may  go  to  sleep  again 
without  coming  to  full  consciousness.  The  next  day  there  is  no  recollec- 
tion of  what  has  happened.  Usually  no  after-effects  are  seen,  but  some- 
times a  large  amount  of  pale  urine  is  passed.  The  attacks  may  be  re- 
peated at  intervals  of  a  few  months,  or  they  may  occur  every  few  nights ; 
but  whatever  the  peculiar  nature  of  the  vision,  it  is  likely  to  be  repeated 
in  nearly  the  same  form.  Such  attacks  have  something  in  common  with 
epileptic  seizures,  and  the  diagnosis  between  them  may  at  times  be  diffi- 
cult. They  are  always  to  be  regarded  seriously,  not  only  on  account  of 
what  they  are  in  themselves,  but  on  account  of  what  may  follow. 

Treatment. — All  mental  and  nervous  strain  should  be  most  carefully 
avoided,  and  where  the  attacks  are  frequent  the  bromides  should  be  given 
at  bedtime.  Some  person  should  sleep  in  the  same  room  with  the  child, 
or  in  an  adjoining  one  with  the  door  open. 

*  American  Journal  of  the  Medical  Sciences,  February,  1896. 


INJURIOUS  HABITS   OP   INFANCY   AND   CHILDHOOD.  739 

Excessive  Sleep. — It  is  rare  that  either  infants  or  children  sleep  an  un- 
natural amount  of  the  time  unless  one  of  two  causes  is  present — organic 
ibrain  disease  or  the  use  of  drugs.  The  latter  is  always  to  be  suspected  if 
with  the  sleep  there  is  associated  obstinate  constipation.  Opium  in  the 
form  of  "  soothing  syrup  "  or  paregoric,  is  the  drug  which  has  usually  been 
given. 

INJURIOUS   HABITS  OP  INFANCY  AND  CHILDHOOD. 

On  account  of  the  close  connection  of  such  habits  with  disturbances 
•of  the  nervous  system,  they  may  be  properly  considered  with  the  func- 
tional nervous  diseases.  Although  some  of  these  habits  may  not  be  of 
serious  importance,  yet  as  a  group  they  have  received  altogether  too  little 
.attention  at  the  hands  of  the  physician. 

Sucking. — This  is  a  very  common  habit  in  infants,  and  during  the  first 
iew  months  it  is  seen  to  some  degree  in  most  of  them.  If  they  are  care- 
fully watched  the  habit  is  easily  stopped  ;  otherwise  it  may  continue  in- 
■definitely.  Young  infants  usually  suck  the  fingers  when  hungry,  and  this 
•can  scarcely  be  considered  abnormal,  but  an  effort  should  always  be  made 
to  stop  it,  lest  the  habit  become  fixed.  Lindner  *  distinguishes  between 
simple  sucking  and  sucking  with  combinations.  In  the  former,  the  child 
.sucks  some  part  of  the  body,  such  as  the  thumb,  fingers,  toes,  tongue,  lips, 
back  of  the  hand  or  arm,  or  it  may  be  some  foreign  substance,  such  as 
part  of  the  clothing,  the  blanket,  a  rubber  nipple,  or  a  "  sugar-teat."  This 
is  the  most  common  form  that  is  seen.  In  the  second  variety  the  suck- 
ing is  accompanied  by  the  rubbing  of  some  other  parts,  which  seems  to 
afford  a  pleasurable  excitement ;  this  may  be  the  ear,  the  genitals,  or  any 
other  portion  of  the  body.  Sometimes  sucking  is  accompanied  by  some 
practice  which  produces  actual  pain,  such  as  pulling  of  the  hair  or  scratch- 
ing the  body.  Habits  of  sucking  often  persist  throughout  infancy,  and 
not  infrequently  throughout  childhood  ;  they  have  often  been  known  to 
•continue  up  to  puberty.  The  longer  the  habit  has  lasted  the  more  dififi- 
•cult  is  it  to  break. 

The  results  of  sucking  may  be  serious.  Deformities  of  the  thumb  or 
finger,  of  the  lips  and  teeth,  and  even  of  the  jaws,  are  sometimes  pro- 
duced. I  know  a  lady,  now  in  advanced  life,  whose  thumbs  to  this  day 
show  a  deformity  resulting  from  the  habit  of  thumb-sucking  while  a  child. 
In  her  case  the  habit  was  not  broken  until  she  was  eight  or  nine  years 
old.  Probably  the  most  pernicious  result  of  sucking  is  its  tendency  to 
•develop  the  habit  of  masturbation.  Habitual  sucking  of  one  hand  or 
finger  may  lead  to  spinal  curvature. 

Treatment. — In  the  management  of  these  cases  the  most  important 
i;hing  is  to  arrest  the  habit  early,  before  it  becomes  fixed.     Too  often  the 

*  Jahrbiich  fiir  Kinderheilkuiule,  vol.  xiv,  p.  08. 


740  DISEASES   OF  THE   NERVOUS  SYSTEM. 

habit  of  thumb-sucking^  or  of  sucking  a  rubber  nijjple,  is  encouraged  by 
mothers,  nurses,  and  sometimes  eren  by  jDhysicians  because  of  the 
temporary  quiet  which  is  thereby  produced.  Under  no  circumstances 
should  it  be  resorted  to  as  a  means  of  putting  children  to  sleep  or  other- 
wise quieting  the  nervous  system.  With  infants,  the  only  treatment 
which  is  at  all  successful  is  mechanical  restraint.  It  is  of  no  use  to 
cover  the  part  which  is  sucked  with  bitter  solutions.  The  hands  of 
young  infants  may  be  covered  with  mittens,  or  with  the  long  sleeves  of 
a  night-gown  which  is  pinned  to  the  bed,  so  that  it  is  impossible  for  the 
child  to  get  the  part  to  the  mouth;  or  pasteboard  splints  may  be  applied 
at  the  bend  of  the  elbow,  so  as  to  prevent  flexion  of  the  arms.  In  the 
milder  cases  the  habit  is  often  discontinued  spontaneously;  but  when 
it  has  been  indulged  until  a  child  is  four  or  five  years  old,  it  is  broken 
only  Avith  the  greatest  difiiculty.  Punishments  are  of  little  avail,  but 
rewards  are  often  successful. 

Masturbation. — This  is  not  uncommon  even  in  infancy.  Many  ciises 
have  been  observed  during  the  first  year,  and  some  as  early  as  the  seventh 
or  eighth  month.  It  is  seen  in  children  of  all  ages  and  in  both  sexes; 
but  in  infants  and  young  children  it  is,  in  my  experience,  much  more 
common  in  girls  than  in  boys. 

Etiology. — Local  causes  are  present  in  a  large  number  of  the  eases, 
and  this  is  usually  something  which  produces  undue  irritation.  The 
most  frequent  are,  long  or  adherent  prepuce,  phimosis,  balanitis,  vulvo- 
vaginitis, eczema  of  the  labia,  threadworms,  and  tight  clothing.  A  urine 
which  is  irritating  because  of  excessive  acidity  or  the  presence  of  crystals 
of  uric  acid  may  be  a  cause.  Any  irritation  may  lead  the  child  to  rub 
the  parts  in  some  way,  and  a  pleasurable  sensation  being  excited,  this 
action  is  repeated  until  a  habit  is  formed.  Other  causes  are  exercises 
in  which  the  legs  are  rubbed  together,  or  the  body  against  a  jDole,  as  in 
climbing.  To  these  causes  must  be  added,  in  infants  at  least,  the  habit 
of  sucking.  xA.fter  infancy  the  habit  of  masturbation  is  usually  ac- 
quired from  other  children,  sometimes  taught  by  vicious  nurses. 

General  causes  are  also  important  as  predisposing  factors.  These 
are  the  same  as  underlie  most  of  the  neuroses  of  childhood — viz.,  marked 
auEemia,  general  malnutrition,  and  a  highly  neurotic  constitution,  which 
is  often  an  inheritance,  and  is  always  aggravated  by  surroundings  which 
tend  to  unnatural  stimulation  of  the  nervous  system.  When  masturba- 
tion develops  in  a  young  child  Avithout  any  local  cause,  it  may  lie  an 
early  sign  of  either  mental  deficiency  or  moral  delinquency;  if  looked 
for,  other  stigmata  of  degeneration  will  usually  be  found,  and  in  most 
cases  other  vicious  traits  will  soon  appear. 

Symptoms. — In  infants  and  very  young  children  masturbatioi>-  is 
often  accomplished  by  thigh  friction  or  by  rubbing  the  body  against  a 
pillow,  chair,  or  some  other  object.    The  variety  of  ways  is  almost  end- 


INJURIOUS  HABITS  OF  INFANCY  AND  CHILDHOOD.  741 

less.  Frequently  the  child  will  simply  lie  upon  the  floor  with  the  thighs 
crossed  and  rigidly  held,  and  only  a  backward  and  forward  motion  of 
the  body  made.  This  lasts  for  a  few  moments,  is  accompanied  by  fliLsh- 
ing  of  the  face  and  some  appearance  of  excitement,  followed  by  relaxa- 
tion, and  often  by  perspiration.  It  frequently  happens  with  little  chil- 
dren that  these  "  queer  tricks,"  as  they  are  often  regarded,  have  been 
continued  for  months  before  their  true  nature  is  suspected. 

A  consciousness  that  they  are  doing  something  wrong  early  leads 
even  young  children  to  get  by  themselves  when  they  repeat  the  habit. 
It  is  especially  likely  to  be  practised  when  children  lie  long  awake  alone 
after  they  go  to  bed,  or  if  they  wake  early.  The  habit  is  always  made 
worse  by  any  deterioration  of  the  general  health.  I  have  known  chil- 
dren, who  were  thought  to  be  cured,  to  relapse  under  such  conditions. 

It  is  somewhat  difficult  to  separate  the  general  symptoms  with  which 
masturbation  is  associated,  and  upon  which  it  largely  depends,  from 
those  which  are  the  direct  result  of  the  habit.  There  are  some  children 
in  whom  the  condition  is  chiefly  or  entirely  dependent  upon  a  local 
cause,  or  when  it  is  only  occasionally  practised,  in  whom  no  general 
symptoms  are  seen,  or  at  most  only  an  unnatural  shyness  and  a  disposi- 
tion to  seek  seclusion.  Others  are  precocious  and  excitable  with  an  ex- 
cessive amount  of  nervous  sensibility.  There  are  others  in  whom  more 
marked  nervous  symj^toms  are  present;  the  most  striking  are  absent- 
mindedness,  loss  of  power  of  concentration,  loss  of  interest  in  all  amuse- 
ments, and  mental  depression.  In  some  cases  nymphomania,  or  even 
insanity,  may  be  the  result.  Epilepsy,  chorea,  or  hysteria  may  develop, 
particularly  where  a  strong  predisposition  to  them  already  exists  in 
the  family.  The  effect  of  masturbation  upon  the  physical  and  mental 
development  of  the  child  may  be  serious  when  it  is  begun  at  an  early 
age  or  is  frequently  practised.  But  even  more  striking  is  the  change 
sometimes  brought  about  in  a  child's  moral  nature.  Even  little  children 
of  eight  or  nine  years  may  become  centres  of  moral  infection,  which 
may  involve  a  group  of  playmates  or  even  a  whole  school. 

Local  symptoms  of  masturbation  are  not  always  present;  in  the 
male  there  may  be  redness  and  slight  swelling  of  the  prepuce ;  the  or- 
gans may  be  abnormally  large  or  simply  much  relaxed.  In  the  female 
similar  conditions  may  exist,  and  sometimes  there  is  vaginitis. 

Prognosis. — Masturbation  in  children  is  at  all  times  a  most  difficult 
condition  to  deal  with.  The  outlook  is  better  in  infants  and  young  cliil- 
dren  than  in  those  who  are  older,  because  the  latter  are  more  difficult  to 
watch  and  control  :  besides,  in  lliem  the  habit  has  usually  become  more 
firmly  fixed.  In  young  children  local  causes  are  frequently  found  to  be 
at  the  root  of  the  trouble;  in  those  who  are  older  general  causes  are 
more  oflen  ])resent.  and  these  it  may  be  iiii])()ssilile  to  remove.  When 
masturbation  is  a  symptom  of  degenei'acy  it  is  usually  hopeless. 


Y42  DISEASES   OF  THE  NERVOUS  SYSTEM. 

Treatment. — The  most  important  thing  is  an  early  recognition  of 
the  condition.  The  phj^sician  should  put  parents  and  nurses  on  their 
guard,  and  the  first  suspicions  should  be  reported  and  the  child  care- 
fully watched  until  all  doubt  is  removed.  In  young  infants  much  may 
be  accomplished  by  mechanical  restraint.  The  kind  of  restraint  which 
is  necessary  will  depend  upon  the  manner  of  masturbating.  If  by  the 
hands,  they  should  be  tied  during  sleep,  so  that  the  child  can  not  reach 
the  genitals ;  if  by  the  thigh-friction,  the  thighs  should  be  separated  by 
tying  one  to  either  side  of  the  crib.  In  inveterate  cases,  a  double  side- 
splint,  such  as  is  used  in  fracture  of  the  femur,  may  be  applied.  In 
children  that  are  over  three  years  old,  all  such  contrivances  are  almost 
invariably  unsuccessful.  It  is  of  the  utmost  importance  in  every  case  to 
have  the  child  under  the  close  surveillance  of  a  competent  and  trust- 
worthy person.  He  should  be  especially  watched  just  after  being  put 
io  bed  and  immediately  after  waking.  Corporal  punishment  is  often 
useful  in  very  young  children,  but  of  little  or  no  benefit  in  those  who  are 
over  three  years  old.  In  fact,  in  such  cases  it  may  do  positive  harm,  for 
■deception  and  lying  are  soon  added  to  the  previous  vice.  The  mother 
should  secure  the  child's  confidence,  and  in  every  way  possible  seek  to 
strengthen  his  will  and  stimulate  his  self-control,  using  her  influence  to 
help  him  break  the  habit.  The  local  causes,  too,  must  be  examined  into 
and  removed  whenever  found.  Circumcision  should  be  done  if  phimosis 
exists,  and  even  v/here  it  is  not,  the  moral  effect  of  the  operation  is 
.sometimes  of  very  great  benefit.  In  girls  improvement  sometimes  fol- 
lows a  separation  under  anaesthesia  of  the  preputial  hood  from  the  cli- 
toris. If  a  dorsal  slit  is  made  in  the  prepuce  a  recurrence  of  the  adhe- 
sions can  easily  be  prevented.  Complete  circumcision  is  sometimes  done 
with  advantage,  and  in  very  obstinate  cases  the  clitoris  may  be  cauterized. 
Blistering  the  inside  of  the  thighs,  the  vulva,  or  the  prepuce  is  sometimes 
useful.  Care  should  be  taken  that  the  clothing  does  not  irritate  the 
parts.  The  child  should  not  only  be  removed  from  all  vicious  compan- 
ions, but  constant  watchfulness  should  be  exercised  in  the  home  and  at 
school,  that  the  child  should  have  no  opportunity  to  teach  other  children 
the  habit.  In  the  most  serious  cases  the  child  should  be  sent  away  from 
home  and  kept  from  other  children.  The  co-operation  of  a  trustworthy 
nurse  or  companion  is  indispensable.  General  treatment  should  be  di- 
rected to  the  child's  condition;  it  is  required  in  most  of  the  cases. 
A  child  suffering  from  malnutrition  and  anaemia  should  be  sent  to 
the  country,  kept  out  of  doors  and  away  from  books,  studies,  and  from 
everything  which  stimulates  or  excites  the  nervous  system.  Almost  all 
■exercises  except  horseback  may  be  recommended.  Every  means  should 
be  employed  to  build  up  the  child  physically.  Cure  results  in  most 
cases  only  by  using  all  these  measures  and  for  a  long  time. 


MALFORMATIOXS. 


r43 


Nail-biting  and  Tongue-sucking  are  two  forms  of  habit  which  are  less 
frequent  and  less  important  than  those  already  mentioned.  The  former 
is  best  remedied  by  keeping  the  nails  cut  very  short.  Tongue-sucking 
seldom  becomes  a  fixed  habit,  and  the  child  usually  ceases  it  of  his  own 
iiccord  as  he  grows  older. 


CHAPTEE    III. 

DISEASES  OF  THE  BRAIN  AND  MENINGES. 

MALFORMATIONS. 

The  malformations  of  the  brain  are  of  great  variety,  and  many  of 
ihem  are  solely  of  anatomical  interest,  as  the  conditions  are  incompatible 
with  life.  Only  the  most  frequent  and  the  best-kno'^^Ti  types  will  be  men- 
tioned, and  those  which  are  of  interest  from  a  clinical  point  of  view. 

Meningocele,  Encephalocele,  and  Hydrencephalocele. — These  three 
conditions  have  in  common  a  protrusion  of  some  part  of  the  cranial  con- 


FiG.  123. — Menincrocele. 


Fig.  124. — Encephalocele. 


Fig.  125. — Hydrencephalocele. 


tents  through  an  opening  in  the 
skull.  In  meningocele  (Figs.  123, 
12G)  there  is  protrusion  of  the 
membranes  alone.  These  form  a 
sac,  which  is  usually,  but  not  inva- 
riably, distended  by  fluid.  In  en- 
cephalocele (Fig.  124)  there  is  a 
protrusion  of  a  portion  of  the  brain 
substance ;  this  is  connected  with 
the  rest  of  the  brain  by  a  constrict- 
ed neck  or  pedicle.  The  tumour 
may  or  may  not  contain  fluid.  In 
hydrencephalocele   (Fig.  125)   there 

is  a  protrusion  of  a  portion  of  the  brain  substance  whidi  contains  within 
it  a  cavity  filled  with  fluid,  this  cavity  communicating  witli  the  distended 
lateral  ventricles. 


M.- 


From  a  paliriit  in  Uir  llabius"  IIo.spital. 
The  autonsy  sho\vt.-d  tliat  tlie  sac  communi- 
cated with  tlie  lateral  ventricles. 


7U 


DISEASES  OP  THE   NERVOUS  SYSTEM. 


In  all  these  conditions  there  is  a  tumour,  usually  pedunculated,  of  a 
round  or  pyriform  shape,  with  a  smooth  or  lobulated  surface.  The  ordi- 
nary size  is  that  of  a  mandarin  orange  ;  it  may  be  as  small  as  a  walnut,  or 
as  large  as  the  patient's  head.  It  is  generally  covered  by  the  scalp,  which 
is  often  denuded  of  hair ;  but  it  may  be  covered  only  by  granulation- 
tissue,  or  it  may  show  a  central  cicatrix,  like  that  of  spina  bifida.  Its 
coverings  are  usually  thin  and  translucent.  Other  deformities,  such  as 
spina  bifida,  club-foot,  and  hare-lip,  are  frequently  present. 

All  these  conditions  are  rare,  but  the  most  frequent  and  most  serious 
one  is  hydrencejDhalocele,  this  being  usually  associated  with  hydrocephalus. 
The  next  in  frequency  is  encephalocele,  which  has  the  best  prognosis. 
This  is  frequently  termed  hernia  cerebri.  It  may  exist  without  very  serious 
alteration  in  the  cranial  contents.  If  fluid  is  present,  it  is  external  to 
the  brain.     Meningocele  is  the  rarest  form,  and   consists  simply  of  an 

accumulation  of  fluid  in  the  arach- 
noid cavity,  which  communicates  by  a 
small  opening  with  the  general  arach- 
noid cavity  of  the  brain. 

Of  one  hundred  and  five  cases  col- 
lected by  Schatz,  fifty-nine  occupied 
the  occipital  region  and  forty- six  were 
frontal.  The  aperture  through  which 
the  occipital  protrusion  takes  jolace  is 
usually  in  the  median  line.  It  may 
communicate  with  the  posterior  fon- 
tanel, with  the  foramen  magnum,  or 
with  the  cleft  of  a  spina  bifida.  The 
occipital  bone  may  be  divided  in  the 
median  line,  or  rarely  it  may  be  absent. 
In  the  naso-f rental  form  (Fig.  127)  the  tumour  is  usually  at  the  root 
of  the  nose,  a  little  to  one  side  of  the  median  line.  The  aperture  is  most 
frequently  between  the  cribriform  plate  of  the  ethmoid  and  the  frontal 
bones.  It  may  be  between  the  lateral  halves  of  the  frontal  bone,  causing  a 
median  tumour.  The  point  of  protrusion  may  also  be  the  lateral  region 
of  the  skull,  generally  about  the  lateral  fontanel,  or  along  the  line  of  the 
sutures;  it  may  project  into  the  mouth  or  the  pharynx.  These  anterior 
tumours  are  usually  small,  although  large  ones  containing  the  anterior 
lobes  of  the  brain,  have  been  seen. 

The  theory  of  the  origin  of  these  malformations  which  is  most  widely 
accepted  is  that  they  are  primarily  cases  of  intra-uterine  hydrocephalus, 
and  as  the  cranial  cavity  is  gradually  closed  by  the  development  of  the 
bones,  a  certain  portion  of  the  brain  is  left  outside. 

Symptoms. — The  tumour  is  always  congenital,  although  after  birth 
it  frequently  increases  very  much  in  size.     A  typical  tumour  is  round 


Fig.  127. — iSIaso-frontai  uieniugocele  (after 
.Demmej. 


MALFORMATION'S   OP   THE   BRAIN.  745 

and  elastic,  usually  giving  evidences  of  fluid  ;  it  pulsates  synchronously 
with  the  heart;  during  screaming  or  forced  inspiration,  it  increases  in 
size ;  partial  and  in  some  cases  complete  reduction  is  possible,  but  this  is 
usually  followed  by  marked  cerebral  symptoms,  even  by  convulsions.  After 
partial  reduction,  an  opening  in  the  skull  may  often  be  made  out.  Micro- 
cephalus  may  be  present,  or  there  may  be  unequal  development  of  the  two 
sides  of  the  head. 

The  following  differential  points  given  by  Treves,  indicate  the  most 
characteristic  features  of  the  three  varieties  :  In  meningocele,  the  tumour 
is  at  first  small,  but  increases ;  it  has  a  smooth  surface  ;  it  is  pedunculated  ; 
there  is  distinct  fluctuation,  perfect  translucency,  rarely  pulsation ;  often 
it  is  completely  reducible;  compression  of  the  tumour  causes  cerebral 
sym^Dtoms ;  the  skull  is  normal.  In  encephalocele,  the  tumour  is  small 
and  smooth ;  it  is  rarely  pedunculated ;  fluctuation  is  absent ;  it  is  not 
translucent ;  there  is  distinct  pulsation ;  it  is  usually  reducible ;  pressure 
causes  cerebral  symptoms;  the  skull  is  normal.  In  hydrencephalocele, 
there  is  a  large  pendulous  tumour  with  an  irregular  or  lobulated  sur- 
face ;  it  is  pedunculated  ;  translucency  is  rarely  complete ;  fluctuation  is 
distinct ;  it  is  irreducible  ;  pressure  rarely  causes  symptoms ;  microcepha- 
lus  and  other  deformities  are  often  associated. 

The  occipital  tumours  are  usually  more  serious  than  the  frontal  ones. 
The  majority  of  cases  die  in  the  course  of  the  first  few  weeks  of  life, 
death  resulting  from  meningitis,  convulsions,  or  rupture.  In  meningocele 
the  tumour  usually  grows  slowly,  and  ultimately  may  be  shut  off  from  the 
cranial  cavity  ;  but  gradual  thinning  of  the  membrane  may  take  place,  and 
spontaneous  or  accidental  rupture  occur.  In  encephalocele  the  tumour 
grows  slightly,  or  not  at  all.  Most  of  these  patients  exhibit  signs  of 
mental  impairment  or  other  evidences  of  organic  brain  disease. 

Treatment. — According  to  Treves,  operation  is  justifiable  only  in  case 
of  impending  rupture.  The  conditions  present  are  essentially  the  same 
as  in  spina  bifida.  Meningocele  may  be  aspirated,  injected  with  iodine, 
or  with  Morton's  iodine  and  glycerin  solution  (page  811) ;  the  sac  may  be 
laid  open  and  a  plastic  operation  performed  for  the  closure  of  the  com- 
munication with  the  cranial  cavity ;  or  the  skin  may  be  divided,  and  a 
ligature  or  clamp  applied  to  shut  off  the  communication  with  the  brain. 
All  these  methods  have  been  at  times  successful,  but  cure  has  in  many  in- 
stances been  followed  by  the  development  of  chronic  hydrocephalus.  En- 
cephalocele is  to  be  treated  by  protection  and  compression.  Aspiration 
may  be  resorted  to  if  fluid  is  present.  In  hydrencephalocele  the  prognosis 
is  absolutely  bad  under  all  circumstances.  Schatz  *  gives  the  following 
statistics,  showing  the  results  with  and  without  operation,  all  varieties 
being  included  :  Of  twenty-four  occipital  tumours  not  operated  on,  three 

*  Berlin,  klin.  Wochenschrift,  No.  28.  1885. 


746  DISEASES   OF  THE  NERVOUS  SYSTEM. 

recovered ;  of  thirty-five  operated  on  by  excision,  ligation,  or  injection, 
six  recovered.  Of  forty-six  frontal  tumours,  there  were  six  recoveries  in 
thirty-two  cases  without  operation,  and  two  recoveries  in  fourteen  cases 
with  operation. 

Microcephalus.— This  is  generally  regarded  as  due  to  premature  ossi- 
fication of  the  skull ;  but  this  theory  is  certainly  inadequate  to  explain 
all  the  cases.  In  many  children  suffering  from  marasmus,  the  sutures 
ossify  and  the  fontanels  close  much  earlier  than  in  healthy  infants  of 
the  same  age,  chiefly  because,  with  the  rest  of  the  body,  the  brain  also 
has  ceased  to  grow.  So  it  is  true  of  some  of  the  cases,  at  least,  of  micro- 
cephalus,  that  the  early  ossification  of  the  skull  is  due  to  arrested  growth 
of  the  brain,  and  not  the  reverse.  The  reasons  for  the  developmental 
arrest  in  the  brain  are  for  the  most  part  unknown.  The  condition  usually 
dates  back  to  intra-uterine  life,  although  in  some  cases  it  appears  to  begin 
after  birth. 

It  is  well  known  that  there  is  not  an  invariable  relation  between  the 
size  of  the  head  and  the  size  of  the  brain,  although  generally  the  two  cor- 
respond. If  the  circumference  of  the  head  is  much  below  the  average  for 
the  age  (page  20),  and  relatively  much  less  than  the  measurements  of  the 
rest  of  the  body,  microcephalus  may  be  assumed  to  exist.  Sachs  calls 
attention  to  the  fact  that  the  circumference  of  the  head  may  be  nearly 
normal  and  yet  the  essential  conditions  of  microcephalus  exist,  owing  to 
imperfect  development  of  the  anterior  part  of  the  brain. 

The  symptoms  of  microcephalus  are  those  of  idiocy  and  cerebral 
paralysis,  existing  in  all  possible  combinations  and  with  variable  degrees 
of  severity. 

A  new  surgical  interest  in  these  cases  has  been  awakened  during  the 
last  few  years  by  the  operation  of  craniectomy.  The  purpose  of  this  oper- 
ation, which  was  devised  by  Lannelongue,  is  to  relieve  the  intracranial 
pressure  by  making  a  longitudinal  opening  in  the  skull,  on  one  or  both 
sides.  The  opening  made  is  usually  about  half  an  inch  wide  and  four 
or  five  inches  long.  It  is  one  or  two  inches  from  the  sagittal  suture,  to 
which  it  is  parallel.  For  the  time  being  the  cranial  capacity  is  increased, 
but  it  is  doubtful  if  even  this  is  permanent.  Jacobi*  gives  a  report  of 
thirty-three  cases  operated  upon  by  American  surgeons,  with  fourteen 
deaths  and  nineteen  recoveries.  At  the  time  of  report  the  condition  in 
the  cases  which  survived  the  operation  was  as  follows :  no  improvement 
in  seven ;  slight,  in  seven  ;  "  some,"  in  one ;  much,  in  two  ;  no  history,  in 
one ;  uncertain,  in  one.  I  quite  agree  with  him  that  such  results  do  not 
justify  the  performance  of  this  operation. 

Cong-enital  Hydrocephalus. — These  cases  may  fairly  be  considered  as 
belonging  in  this  group,  although  they  have  been  discussed  elsewhere. 


*  Xew  York  Medical  Record,  May  19.  1894. 


PACHYMENINGITIS.  747 

Porenceplialus  (literally,  a  hole  in  the  brain)  is  a  condition  in  which 
there  is  a  large  depression  in  some  part  of  the  brain,  but  with  surrounding 
parts  well  developed.  Such  depressions  may  involve  a  whole  lobe,  and 
they  may  be  deep  enough  to  reach  the  lateral  ventricles. 

Porencephalus  is  described  as  congenital  or  acquired.  In  the  congeni- 
tal form,  the  defect  is  usually  found  in  the  anterior  or  middle  part  of  the 
brain.  The  origin  of  these  conditions  is  still  a  disputed  question.  They 
are  probably  due  to  early  vascular  changes.  Childi-en  sometimes  live 
several  years  with  very  large  defects,  the  symptoms  depending  upon  the 
seat  of  the  lesion.  The  acquired  form  of  porencephalus  is  usually  one  of 
the  late  results  of  meningeal  hsmorrhage.  It  may  affect  one  or  both 
sides.  Such  cases  present  the  symptoms  of  spastic  paralysis — usually 
diplegia.     In  all  cases  with  large  brain  defects,  the  space  is  filled  with  fluid. 

PACHYMENINGITIS. 

Pachymeningitis,  or  inflammation  of  the  dura  mater,  occurs  both  as 
an  acute  and  a  chronic  disease. 

Acute  Pachymeningitis. — This  is  very  rare  in  children.  Only  pachy- 
meningitis externa  is  generally  iucluded  under  this  term,  as  acute  23achy- 
meningitis  interna  does  not  occur  alone,  but  usually  with  inflammation  of 
the  pia  mater  (leptomeningitis).  It  may  be  associated  with  disease  or 
injury  of  the  bones  of  the  skull,  but  is  most  frequently  seen  in  connection 
with  middle-ear  disease.  It  generally  begins  as  a  localized  process,  but 
the  inflammation  may  extend  to  the  inner  layer  of  the  dura,  and  to  the 
pia  mater;  or  it  may  remain  circumscribed^  and  terminate  in  the  forma- 
tion of  an  abscess  between  the  dura  mater  and  the  bone. 

The  symptoms  of  acute  pachymeningitis  are  distinctive  only  when 
the  process  is  localized.  They  are  then  usually  associated  with  middle- 
ear  disease,  and  are  indistinguishable  from  those  of  cerebral  abscess. 
The  treatment  is  surgical. 

Chronic  Pachymeningitis. — This,  in  children,  almost  invariably  af- 
fects the  inner  layer  of  the  dura  mater  (pachymeningitis  interna) ;  it  is 
also  known  as  pseudo-membranous  and  as  hcemorrhagic  pachymeningitis 
or  licematoma  of  the  dura  mater.  Its  causes  are  for  the  most  part  un- 
known. It  is  not  very  rare,  being  usually  discovered  at  autopsy  in  chil- 
dren, chiefly  cachectic  infants,  who  have  died  of  other  diseases.  In  the 
Eeport  of  the  jSTew  York  Pathological  Society  for  1890  Xorthrup  records 
six  such  cases.  I  have  seen  five  similar  ones,  as  well  as  one  other  asso- 
ciated with  chronic  hydrocephalus. 

Two  classes  of  cases  are  to  be  distinguished — those  with,  and  those 
without  extensive  liaMuorrhages.  In  the  latter  group  there  is  found  a  thin, 
translucent,  vascular  membrane  lining  the  inner  surface  of  the  dura.  It 
may  be  only  a  delicate  film  wliich  can  be  scraped  ofl^;  it  may  be  as  thick 
as  ordinary  l)lotting-paper,  or  even  twice  that  tliiekness.    The  meml)rane 


Y48  DISEiiSES   OF   THE  NERVOUS  SYSTEM. 

is  often  oedematous ;  it  is  exceedingly  vascular,  and  the  vessels  have  very 
thin  walls.  There  are  usually  scattered,  punctate  haemorrhages,  and 
there  may  be  a  few  of  larger  size.  This  membrane  may  cover  the  whole 
inner  surface  of  the  dura,  but  in  most  cases  it  is  principally  over  the  con- 
vexity and  may  be  found  only  here  ;  it  is  apt  to  be  more  upon  one  side 
than  upon  the  other.  In  cases  of  long  standing  there  may  be  adhesions 
between  the  dura  and  the  pia.  When  large  haemorrhages  have  taken  place, 
quite  a  different  pathological  appearance  is  presented.  The  lesions  found 
in  a  case  upon  which  I  made  an  autopsy  in  the  New  York  Infant  Asylum, 
are  fairly  typical :  The  infant  was  six  months  old,  and  the  symptoms  had 
existed  for  six  days.  The  fontanel  was  bulging  to  a  marked  degree,  and 
the  sagittal  and  coronal  sutures  were  separated.  A  thin  recent  clot  from 
one  eighth  to  one  fourth  of  an  inch  in  thickness  covered  nearly  the  whole 
of  the  right  hemisphere  and  part  of  the  convexity  of  the  left.  The  entire 
dura  was  lined  both  at  its  convexity  and  base  by  a  pseudo-membrane  of 
grayish  color,  about  one  sixteenth  of  an  inch  in  thickness.  The  brain 
was  anaemic. 

In  cases  of  longer  standing  partial  organization  of  the  clot  may  be 
seen  ;  in  more  recent  ones  the  blood  is  partly  or  entirely  fluid.  I  once 
found  acute  leptomeningitis  with  a  purulent  exudation,  associated  with 
hgemorrhagic  pachymeningitis.  In  cases  where  life  is  prolonged  for  years, 
there  may  be  partial  or  even  complete  absorption  of  the  clot,  followed  by 
the  formation  of  cysts,  considerable  inflammatory  thickening  of  the  pia 
with  deposits  of  blood  pigment,  and  finally  atrophy  and  sclerosis  of  the 
cortex.  The  source  of  the  hsemorrhage  may  be  the  rupture  of  a  single 
large  vessel,  but  more  frequently  the  blood  comes  from  many  small 
vessels. 

Symptoms. — These  are  due  to  the  haemorrhage,  and  not  to  the  inflam- 
matory process.  Until  haemorrhage  occurs  there  are  no  symptoms  by 
which  the  disease  can  be  recognised.  Thus  in  many  of  the  cases  in  which 
pachymeningitis  is  found  at  autopsy,  its  existence  is  not  suspected  dur- 
ing life.  The  occurrence  of  haemorrhage  is  sometimes  marked  by  vomit- 
ing or  convulsions,  and  usually  there  is  loss  of  consciousness.  It  may 
be  a  question  whether  the  convulsions  are  the  cause  or  the  result  of 
the  haemorrhage.  In  most  cases  they  seem  to  be  the  result.  They  are 
usually  general  and  repeated.  If  the  haemorrhage  occurs  slowly,  there 
may  be  stupor  without  convulsions  until  nearly  the  close  of  the  disease- 
In  the  fatal  cases  the  symptoms  generally  continue  from  two  days  to  a 
week.  There  are  dulness,  stupor,  and  finally  coma,  death  occuring  in  coma 
or  convulsions.  If  the  hsemorrhage  is  diffuse — and  this  is  apt  to  be  the 
case — there  is  rigidity  of  all  the  extremities ;  if  it  is  of  one  side  only,  the 
rigidity  affects  only  one  arm  and  leg.  The  pupils  are  more  frequently 
contracted,  but  may  be  dilated  or  unequal.  There  is  diplegia,  hemi- 
plegia, or  monoplegia,  according  to  the  seat  and  extent  of  the  hfemor- 


PACHYMENIXGITIS.  749 

rhage.  The  respiration  is  slow  and  irregular  and  may  be  of  the  Cheyue- 
Stokes  variety.  The  pulse  is  slow,  irregular,  and  sometimes  intermittent. 
The  temperature  is  at  first  normal,  but  rises  slowly  until  death  occurs, 
when  it  is  from  100°  to  103°  F.  Generally  the  cranial  nerves  are  not 
affected,  and  opisthotonus  is  absent.  The  knee-jerk  is  often  exagger- 
ated. In  cases  which  do  not  prove  fatal — these  being  chiefly  in  older 
children — we  have  a  similar  onset,  but  after  a  few  days  consciousness  is 
regained,  and  only  hemiplegia  or  monoplegia  remains.  The  course  of  the 
paralysis  is  that  seen  after  meningeal  hsemorrhage  due  to  other  causes. 
Wagner  has  reported  a  case  in  which  recurring  hsemorrhages  took  place 
at  intervals  of  several  months,  the  autopsy  showing  distinct  evidences  of 
both  old  and  recent  lesions. 

Pachymeningitis,  I  believe,  plays  a  much  more  important  role  in  the 
production  of  meningeal  hsemorrhages  in  children  than  has  generally  been 
accorded  to  it.  From  the  frequency  with  which  this  lesion  is  found  as  a 
cause  of  sudden  meningeal  heemorrhages  which  are  fatal,  it  is  not  unlikely 
that  many  of  the  cases  which  recover  with  hemiplegia  or  monoplegia,  may 
be  due  to  the  same  cause. 

The  prognosis  depends  upon  the  age  of  the  patient  and  the  extent  of 
the  hgemorrhage.  Extensive  haemorrhages  are  usually  fatal  in  infancy, 
but  small  ones  are  seldom  so,  for  they  are  rarely  at  the  base.  The  prog- 
nosis of  the  paralysis  in  cases  not  terminating  fatally,  is  the  same  as  after 
meningeal  haemorrhage  due  to  other  causes,  with  perhaps  an  added  liabil- 
ity to  recurrent  attacks. 

Without  large  hsemorrhages,  pachymeningitis  interna  can  not  be  diag- 
nosticated ;  and  it  is  impossible  to  differentiate  the  haemorrhagic  cases 
from  other  varieties  of  meningeal  hgemorrhage.  It  is  important  to  make 
a  diagnosis  between  pachymeningitis  with  haemorrhage,  and  acute  simple 
meningitis.  In  the  former  we  have  a  sudden  onset;  stupor  occurring 
early,  usually  on  the  first  day,  gradually  diminishing  in  cases  of  recovery, 
or  deepening  into  coma  in  fatal  cases ;  localized  or  general  parah'sis,  also 
occurring  early ;  there  is  no  fever  in  the  beginning,  and  onl}'  moderate 
fever  at  the  close.  In  acute  meningitis  we  usually  have  a  higher  tem- 
perature, especially  early  in  the  disease  ;  coma  develops  later,  and  rigidity 
of  the  extremities  is  less  pronounced.  In  certain  cases,  however,  where 
the  haemorrhage  occurs  in  the  course  of  some  other  disease,  a  differential 
diagnosis  may  be  impossible. 

Treatment. — The  treatment  of  pachymeningitis  hemorrhagica  is  symp- 
tomatic. The  indications  are,  to  relieve  cerebral  congestion  by  applying 
ice  to  the  head,  to  allay  irritative  symptoms  by  the  use  of  bromides,  and 
to  keep  the  patient  perfectly  quiet. 


49 


Y50  DISEASES  OF  THE  NERVOUS  SYSTEM. 

ACUTE  MENINGITIS. 
Acute  inflammation  of  the  pia  mater,  or  acute  leptomeningitis,  is  seen 
under  a  variety  of  circumstances  : 

1.  It  occurs  epidemically.  It  is  then  usually  associated  with  the  same 
process  in  the  cord,  and  is  known  as  cerebro- spinal  meningitis,  or  spotted 
fever,  being  regarded  by  many  as  a  general  infectious  disease  with  a  local 
lesion. 

2.  It  occurs  sporadically  as  a  primary  disease,  with  symptoms  and 
lesions  which  may  be  identical  with  those  seen  in  the  first  group  of  cases. 

3.  It  occurs  as  a  secondary  disease,  complicating  other  acute  infectious 
diseases  and  local  inflammations. 

Etiology. — Epidemic  meningitis  occurs  especially  in  winter  and  spring  j 
it  affects  children  of  all  ages,  but  males  more  often  than  females.  It  has 
been  attributed  to  overcrowding  and  to  bad  drainage.  Epidemics  are  in- 
frequent, usually  separated  by  quite  long  intervals,  and  the  number  of 
persons  attacked  is  rarely  large.  In  New  York  and  in  many  other  large 
cities  cases  occur  almost  every  year ;  but  in  some  seasons  their  number  is 
much  greater  than  usual  and  the  disease  is  said  to  be  epidemic.  Out- 
breaks are  occasionally  seen  in  small  towns  or  in  remote  country  districts 
where  their  origin  is  hard  to  trace.     The  disease  is  not  contagious. 

It  is  now  well  established  that  epidemic  meningitis  is  caused  by  the 
diplococcus  intracellularis  of  Weichselbaum.  This  is  present  in  the  me- 
ningeal exudate,  in  the  diseased  tissues,  and  in  the  cerebro-spinal  fluid 
obtained  by  lumbar  puncture.  It  is  found  almost  invariably  within  the 
cells,  chiefly  the  polynuclear  leucocytes,  where  it  exists  in  pairs  or  tet- 
rads. It  is  decolourized  by  Gram's  method.  It  is  hard  to  cultivate, 
the  best  medium  being  Loefiler's  blood  serum.  The  mode  of  infection 
is  as  yet  somewhat  uncertain,  but,  as  a  diplococcus  resembling  Weich- 
selbaum's  has  been  found  by  Councilman*  and  others  high  up  in  the 
nose  of  affected  persons,  it  seems  probable  that  it  is  in  this  way  that  the 
organism  frequently  reaches  the  brain. 

Sporadic  eases  of  meningitis  may  occur  either  before  or  after  epi- 
demics, or  without  assignable  cause  where  there  has  been  no  epidemic. 
Many  cases  regarded  as  primary  are  secondary  to  otitis  which  has  been 
overlooked.  Some  of  the  sporadic  cases  are  due  to  the  diplococciis  intra- 
cellularis, others  to  the  pneumococcus,  and  still  others  to  the  streptococ- 
cus or  staphylococcus.  In  twenty-five  cases  studied  by  Netter  the  pneu- 
mococcus was  present  in  eighteen,  and,  according  to  some  observers,  this 
is  the  organism  frequently  found.  However,  it  is  only  recently  that  the 
diplococcus  intracellularis  and  the  pneumococcus  have  been  generally 
differentiated,  and  these  figures  can  not  be  altogether  trusted. 

*  Report  of  the  State  Board  of  Health  of  Massachusetts,  1898. 


ACUTE   MENINGITIS.  751 

Acute  secondary  meningitis  may  complicate  pneumonia,  influenza, 
scarlet  or  typhoid  fever,  malignant  endocarditis,  or  acute  nephritis.  It 
also  follows  cerebral  abscess,  erysipelas  of  the  scalp,  disease  or  injury  of 
the  skull,  otitis,  mastoid  abscess,  or  an  infectious  process  in  any  of  the 
other  cavities  adjacent  to  the  cranium — ethmoid  sinus,  nose,  orbit,  etc. 
Infection  may  take  place  by  direct  extension  through  the  blood-vessels  or 
the  lymph  channels  of  the  neighbourhood,  or  the  primary  focus  may  be 
in  some  distant  part,  the  brain  being  reached  through  the  general  circu- 
lation. 

In  secondary  meningitis  the  nature  of  the  infection  varies  with  that  of 
the  primary  disease,  it  being  perhaps  most  frequently  the  streptococcus. 

Lesions. — In  epidemic  meningitis  death  may  take  place  so  early  that 
the  changes  found  at  autopsy  are  slight.  There  may  be  only  a  serous 
exudation  and  intense  hypersemia,  which  is  doubtless  much  less  marked 
after  death  than  during  life.  The  microscope,  however,  may  show,  even 
in  these  early  cases,  an  abundant  exudation  of  leucocytes  in  the  pia 
mater.  It  is  rare  to  find  much  pus  before  the  third  day,  but  after  this 
the  lesions  are  quite  uniform.  The  convolutions  appear  somewhat  flat- 
tened from  pressure  due  to  distention  of  the  ventricles.  The  inner  sur- 
face of  the  dura  is  usually  normal  or  only  congested.  There  may  be 
thrombi  in  any  of  the  cerebral  sinuses,  or  in  the  meningeal  veins  of  the 
convexity.  There  is  an  exudation  of  greenish-yellow  lymph,  which  is 
usually  abundant,  and  in  places  may  nearly  conceal  the  convolutions.  It 
is  generally  most  marked  over  the  anterior  half  of  the  brain  and  at  the 
base,  but  usually  it  is  very  extensive.  There  is  an  increase  in  the  quan- 
tity of  cerebro-spinal  fluid.  The  ventricles  are  moderately  distended 
with  serum  or  sero-pus,  and  their  walls  may  be  slightly  softened.  The 
brain  substance  of  the  cortex  may  be  reddened  or  may  appear  normal. 
In  the  meninges  of  the  cord,  lesions  similar  to  those  of  the  brain  are 
usuall}^  seen.  The  exudation  is  principally  upon  the  posterior  surface, 
and  may  extend  throughout  the  entire  length  of  the  cord,  or  be  limited  to 
its  upper  or  to  its  lower  portion.  In  some  cases  the  cord  lesion  is  over- 
looked, because  the  whole  cord  is  not  examined. 

Microscopical  examination  shows  the  exudation  to  consist  of  fibrin 
and  pus  cells,  which  infiltrate  the  pia  mater  and  may  cover  its  surface. 
The  superficial  layers  of  the  cortex  in  the  inflamed  areas  often  show 
minute  haemorrhages  and  very  marked  cell-infiltration.  Minute  ab- 
scesses may  be  present.  Very  marked  degenerative  changes  can  usu- 
ally be  demonstrated  in  the  nerve  cells  themselves.  The  cells  of 
the  neuroglia  are  also  affected;  they  are  swollen  and  increased  in 
number;  and  there  may  be  proliferation  of  the  connective  tissue  about 
the  blood-vessels.  Changes  in  the  cord  similar  to  those  just  de- 
scribed may  be  found,  but  these  are  less  frequent  and  as  a  rule  much 
less  severe  than  those  in  the  brain.     Inflammatory  products  are  some- 


Y52  DISEASES  OP  THE  NERVOUS  SYSTEM. 

times  present  in  the  central  canal  of  the  cord  and  in  the  walls  of  the 
lateral  ventricles  of  the  brain.  The  inflammatory  process  frequently  ex- 
tends along  the  cranial  nerves,  especially  the  optic  and  auditory,  and  this 
may  result  in  choroiditis  or  otitis ;  from  the  cord  it  may  extend  along 
both  the  anterior  and  posterior  nerve  roots.  Descending  degeneration  is 
found  in  the  nerves  both  of  the  brain  and  cord. 

In  cases  that  survive  the  acute  stage  the  inflammatory  process  may 
continue  and  the  late  results  of  these  lesions  be  seen.  There  is  usually  a 
chronic  meningo-encephalitis.  It  leads  to  thickening  of  the  meninges, 
the  formation  of  organized  adhesions  between  them  and  the  brain,  and 
the  development  of  permanent  changes  in  the  cortex.  These  are  some- 
time diffuse,  as  in  a  case  of  my  own  where  death  occurred  six  months 
after  the  acute  attack  ;  the  pia  was  much  thickened  and  everywhere 
adherent  to  the  brain,  while  in  the  cortex  were  the  early  changes  of  a 
general  encephalitis.*  More  often,  however,  they  are  in  patches  and 
result  in  the  formation  of  areas  of  sclerosis,  especially  over  the  frontal 
and  temporo-sphenoidal  lobes,  with  which  there  are  almost  always  as- 
sociated marked  descending  degenerative  changes  in  the  cord.  Such 
lesions  are  of  course  permanent,  and  seriously  interfere  not  only  with  the 
functions,  but  also  with  the  growth  and  development  of  the  brain.  An 
infrequent  sequel  is  chronic  hydrocephalus. 

The  lesions  most  frequently  associated  with  epidemic  meningitis  are 
in  the  lung.  There  may  be  lobar  or  broncho-pneumonia,  and  in  the  cells 
of  the  exudation  may  be  found  the  same  organism  as  in  the  brain. 
Acute  degeneration  of  the  liver  and  kidneys  is  also  frequent.  The 
•other  viscera  are  seldom  affected. 

In  cases  of  acute  meningitis  due  to  other  organisms  than  the  diplo- 
coccus  the  lesions  resemble  in  a  general  way  those  above  described  ;  how- 
ever, the  cord  is  less  frequently  and  usually  less  seriously  involved.  The 
most  extensive  fibrinous  exudation  is  seen  in  cases  due  to  the  pneumo- 
coccus,  where  it  is  even  greater  than  in  epidemic  form.  It  may  be  so 
abundant  as  almost  to  envelop  the  brain,  and  in  places  to  conceal  the  con- 
volutions (Plate  XYI). 

When  meningitis  is  secondary  to  otitis  or  some  other  local  process  in 
the  neighbourhood,  it  often  begins  as  a  localized  inflammation,  afterward 
becoming  general ;  it  may  be  associated  with  thrombosis  of  the  lateral  sinus. 

*  The  clinical  features  of  this  case  were  also  interesting.  The  patient  was  a  bright 
little  girl  of  four  and  a  half  years,  who  had  in  May  a  typical  attack  of  meningitis  of 
moderate  severity.  She  made  a  very  slow  convalescence,  but  at  the  end  of  two  mouths 
recovery  was  perfect  in  everything  but  her  mental  condition.  She  remembered  noth- 
ing which  she  had  previously  learned  in  the  kindergarten,  where  she  had  been  an  ex- 
ceptionally bright  pupil.  Her  mind  was  a  blank.  She  was  dull,  listless,  and  her  face 
had  a  vacant,  idiotic  expression.  The  special  senses  seemed  unaffected,  and  speech 
was  retained.     Slie  died  during  an  attack  of  convulsions  in  November. 


PLATE   XVI 


Acute  Meningitis,  complicating  Pleuro-Pneumonia. 

Child  twenty  months  old  ;  on  twenty-third  day  of  a  protracted  attack  of  pneumonia, 
vomited  six  times,  and  the  temperature,  which  had  hocn  nearly  normal  for  four  days, 
rose  to  103'  F.  On  the  following  day  general  convulsions,  wliicli  were  rei)eatod  fre- 
quently during  the  next  few  days;  temperature,  101  to  104=  F. ;  death  in  convulsions 
on  twenty-eighth  day. 

^w/o/w/.— Pleuro-pneumonia  of  left  side;  lung  resolving.  Anterior  portion  of 
brain  enveloped  in  lympli  and  pus,  more  marked '"at  the  convexity,  but  present  also 
over  the  base. 


ACUTE  MENINGITIS.  753 

Symptoms. — Few  diseases  are  so  irregular  in  their  course,  or  present 
so  many  atypical  forms,  as  does  acute  meningitis. 

1.  The  common  form. — Most  of  the  sporadic  and  epidemic  cases  are 
of  this  type.  The  acute  symptoms  are  sometimes  preceded  by  a  prodro- 
mal stage  of  one  or  two  days,  characterized  by  general  weakness  and  in- 
definite malaise,  but  in  the  majority  of  cases  this  is  wanting,  and  the 
attack  begins  suddenly  with  vomiting  or  convulsions,  headache,  and  high 
fever.  The  initial  temperature  is  from  102°  to  105°  F.  There  is  pres- 
ent, intense  headache,  marked  prostration,  pain  in  the  back  of  the  neck 
and  along  the  spine,  general  hypersesthesia,  opisthotonus,  constipation, 
retraction  of  the  neck,  and  rigidity  of  the  cervical  muscles.  Later,  more 
intense  nervous  symptoms  develop.  There  is  delirium,  which  is  often 
active,  to  which  are  added  muscular  twitchings,  and  sometimes  convul- 
sions ;  or  there  may  be  dulness,  apathy,  and  finally  complete  coma.  The 
respiration  is  slow,  sometimes  irregiilar.  The  temperature  is  elevated, 
usually  between  101°  and  104°  F.  There  are  seen  in  a  few  of  the  cases 
fine  petechial  spots  upon  the  face,  abdomen,  or  all  over  the  body.  The 
pupils  are  irregular;  there  may  be  strabismus  or  nystagmus.  The  pulse 
is  weak,  and  sometimes  slow,  sometimes  rapid. 

After  these  symptoms  have  lasted  from  two  to  ten  days,  the  patient 
may  become  completely  comatose,  with  general  relaxation  and  dilated 
pupils,  and  may  die  in  this  condition  or  in  convulsions.  In  other  cases 
he  passes  into  a  typhoid  condition,  and  death  occurs  from  exhaustion  or 
complications,  particularly  pneumonia.  The  usual  duration  of  these  at- 
tacks is  from  one  to  two  weeks.  In  cases  recovering  convalescence  is 
sometimes  quite  rapid ;  or  the  disease  may  pass  into  a  subacute  form, 
lasting  from  three  weeks  to  two  or  three  months,  improvement  being  slow 
and  interrupted  by  relapses. 

2.  Abortive  cases. — In  every  epidemic  there  are  seen  attacks  which 
begin  precisely  like  those  above  described,  but  where  the  symptoms  last 
only  two  or  three  days  and  then  subside  rapidly,  the  case  going  on  to 
a  complete  and  permanent  recovery.  In  some  epidemics  the  number  of 
such  cases  is  quite  large. 

3.  Malignant  or  fulminati7ig  cases. — These  also  occur  principally  in 
epidemics,  but  are  not  confined  to  them.  The  onset  in  this  type  is  very 
abrupt,  and  the  patient  may  be  overcome  by  the  poison  and  die  in  fromL 
twelve  to  thirty-six  hours.  These  cases  often  begin  with  convulsions 
and  very  high  temperature,  from  105°  to  106-5°  F.  There  is  very  great 
prostration  and  frequently  cyanosis.  There  may  be  opisthotonus  and 
general  hypersesthesia,  or  these  may  be  absent.  The  patient  may  pass  in 
a  few  hours  into  a  condition  of  collapse,  with  general  relaxation,  feeble, 
irregular  pulse,  and  cold  extremities,  followed  by  convulsions  and  death. 
If  life  is  prolonged,  there  may  follow  after  a  few  hours  a  period  of  re- 
action, in  which  irritative  symptoms  are  prominent, — headache,  photo- 


Y54:  DISEASES  OF  THE  NERVOUS  SYSTEM. 

phobia,  contracted  pupils,  general  liypersesthesia,  and  active  delirium. 
The  eruption  may  appear  within  the  first  twenty-four  hours  after  the 
onset.  In  most  of  these  cases  a  positive  diagnosis  is  impossible,  except 
by  finding  the  diplococcus  in  the  fluid  drawn  by  lumbar  puncture,  as 
the  general  toxic  symptoms  mask  the  local  evidences  of  cerebral  inflam- 
mation. 

4.  Acute  primary  r)ieningitis  occurring  sporadically  does  not  differ 
in  any  essential  particulars  from  the  epidemic  form.  The  fulminating 
and  the  abortive  cases  are,  however,  less  frequent  than  when  the  disease  is 
epidemic. 

5.  Acute  secondary  meningitis  presents  quite  a  different  clinical  pic- 
ture, and  the  symptoms  are  greatly  modified  by  those  of  the  original  dis- 
ease. Generally  in  this  form  the  disease  runs  a  short  course  and  it  is 
almost  invariably  fatal.  The  diagnosis  is  difficult,  and  in  many  cases  the 
lesions  are  found  at  autopsy  where  no  marked  cerebral  symptons  have 
existed  during  life.  This  is  particularly  true  where  the  process  is  mainly 
at  the  convexity.  The  onset  is  generally  with  convulsions,  after  which 
there  may  develop  quite  rapidly  stupor  and  finally  coma,  with  dilated 
pupils,  slow  pulse,  and  irregular  respiration.  Convulsions  and  gradually 
deepening  stupor  may  be  the  only  symptoms  ;  or  there  may  be  opisthoto- 
nus, retracted  abdomen,  and  rigidity  of  the  extremities.  The  duration  of 
these  cases  is  quite  short,  being  rarely  more  than  three  or  four  days,  and 
often  but  one  or  two.     Death  usually  occurs  in  convulsions. 

The  nervous  symjJtoms. — Headache  is  a  frequent  symptom  of  menin- 
gitis and  is  often  severe ;  it  is  more  likely  to  be  frontal  than  elsewhere, 
although  it  may  be  general  and  associated  with  vertigo.  There  may  also 
be  pains  in  the  back  of  the  neck,  along  the  spine,  or  in  the  muscles,  which 
may  be  so  intense  as  to  cause  the  patient  to  scream  out.  Pain  may  be 
present  only  in  the  early  stage,  or  continue  throughout  the  disease.  With 
this  there  may  be  tenderness  along  the  spine,  and  often  general  hyperes- 
thesia, which  may  be  so  acute  that  any  movement  causes  agonizing  cries. 
Delirium  is  frequent  in  the  severe  cases  after  the  first  day ;  it  may  be  wild 
and  active,  or  low  and  muttering.  After  delirium  there  follows  usually  a 
stage  of  apathy  which  may  develop  into  complete  coma ;  deep  coma,  how- 
ever, is  not  often  present  in  cases  that  recover.  Convulsions  mark  both 
the  onset  and  the  close  of  the  disease,  but  rarely  occur  during  its  progress. 
Tonic  spasm  of  the  various  muscles  gives  rise  to  deformities  which  may 
continue  throughout  the  attack.  The  rigidity  and  contraction  of  the 
muscles  of  the  neck  produce  cervical  or  general  opisthotonus ;  there  may 
be  tonic  flexion  or  extension  of  the  extremities,  especially  of  the  legs. 
In  some  epidemics  opisthotonus  is  seen  in  nearly  every  case,  in  others 
it  is  infrequent.  In  most  of  the  protracted  cases  localized  paralysis  is 
present  in  the  course  of  the  disease.  It  may  affect  one  side  of  the  body, 
or  one  extremity. 


ACUTE   MENINGITIS.  Y55 

Special  seyises. — The  eyes  are  affected  iu  almost  all  severe  attacks.  The 
pupils  in  the  early  stage  are  generally  contracted,  later  they  may  be  irreg- 
ular, and  toward  the  close  they  are  usually  widely  dilated.  External 
strabismus  is  by  far  the  most  frequent  form  of  ocular  paralysis.  The 
fundus  is  rarely  normal.  In  a  study  of  thirty-five  cases,  Randolph  (Balti- 
more) noted  the  following  changes  :  The  fundus  was  the  seat  of  venous 
engorgement  and  tortuosity,  with  more  or  less  congestion  of  the  optic  disc 
in  nineteen  cases ;  there  was  optic  neuritis  in  six  cases ;  retinitis  with 
thrombosis  of  the  central  vein  in  one  case.  Of  the  seven  cases  in  which 
the  fundus  was  normal,  one  had  strabismus,  one  nystagmus,  and  one 
greatly  dilated  pupils.  Inflammation  of  the  conjunctiva  is  also  very  fre- 
quent. Deafness  is  common  during  the  acute  stage  of  the  disease,  and  is 
its  most  frequent  sequel.  It  may  be  due  to  the  cerebral  lesion,  to  otitis 
media,  or  to  otitis  interna. 

Speech  is  disturbed  in  most  of  the  protracted  cases.  Bulging  of  the 
fontanel  is  one  of  the  regular  symptoms  in  young  infants.  Marked  pros- 
tration is  always  present;  it  may  come  very  early,  and  may  be  followed 
by  collapse,  or  may  last  but  a  short  time  and  be  followed  by  a  period  of 
reaction. 

The  temperature  is  always  elevated,  being  especially  high  at  the  onset. 
In  the  fulminating  cases  there  may  be  hyperpyrexia — 106°  or  even  107°  F. 
The  usual  range  is  between  100°  and  104°  F.  In  cases  terminating  in 
recovery,  the  fever  usually  lasts  from  one  to  two  weeks  and  gradually  falls 
to  normal.  There  is  no  regular  or  typical  curve.  The  height  of  the  tem- 
perature may  bear  no  relation  to  the  severity  of  the  other  symptoms. 
It  may  be  low  throughout,  even  in  the  fatal  cases. 

The  respiration  is  slow  and  irregular  as  the  disease  progresses,  and  it 
may  be  of  the  typical  Cheyne-Stokes  variety.  Cyanosis  is  often  present 
in  cases  where  no  cause  for  it  can  be  found  in  the  heart  or  lungs ;  it  is  es- 
pecially frequent  in  the  fulminating  cases. 

The  pulse  in  the  early  stages  is  full  and  rapid ;  later  it  becomes  slow, 
irregular,  and  feeble,  and  may  be  intermittent. 

The  examinations  of  the  blood  made  by  Barker  and  Flexner  showed 
the  presence  of  marked  leucocytosis  in  every  fatal  case  examined. 
Epistaxis  is  not  uncommon  as  an  early,  and  sometimes  as  a  late 
symptom. 

Digestive  system. — Vomiting  is  frequent  at  the  onset  and  may  bo 
persistent.  The  bowels  as  a  rule  arc  constii)atcd.  The  tongue  is  often 
coated;  sometimes  it  is  dry  and  glazed,  or  covered  with  sordes.  Deglu- 
tition is  sometimes  difficult  on  account  of  the  retraction  of  the  neck. 
The  spleen  is  usually  not  enlarged.  Jaundice  occurs  in  a  small  projior- 
tion  of  the  cases. 

Eruptions. — In  the  majority  of  cases  the  skin  presents  no  changes. 
In  others  there  is  herpes  of  tli(>  li])s.  face,  or  nose,  or  an  orn]iti(in  over  the 


756  DISEASES   OF  THE  NERVOUS  SYSTEM. 

face  or  body  consisting  of  fine  purpuric  spots,  and  sometimes  larger  ex- 
travasations. These  are  particularly  significant  when  seen  upon  the  face 
or  the  ears,  and  from  this  symptom  the  name  "  spotted  fever  "  has  arisen. 
In  some  cases  a  general  erythema  is  present.  The  petechial  eruption  may 
be  seen  during  the  early  part  of  the  disease,  even  in  the  first  twenty-four 
hours.  Late  in  the  protracted  cases  there  may  be  fine  punctate  haemor- 
rhages over  the  abdomen,  as  in  any  exhausting  disease. 

The  large  joints,  particularly  the  knees,  are  sometimes  swollen,  tender, 
and  painful,  tlie  symptoms  resembling  those  of  acute  rheumatism.  Incon- 
tinence of  urine  and  fteces  may  occur  in  the  late  stages  of  the  disease,  asso- 
ciated with  low  delirium  and  other  typhoid  symptoms.  Retention  of  urine 
is  not  infrequent,  and  often  overlooked. 

Course,  Termination,  and  Prognosis. — The  duration  of  the  disease  in 
the  fatal  cases  is  usually  less  than  a  week.  In  epidemics  many  deaths 
occur  within  forty-eight  hours.  In  infants  the  course  is  very  short.  Of 
the  cases  which  terminate  in  recovery,  if  we  exclude  the  abortive  cases, 
the  majority  last  at  least  three  weeks,  and  very  many  run  a  protracted 
course.  After  three  or  four  weeks,  there  is  in  such  cases  a  gradual  subsi- 
dence of  the  fever  and  of  most  of  the  acute  nervous  symptoms ;  but  the 
child  remains  emaciated,  very  weak,  with  occasional  attacks  of  headache, 
general  pains  or  hypergesthesia,  and  often  with  some  localized  paralysis. 
This  may  slowly  disappear,  or  it  may  be  permanent.  In  the  majority  of 
cases  recovery  is  only  partial.  The  child  may  recover  perfectly  so  far  as  all 
the  physical  functions  are  concerned,  but  be  mentally  deficient.  But  more- 
frequently  there  is  also  hemiplegia  or  monoplegia,  and  often  contractures, 
which  are  sometimes  temporary  but  are  apt  to  be  permanent.  Of  the 
special  senses,  hearing  is  most  liable  to  be  affected,  deafness  being  quite 
common  after  severe  attacks,  and  deaf-mutism  not  an  infrequent  result 
in  young  children.  Blindness  is  rare,  and  may  be  due  to  optic-nerve 
atrophy  or  rarely  to  the  cerebral  lesion.  As  a  late  result  epilepsy  may 
develop. 

The  mortality  of  epidemic  meningitis  varies  much  at  different  times, 
ranging  from  forty  to  eighty  per  cent.  It  is  now  pretty  well  established 
that  many  more  such  cases  recover  than  of  meningitis  due  to  other  bac- 
teria ;  infection  by  the  pneumococcus  is  usually,  and  that  by  the  strepto- 
coccus nearly  always,  fatal. 

Diagnosis. — The  diagnosis  of  acute  meningitis  presents  unusual  diffi- 
culties in  young  children,  because  of  the  frequency  with  which  cerebral 
symptoms  are  seen  in  all  forms  of  acute  disease,  both  at  the  onset  and  late 
in  their  course.  In  infants  the  usual  mistake  made  is  to  diagnosticate 
meningitis  where  there  is  none,  rather  than  to  overlook  it  when  it  is 
present.  The  symptoms  most  to  be  relied  upon  for  diagnosis  are  con- 
tinued stupor  or  coma,  opisthotonus,  slow  pulse  and  irregular  respiration 
— especially  if  associated  with  high  fever — localized  paralysis,  muscular 


ACUTE   MENINGITIS.  75Y 

rigidity,  general  hypertesthesia,  and  a  retracted  abdomen.  Cases  where  the 
principal  lesion  is  at  the  convexity  are  particularly  obscure,  and  often  the 
diagnosis  is  not  made  during  life.  There  is  no  opisthotonus  or  cranial- 
nerve  symptoms,  and  irregularity  of  pulse  and  respiration  is  rare. 

At  the  onset,  meningitis  is  most  likely  to  be  confounded  with  pneu- 
monia, scarlet  fever,  and  iniiuenza.  Pneumonia  is  recognised  by  the 
accelerated  respiration  and  the  physical  signs ;  scarlet  fever,  by  the  con- 
gestion of  the  throat  and  the  eruption  ;  from  influenza  the  diagnosis  may 
be  almost  impossible  except  from  the  course  of  the  disease.  From  all  other 
diseases,  meningitis  is  differentiated  by  the  continuance  and  the  severity  of 
the  nervous  symptoms,  rather  than  by  the  presence  or  absence  of  single  or 
special  symptoms. 

Quincke's  procedure  of  lumbar  puncture*  is  of  much  value,  first  in 
distinguishing  meningitis  from  other  diseases  with  cerebral  symptoms,  and 
secondly  in  determining  the  form  of  meningitis  which  is  present.  Menin- 
gitis is  indicated  by  cloudiness  in  the  fluid  drawn,  sometimes  marked  and 
sometimes  scarcely  recognisable,  by  an  increase  in  the  amount  of  fibrin 
present  so  that  spontaneous  coagulation  may  occur,  and  by  the  presence 
of  leucocytes  which  frequently  form  a  heavy  deposit  in  twenty-four  hours. 
The  different  forms  of  meningitis  are  distinguished  by  the  discovery  of  the 
form  of  bacteria  present.  Councilman  found  the  diplococcus  in  thirty-eight 
of  fifty-five  cases  of  epidemic  meningitis  examined ;  positive  results  being 
obtained  in  nearly  all  cases  at  the  most  active  period  of  the  disease.  In 
other  varieties  of  meningitis,  the  pneumococcus,  streptococcus,  or  tubercle 
bacillus  may  be  found,  or  mixed  forms.  The  number  of  bacteria  present 
may  be  few  or  many,  but  their  discovery  in  the  cerebro- spinal  fluid  may  be 
regarded  as  definitely  establishing  the  nature  of  the  infection,  a  point 
which  can  not  be  settled  in  any  other  way  during  life. 

The  most  striking  points  which  contrast  simple  and  tuberculous  men- 
ingitis are  that  in  the  former  the  onset  is  usually  abrupt ;  the  temperature 
is  high;  the  disease  develops  rapidly ;  and  in  forty-eight  hours — sometimes 
in  twenty-four — nearly  all  the  severe  nervous  symptoms  may  be  present ; 
pain  in  the  spine  and  general  hyper^esthesia  are  quite  frequent.  Usually 
the  patient  is  a  child  who  has  been  in  perfect  health  up  to  the  beginning 
of  the  disease  ;  or  there  is  present  some  local  cause,  such  as  middle-ear 

*  Puncture  is  usually  made  between  the  third  and  fourth  lumbar  vertebra?  a  little 
to  one  side  of  the  median  line.  The  smallest  exploring  needle  may  be  used,  and  for 
convenience  it  may  be  attached  to  a  syringe  as  a  handle,  as  it  is  not  necessary  to  aspi- 
rate. The  canal  is  reached  at  a  variable  depth,  usually  about  one  inch  from  the  skin. 
'J'he  body  should  be  flexed  during  the  operation  so  as  to  separate  the  vertebra',  and 
unless  the  patient  is  comatose  an  aniPsthetic  is  advisable.  All  observers  agree  that 
with  a  clean  needle  lumbar  puncture  is  harmless.  See  Jacoby,  New  York  Medical  Jour- 
nal. December  28. 1895.  and  .Tanuary  4, 1896 :  Connor.  New  York  iVredical  Journal,  May 
12.  1900;  and  Weiilworth,  Transactions  of  the  American  Pa?diatric  Society,  1896. 


758  DISEASES  OF  THE  NERVOUS  SYSTEM. 

disease,  or  traumatism ;  or  an  epidemic  may  be  prevailing.  In  tuberculous 
meningitis,  the  onset  is  usually  insidious  ;  the  temperature,  low ;  the  pros- 
tration not  marked  for  the  first  few  days ;  the  evolution  of  the  nervous 
symptoms  is  often  slow  and  irregular,  and  the  child  may  be  sick  a  week 
before  he  appears  to  be  seriously  ill ;  pain  in  the  spine  and  general  hyper- 
aesthesia  are  rare.  The  child  is  usually  one  who  has  a  history  of  heredi- 
tary tuberculosis ;  or  who  has  been  previously  delicate,  or  who  has  suffered 
-already  from  some  other  form  of  tuberculosis,  in  the  lungs,  bones,  or 
lymph  nodes.  In  cases  of  sporadic  meningitis  which  are  apparently  pri- 
mary, the  tuberculous  is  much  more  frequent  than  the  simple  form — in 
my  experience  fully  three  to  one. 

Treatment. — The  treatment  of  acute  meningitis  is  quite  unsatisfactory, 
and  it  is  very  doubtful  whether  the  result  is  greatly  modified  by  any  spe- 
cial plan  of  treatment ;  it  seems  to  depend  upon  the  age  of  the  patient, 
-and  the  nature  and  severity  of  the  attack,  rather  than  upon  its  manage- 
ment. The  treatment  directed  toward  the  inflammation  consists  in  the 
constant  use  of  an  ice-cap  to  the  head,  and  at  times  an  ice-bag  along  the 
spine.  Counter-irritation  may  be  maintained  by  painting  the  nape  of 
the  neck  and  the  spine  daily  with  a  strong  tincture  of  iodine,  or  by  blis- 
ters, but  best  of  all  by  the  Paquelin  cautery.  The  bowels  should  be  kept 
freely  open  by  calomel  or  saline  cathartics.  Internally,  ergot  and  iodide 
of  potassium  should  be  given  in  as  full  doses  as  will  be  tolerated  by  the 
stomach. 

Of  the  symptoms  which  call  for  special  treatment,  the  most  prominent 
one  is  pain,  which  when  severe  requires  morphine,  even  in  large  doses. 
It  is  often  best  to  give  it  hypodermically.  For  other  nervous  symptoms — 
delirium,  sleeplessness,  etc. — the  bromides  and  chloral,  sulfonal,  or  trional 
may  be  given,  or  warm  sponge  baths.  Stimulants  are  required  in  most  of 
the  cases  at  some  time  in  the  course  of  the  disease.  They  are  indicated 
by  weak,  rapid,  and  irregular  pulse.  Alcohol  and  digitalis  should  be 
used,  but  not  strychnine.  The  difficulties  in  feeding  these  patients  are 
sometimes  great,  but  they  can  often  be  overcome  by  the  use  of  gavage 
(page  62),  which  may  be  advantageously  employed  as  a  routine  practice  in 
the  most  severe  cases.  The  physician  should  be  on  the  watch  for  bed- 
sores, and  endeavour  to  prevent  them  by  cleanliness,  frequently  changing 
the  patient's  position,  etc.  The  bladder  also  must  not  be  forgotten,  as 
retention  of  urine  is  not  uncommon  and  may  require  the  use  of  the 
catheter. 

For  the  residual  paralysis,  massage,  warm  baths,  and  friction  should  be 
employed,  but  electricity  only  when  all  symptoms  of  central  irritation 
have  subsided.  The  prolonged  use  of  iodide  of  potassium,  especially  in 
combination  with  mercury,  seems  to  have  considerable  influence  in  pro- 
moting absorption  of  the  inflammatory  products  in  cases  where  there  is  a 
persistence  of  symptoms  for  two  or  three  months. 


TUBERCULOUS  MENINGITIS.  T59 


TUBERCULOUS  MENINGITIS. 
Synonyms :  Acute  hydrocephalus ;  basilar  meningitis ;  water  on  the  brain. 

Tuberculous  meningitis  is  a  tuberculous  inflammation  of  the  pia  mater 
of  the  brain,  sometimes  involving  also  that  of  the  cord.  It  is  doubtful  if 
it  ever  occurs  as  the  only  tuberculous  lesion  of  the  body.  It  is  quite 
frequently  seen,  and  is  more  uniformly  fatal  than  any  other  disease  of 
early  life.  In  infancy  it  is  usually  associated  with  general  or  pulmonary 
tuberculosis ;  in  older  children  with  tuberculosis  of  the  bones,  joints,  or 
lymph  nodes.  Of  my  own  cases,  twenty-five  per  cent  of  all  deaths  from 
tuberculosis  in  children,  were  due  to  meningitis. 

Lesions. — The  lesion  consists  in  the  production  of  miliary  tubercles, 
with  which  are  frequently  found  tuberculous  nodules  of  variable  size,  and 
in  almost  every  case  there  are  also  the  products  of  ordinary  inflamma- 
tion of  the  pia  mater — lymph  and  pus — together  with  an  accumulation  of 
fluid  in  the  lateral  ventricles  of  the  brain.  Frequently  there  are  tubercles 
in  the  pia  mater  of  the  upper  portion  of  the  cord.  The  miliary  tu- 
bercles appear  as  small  gray  or  white  granules,  situated  along  the  vessels 
of  the  pia  mater.  When  few  in  number  they  are  usually  only  at  the  base, 
especially  along  the  Sylvian  fissures  and  in  the  interpeduncular  space. 
When  numerous  they  are  most  abundant  at  the  base,  but  are  also  seen 
scattered  over  the  convexity  in  small  groups.  In  about  half  of  my  au- 
toj)sies  they  have  been  limited  to  the  base,  and  in  no  case  were  they  seen 
exclusively  at  the  convexity.  Tubercles  are  often  found  in  the  choroid  coat 
of  the  eye.  The  amount  of  lymph  and  pus  present  is  rarely  great,  and 
never  equal  to  that  seen  in  simple  acute  meningitis.  It  is  often  a 
matter  of  surprise  at  autopsy  to  find  the  lesions  so  few,  after  very  marked 
symptoms.  The  inflammatory  products  are  most  abundant  at  the  base. 
In  addition  to  the  patches  of  greenish-yellow  lymph,  there  are  adhesions 
between  the  lobes  of  the  brain  and  thickening  of  the  pia.  In  cases  which 
have  lasted  for  several  weeks,  the  pia  mater  in  places  is  often  very  much 
thickened,  owing  to  cell  infiltration  and  the  production  of  new  connective 
tissue,  and  it  is  studded  with  miliary  tubercles,  sometimes  wath  small  yel- 
low tuberculous  nodules ;  frequently  there  is  arteritis,  which  is  sometimes 
obliterating. 

In  the  most  acute  cases  the  brain  substance  immediately  beneath  the 
pia  is  intensely  congested,  slightly  softened,  and  shows  under  the  micro- 
scope a  superficial  encephalitis.  The  lateral  ventricles  are  usually  dis- 
tended with  clear  scrum,  sometimes  with  serum  containing  flocculi  of 
lymph  or  pus ;  the  amount  present  varies  from  one  to  four  ounces  in  each 
ventricle,  being  always  greater  in  the  subacute  cases.  The  walls  of  the 
ventricles  may  be  softened.  The  distention  of  the  ventricles  leads  to 
flattening  of  the  convolutions  from  pressure  against  the  skull,  to  bulging 


Y60 


DISEASES  OF   THE  NERVOUS   SYSTEM. 


of  the  fontanel,  and  sometimes  to  separation  of  the  sutures,  if  they  are  not 
completely  ossified. 

Tuberculous  nodules  varying  in  size  from  a  small  pea  to  a  walnut  are 
frequently  seen  associated  with  meningitis  in  older  children,  but  not  so 
often  in  infants.  These  nodules  may  be  connected  with  the  meninges,  or 
they  may  be  situated  within  the  brain  substance,  usually  in  the  cerebel- 
lum. The  larger  ones  are  classed  as  brain  tumours.  Inflammatory  prod- 
ucts are  rarely  found  in  the  spinal  canal. 

Although  it  is  not  infrequent  to  see  meningitis  without  symptoms  of 
tuberculosis  elsewhere,  I  have  never  failed  at  autopsy  to  find  other  tuber- 
culous lesions  in  the  body.  In  my  own  experience  the  following  are  those 
most  often  met  with,  given  in  the  order  of  frequency: 

(1)  In  infants,  associated  with  general  or  pulmonary  tuberculosis; 
(2)  in  children  from  three  to  twelve  years  of  age,  with  tuberculosis  of 
the  vertebra,  hip,  knee,  or  ankle;  (3)  at  any  age,  with  tuberculosis  in- 
volving only  the  tracheal,  bronchial,  or  cervical  lymph  nodes;  (4)  much 
less  frequently  with  the  pulmonary  tuberculosis  of  older  children. 
There  seems  now  to  be  good  reasons  for  believing  that  meningitis  may 
follow  tuberculous  adenoids.    (See  page  299.) 

Etiology. — Tuberculous  meningitis  is  produced  only  by  the  transpor- 
tation of  the  tubercle  bacilli  to  the  brain.  They  may  find  their  way  by 
the  blood-vessels  or  lymphatics. 

The  following  table  shows  the  age  at  which  the  disease  is  most  fre- 
quently observed : 


Under  one  year 

One  to  two  years.. . . 
Two  to  five  years  .  . . 
Five  to  nine  years. . . 
Nine  to  sixteen  years 

Totals 


Personal  cases. 


14 
9 

24 

15 

5 


67 


Oxley.* 


3 
16 
26 
18 

0 


63 


Total. 


17 
25 
60 
33 

5 


130 


In  this  series,  males  were  a  little  more  frequently  affected  than  fe- 
males. In  two  or  three  instances  traumatism  was  apparently  an  exciting 
cause.  Tuberculous  meningitis  is  occasionally  seen  in  young  children  who 
were  previously  healthy,  whose  family  history  is  free  from  tuberculosis, 
and  where  no  exposure  can  be  traced.  It  is  probable  that  in  all  such  cases 
there  has  been  latent  tuberculosis  somewhere  in  the  body,  and  that  the 
exposure  was  long  antecedent  to  the  symptoms.  In  the  majority,  how- 
ever, this  is  not  the  case.  There  is  usually  a  history  of  hereditary  tuber- 
culosis or  of  exposure  to  infection  ;  or  there  have  been  previous  evidences 
of  tuberculosis  in  the  lungs,  bones,  or  lymph  nodes. 


Liverpool,  Medico-Chirurgical  Journal,  July,  1885. 


TUBERCULOUS   MENINGITIS.  761 

Symptoms. — In  forty-three  of  sixty-three  cases  tlie  onset  was  gradual ; 
but  iu  a  considerable  number  of  those  classed  as  sudden,  careful  inquiry 
elicited  a  history  of  previous  indisposition.  The  most  frequent  early 
symptoms  are  disinclination  to  play,  or  drowsiness ;  sometimes  there  is 
constant  fretfulness  or  irritability.  Often  a  distinct  change  in  disposition 
is  seen.  In  a  case  recently  under  observation  this  was  most  striking; 
from  being  devoted  to  her  mother,  a  little  girl  could  not  endure  her  presence 
in  the  room.  There  is  loss  of  appetite,  and  usually  constipation.  Sleep 
is  restless  and  disturbed ;  there  may  be  grinding  of  the  teeth.  Older 
children  often  complain  of  headache.  At  all  ages  a  suggestive  symptom 
is  frequent  attacks  of  vomiting  without  apparent  cause.  In  addition  to 
these  there  may  be  a  slight  but  continuous  elevation  of  temperature.  In- 
definite symptoms  may  last  for  four  or  five  days,  or  they  may  be  spread 
over  two  or  three  weeks  without  perhaps  being  sufficiently  severe  to  attract 
much  notice.  Finally,  unmistakable  evidence  of  brain  disease  develops, 
and  then  it  is  recollected  that  symptoms  like  the  above  had  existed  for 
some  time.  These  early  disturbances  are  often  ascribed  to  dentition,  to 
worms,  or  to  indigestion ;  and  sometimes  they  are  regarded  simply  as 
the  result  of  the  constipation. 

In  the  midst  of  such  indefinite  symptoms  there  may  come  an  attack  of 
convulsions,  and,  in  the  course  of  a  few  hours,  deep  stupor.  The  early 
symptoms  of  the  active  stage  are  indicative  of  cerebral  irritation.  There  is 
headache,  often  located  in  the  frontal  region,  and  occasionally  photophobia ; 
sometimes  there  is  sudden  screaming  out  at  night  without  waking.  The 
skin  is  usually  somewhat  hypersesthetic  ;  the  reflexes  are  apt  to  be  exagger- 
ated ;  the  muscles  of  the  neck  may  be  rigid  and  the  head  is  drawn  back,  or 
there  may  be  rigidity  of  one  or  more  of  the  extremities.  The  pupils  are 
normal  or  contracted  ;  there  may  be  nystagmus.  The  child  is  fretful, 
wishes  to  be  left  alone,  and  cries  if  disturbed ;  but  otherwise  is  apt  to  be  un- 
naturally drowsy.  Such  symptoms  may  continue  for  a  day  or  two,  or  even 
for  a  week.  If  prolonged,  they  are  likely  to  alternate  with  periods  of  more 
marked  apathy  and  dulness.  During  this  stage  there  is  occasional  vomit- 
ing, and  the  bowels  are  obstinately  constipated.  The  pulse  is  usually 
somewhat  accelerated,  but  may  be  slow  and  occasionally  is  irregular.  The 
respiration  is  of  normal  frequency,  but  a  careful  observation  during  sleep 
or  perfect  quiet  will  often  show  a  slight  irregularity  which  is  very  signifi- 
cant. This  becomes  more  marked  as  the  disease  progresses.  The  tem- 
perature is  invariably  elevated,  but  never  very  much  so,  generally  being 
from  99°  F.  to  101°  F.  When  a  high  temperature  is  seen,  it  is  usually 
due  to  tuberculosis  elsewhere  than  in  the  brain. 

During  the  intermediate  or  second  stage,  the  irritative  symptoms  sub- 
side, and  stupor  becomes  deeper  and  more  continuous.  If  undisturbed, 
the  child  may  sleep  a  great  part  of  the  time,  but  can  be  roused,  and  then 
appears  quite  rational.     Later  the  stupor  becomes  so  profound  that  the 


762  DISEASES   OF   THE   NERVOUS   SYSTEM. 

child  can  not  be  roused  at  all ;  or,  again,  this  condition  may  alternate  with 
periods  of  complete  lucidity.  Active  delirium  is  rare.  The  pupils  respond 
slowly  to  light  or  not  at  all ;  they  may  be  unequal ;  occasionally  there  is 
seen  strabismus,  ptosis,  or  paralysis  of  the  face.  More  often  there  is  hemi- 
plegia, or  paralysis  of  one  arm  or  leg.  Such  paralyses  are  often  transient, 
disappearing  after  a  day  or  two.  Automatic  movements  of  the  extremi- 
ties, particularly  of  the  arms,  are  frequent.  Muscular  twitchings  may  be 
noticed.  Opisthotonus  is  marked  and  well-nigh  constant.  In  infants 
the  fontanel  is  tense  and  bulging ;  the  abdomen  is  retracted,  giving  the 
typical  "  boat-belly."  On  drawing  the  finger-nail  along  the  skin  of  the 
abdomen,  there  appears,  after  a  few  seconds,  a  distinct  red  streak  one  or 
two  inches  wide,  which  remains  for  three  or  four  minutes.  This  is  the- 
tache  cerebrale,  and  while  not  pathognomonic,  it  is  almost  always  present. 
Other  vaso-motor  disturbances  may  be  seen.  The  reflexes  are  variable ; 
in  the  early  part  of  the  disease  they  are  usually  increased,  later  they  are 
diminished  or  abolished.  The  pulse  now  becomes  slow  and  irregular,. 
often  intermittent.  The  respiration  assumes  the  characteristic  type,  which 
consists  in  the  movements  becoming  deeper  and  deeper  until  there  is 
a  long  sigh,  then  a  complete  arrest  of  respiration  for  several  seconds,  after 

which  the  movements  begin  again,, 
at  first  shallow,  but  gradually  in- 
creasing in  depth  until  the  sigh 

Fig.  128.— Tracing  of  respiration  in  tuberculous       jg    repeated.        The    accompanying 
meningitis.  .  .,,  ,t-,. 

tracing  illustrates  the  type  (-big» 
128).  An  examination  with  the  ophthalmoscope  usually  shows  the  pres- 
ence of  choked  discs. 

The  duration  of  this  stage  is  from  three  to  ten  days.  The  progress 
is  irregular,  and  subject  to  great  variations,  especially  as  regards  the 
mental  symptoms.  Sometimes  a  child  will  be  seen  in  quite  deep  stupor,, 
and  on  the  following  day  will  be  sitting  up  in  bed  playing  with  its  toys. 
Such  a  course  is  to  be  expected,  and  the  physician  should  never  raise 
any  false  hopes  of  recovery  because  of  these  periods  of  temporary  improve- 
ment. 

In  the  third  stage  there  is  complete  coma.  The  child  can  not  be 
roused  at  all.  The  pupils  are  widely  dilated,  and  do  not  respond  to  light. 
There  is  general  muscular  relaxation.  There  may  be  retention  of  the 
urine.  Deglutition  is  difficult,  sometimes  almost  impossible.  The  boat- 
belly  and  opisthotonus  are  still  marked.  The  respiration  is  more  rapid, 
but  still  irregular.  There  are  sordes  on  the  lips  and  teeth,  emaciation, 
and  anaemia.  Toward  the  end  the  temperature  rises  rapidly  to  104°  F., 
sometimes  to  106°  or  107°  F.  (Fig.  129).  The  pulse  becomes  very  rapid 
and  feeble,  often  160  to  180  a  minute.  Death  usually  takes  place  from 
exhaustion  in  deep  coma ;  or  convulsions  develop  and  continue  from  twelvfr 
to  twenty-four  hours  until  death.     The  duration  of  the  stage  of  coma  is. 


TUBERCULOUS  MENINGITIS. 


Y63 


from  two  days  to  a  week.  Often  the  patient  will  live  for  four  or  five  days 
in  a  condition  of  prostration  so  extreme  that  death  is  hourly  expected. 
A  rapidly  rising  temperature  or  the  occurrence  of  convulsions  indicates 


DAY 

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1- 

106° 
105° 
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99° 

M.E. 

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M.E. 

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M.E. 

M.E. 

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M.E. 

M.E. 

M.E. 

M.E. 

M.E. 

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Fig.  129. — Fairly  typical  temperature  curve  in  tuberculous  meningitis;  boy,  twenty  months 
old  ;  death  on  seventeenth  day. 

approaching  death.     Of  fifty-seven  cases,  fifty  died  in  coma,  seven  in  con- 
vulsions. 

The  entire  dui-ation  of  the  disease  from  the  beginning  of  definite 
symptoms,  in  sixty-five  of  my  own  cases,  was  as  follows : 

One  week,  or  less 17 

One  to  two  weeks 15 

Two  to  three  weeks 17 

Three  to  four  weeks 14 

Five  weeks 2 

65~ 

Variations  in  the  course  of  the  disease. — There  are  few  diseases  which 
present  a  greater  variety  of  symptoms  than  tuberculous  meningitis.  Typical 
cases  like  those  above  described  are  seen  most  frequently  in  children  over 
two  years  old,  in  whom  the  cerebral  symptoms  predominate  over  those  of 
general  tuberculosis.  In  infancy,  especially  when  the  disease  follows 
acute  tuberculous  pneumonia,  the  duration  of  the  cerebral  symptoms  may 
be  only  tliree  or  four  days.  The  stages  then  are  not  marked.  The  onset 
is  usually  with  convulsions,  and  in  less  than  twenty-four  hours  there  may 
be  marked  stupor,  and  all  the  symptoms  belonging  to  the  third  stage  of 
the  disease. 

In  some  cases  the  course  is  much  longer  than  that  described,  the 
symptoms  lasting  from  four  to  eight  weeks.  In  character  they  are  much 
the  same  as  those  in  the  typical  cases,  except  that  the  irritative  symptoms 
are  less  marked,  and  there  is  less  fever.  If  the  child  is  young,  there  is 
great  bulging  of  the  fontanel,  or  even  an  increase  in  the  size  of  the  head. 


Y64       '  DISEASES  OP  THE  NERVOUS  SYSTEM. 

In  older  children  the  symptoms  are  chiefly  those  of  a  general  pressure 
npon  the  cortex.  These  are  due  to  the  great  accumulation  of  fluid  in  the 
lateral  ventricles.  The  symptoms  of  general  compression  are  persistent 
drowsiness,  but  rarely  deep  coma,  rigidity  of  all  the  extremities,  and  some- 
times paralysis.  The  pupils  are  usually  contracted,  but  there  are  no 
symptoms  which  are  distinctly  focal.  Opisthotonus  is  nearly  always 
marked  in  these  cases. 

Diagnosis. — There  are  no  diagnostic  symptoms  in  the  first  stage.  If 
the  patient  has  previously  suffered  from  local  or  general  tuberculosis,  and 
symptoms  develop  which  are  enumerated  as  prodromal,  meningitis  may 
be  suspected  with  a  strong  degree  of  probability.  If  the  child  has  pre- 
viously given  no  evidence  of  tuberculosis,  a  diagnosis  is  impossible.  The 
indefinite  symptoms  that  belong  to  the  early  stage  of  the  disease  are  fre- 
quent in  young  children  suffering  from  chronic  indigestion  associated 
with  constipation.  In  nine  out  of  every  ten  cases,  such  will  be  the  ex- 
planation of  the  indisposition  rather  than  incipient  meningitis.  Dis- 
turbances of  nutrition,  classed  as  cyclic  vomiting  (page  328),  may  present 
many  of  the  symptoms  of  meningitis.  I  have  seen  two  cases  in  which  a 
differential  diagnosis  was  impossible  for  two  or  three  days. 

The  most  frequent  symptoms  of  tuberculous  meningitis  enumerated  in 
the  order  of  their  occurrence  in  fifty-eight  cases,  were  as  follows  :  obsti- 
nate constipation,  persistent  drowsiness,  irregular  respiration,  vomiting 
without  apparent  cause,  irregular  pulse,  convulsions,  opisthotonus,  and 
fever  which  was  usually  slight.  Equally  important  for  diagnosis,  and  es- 
pecially significant  when  associated  with  the  above,  are  strabismus,  facial 
paralysis,  and  loss  of  the  pupillary  reflexes. 

The  discovery  of  tubercle  bacilli  in  the  fluid  drawn  by  lumbar  puncture 
(page  757)  is  conclusive.  However,  this  does  not  add  greatly  to  our  means 
of  diagnosis,  as  the  bacilli  are  never  numerous  and  always  difficult  to 
find,  and  in  a  number  of  undoubted  cases  they  can  not  be  found  at  all. 
Without  finding  bacilli  we  may  be  quite  certain,  from  the  other  conditions 
present,  that  meningitis  exists,  but  we  can  not  with  any  certainty  separate 
the  simple  from  the  tuberculous  cases.  The  symptoms  which  distinguish 
these  from  each  other  have  already  been  considered  (page  757). 

The  cerebral  symptoms  of  ileo- colitis  and  other  diarrhoeal  diseases, 
sometimes  closely  resemble  those  of  tuberculous  meningitis ;  but  whenever 
in  a  young  child  there  is  another  disease  present  which  may  furnish  an 
explanation  for  the  cerebral  symptoms,  the  diagnosis  of  meningitis  should 
be  made  with  great  caution.  The  development  of  meningitis  in  the  course 
of  an  ordinary  attack  of  pneumonia  may  simulate  very  closely  pulmonary 
tuberculosis  with  tuberculous  meningitis.  A  diagnosis  may  be  impossible 
during  life.  In  doubtful  cases  the  probabilities  are  greatly  in  favour  of 
tuberculosis,  since  it  is  so  much  more  common. 

Prognosis. — It  is  still  a  matter  of  dispute  whether  tuberculous  menin- 


CHRONIC  BASILAR  MENINGITIS  IN  INFANTS.  7r)5 

gitis  ever  ends  in  recovery.  Such  a  result  is  certain!}^  not  to  be  expected. 
Simple  meningitis  may  so  closely  simulate  the  tuberculous  variety  that 
a  differential  diagnosis  can  not  be  made,  and  it  is  probable  that  most  of 
the  cases  of  alleged  recovery  were  not  tuberculous;  but  Quincke  has  re- 
ported an  instance  of  recovery  from  meningitis  where  tubercle  bacilli 
were  found  in  the  fluid  drawn  by  lumbar  puncture.  On  theoretical 
grounds  there  would  seem  to  be  no  reason  why  recovery  might  not  some- 
times follow  meningitis  as  well  as  other  forms  of  local  tuberculosis. 

Treatment. — From  what  has  been  said  regarding  prognosis,  it  follows 
that  if  the  diagnosis  is  correct  the  case  is  practically  hopeless,'no  matter 
what  treatment  is  employed;  but  as  a  positive  diagnosis  is  not  always 
possible,  all  cases  should  be  treated  like  those  of  simple  meningitis. 

CHRONIC  BASILAR  MENINGITIS  IN  INFANTS. 

Acute  basilar  meningitis  is  generally  tuberculous.  Xot  very  infre- 
quently, however,  there  is  seen  in  infants  a  chronic  form  of  basilar  men- 
ingitis which  is  not  tuberculous.  Attention  was  first  called  to  these  cases 
by  Gee  and  Barlow,  who  in  1878  published,  under  the  title  of  "  Cervical 
Opisthotonus  in  Infants,"  six  cases  of  simple  basilar  meningitis  in  which 
the  diagnosis  was  confirmed  by  autopsy.  Since  that  time  many  cases 
have  been  reported.  The  most  important  contribution  to  our  knowl- 
edge of  this  disease  was  made  by  Still  (London)  in  1898,  who  found 
the  diplococcus  intracellular  is  in  seven  of  eight  cases  examined,  thus 
establishing  its  etiological  identity  with  cerebro-spinal  meningitis.  We 
have  been  able  at  the  Babies'  Hospital  to  confirm  Still's  observations  by 
finding  the  organism  in  the  fluid  drawn  by  lumbar  puncture.  I  do  not 
think,  however,  that  all  the  cases  of  chronic  basilar  meningitis  in  in- 
fants are  due  to  this  cause,  as  I  have  seen  at  least  two  which  seemed 
clearly  sj^philitic ;  one  occurred  in  a  child  who  had  other  manifestations 
of  syphilis  and  was  cured  by  antisyphilitic  treatment;  in  another  case 
the  diagnosis  was  confirmed  by  an  autopsy. 

Lesions. — This  process  is  usually  limited  to  the  base  of  the  brain. 
The  pia  mater  is  thickened  about  the  interpeduncular  space,  also  over  the 
medulla,  pons,  and  cerebellum.  These  different  parts  may  be  adherent  to 
each  other,  or  to  the  inner  surface  of  the  dura.  The  cranial  nerves  may 
be  compressed.  The  openings  in  the  fourth  ventricle  are  usually  obliter- 
ated, and  there  results  a  distention  of  the  lateral  ventricles  witli  clear 
serum,  sometimes  in  sufficient  amount  to  be  regarded  as  hydrocephalus. 
Earely,  pus  may  be  found  in  the  ventricles.  The  lesions  thus  are  very 
much  like  those  seen  in  the  protracted  cases  of  tuberculous  meningitis', 
minus  the  tubercles. 

Symptoms. — The  onset  is  usually  gradual,  although  exccpti(mally 
there  may  be  an  early  active  period  with  convulsions.  The  most  promi- 
nent symptoms  are  cervical  opistliotonus.  mndornte  hydrorephalus,  and 
50 


^IQQ  DISEASES   OP   THE   NERVOUS  SYSTEM. 

usually  general  muscular  rigidity.  The  opisthotonus  is  extreme  and  is 
greater  than  is  seen  in  any  other  disease.  If  placed  upon  its  back  the 
body  of  the  child  often  touches  the  table  only  at  the  occiput  and  the 
sacrum  (Fig.  130).  The  head  is  usually  but  little  enlarged,  the  fontanel 
bulges,  and  the  sutures  are  slightly  separated.  These  symptoms  are  due 
to  an  accumulation  of  fluid  in  the  lateral  ventricles ;  they  are  never  so 
marked  as  in  primary  hydrocephalus.  The  rigidity  of  the  extremities  is 
very  great  and  in  most  cases  constant;  the  legs  and  feet  are  usually 
extended,  while  the  forearms  are  flexed  and  the  hands  clenched.  All 
the  reflexes  are  greatly  exaggerated.     There  is  rarely  coma,  but  mental 


^^/ 


^- 


•»--i'~1!»'TiSv;«!« 


Fig.  180. — Chronic  basilar  meningitis ;  a  patient  in  the  Babies'  Hospital  (diagnosis 
contirined  by  autopsy). 

dulness  alternating  with  periods  of  great  irritability  in  which  general 
convulsions  may  occur.  Vision  may  be  impaired  or  wanting  entirely. 
The  fact  that  in  most  cases  optic  neuritis  is  absent  is  of  some  value  in 
differentiating  this  disease  from  tumour.  Nystagmus  is  often  present 
and  attacks  of  vomiting  occur  without  evident  cause.  There  is  no  fever 
except  for  a  few  days  at  a  time  during  acute  exacerbations.  The  usual 
duration  of  the  disease  is  from  one  to  four  months;  death  may  occur 
from  convulsions,  from  some  intercurrent  disease,  such  as  pneumonia, 
but  most  frequently  from  marasmus.  The  prognosis  is  very  bad  except 
when  the  cause  is  syphilis,  when  recovery  may  take  place. 

Diagnosis. — The  disease  is  to  be  distinguished  from  tuberculous  men- 
ingitis, and  from  the  opisthotonus  of  reflex  origin  which  is  occasionally 
seen  in  infants  suffering  from  marasmus.  It  differs  from  tuberculous 
meningitis  in  its  more  protracted  course,  in  the  absence  of  fever,  paraly- 
sis, and  the  evidences  of  tuberculosis  elsewhere  in  the  body,  and  also  in 
the  greater  prominence  of  the  opisthotonus  and  hydrocephalus.     The 


THROMBOSIS   OP   THE   SINUSES   OP   THE  DURA   MATER.        ^67 

opisthotonus  which  is  seen  in  eases  of  marasmus  is  never  so  extreme  or 
so  continuous,  and  is  not  accompanied  by  any  enlargement  of  the  head, 
or  by  other  cerebral  symptoms. 

Treatment. — This  consists  in  the  administration  of  potassium  iodide. 
Although  this  has  little  or  no  influence  upon  cases  not  syphilitic,  it  may 
cure  those  which  are  syphilitic.  At  least  fifteen  grains  daily  should  be 
given  for  several  weeks  to  an  infant  six  months  old,  and  still  larger  doses 
if  the  stomach  will  tolerate  it.  Lumbar  puncture  is  useful  in  diagnosis, 
and  in  certain  cases  it  has  seemed  to  have  some  therapeutic  value  and 
should  certainly  be  tried. 

THROMBOSIS  OP  THE  SINUSES  OP  THE  DURA  MATER. 

This  is  not  very  frequent.  It  may  depend  upon  certain  general  condi- 
tions, when  it  is  usually  classed  as  cachectic  or  marantic  thrombosis ;  it 
may  be  associated  with  local  pathological  processes,  when  it  is  known  as 
inflammatory  or  septic  thrombosis. 

Cachectic  Thrombosis. — This  is  seen  in  infants  and  young  children, 
but  is  very  rare  after  the  age  of  five  years.  It  occurs  in  the  course  of 
various  diseases,  the  most  frequent  being  pneumonia,  pertussis,  diphtheria, 
nephritis,  tuberculosis,  and  the  acute  intestinal  diseases.  In  connection 
with  the  last-mentioned  group,  altogether  too  much  has  been  made  of  it, 
as  it  is  really  rare,  and  in  only  a  very  few  cases  does  it  explain  the  cerebral 
symptoms  present.  This  statement  is  made  from  personal  observations 
.upon  over  two  hundred  autopsies  upon  cases  of  acute  intestinal  disease. 
The  actual  cause  of  the  thrombosis  is  the  altered  condition  of  the  blood 
and  the  feeble  circulation,  as  the  walls  of  the  sinuses  are  normal. 

The  most  frequent  seat  of  cachectic  thrombosis  is  the  superior  longi- 
tudinal sinus.  At  autopsy  one  must  be  careful  no^  co  confound  the  soft, 
partly-decolorized,  non-adherent  thrombi  of  post-mortem  origin,  with  those 
of  ante-mortem  formation.  The  latter  are  firm,  and  when  of  long  stand- 
ing may  be  very  hard  and  even  show  a  laminated  structure.  They  usually 
fill  the  sinus  completely,  and  are  adherent.  The  thrombus  extends  from 
the  sinuses  to  the  veins  emptying  into  it,  which  stand  out  like  dark  worms 
upon  the  surface  of  the  brain.  The  brain  itself  may  be  deeply  congested, 
or  it  may  be  covered  with  a  diffuse  hasmorrhage,  but  more  frequently  the 
brain  and  the  membranes  are  simply  oedematous. 

The  symptoms  of  cachectic  thrombosis  are  few  and  uncertain,  and 
in  a  large  number  of  cases  the  disease  is  latent.  Very  rarely  is  a  posi- 
tive diagnosis  possible  during  life.  When  the  thrombosis  occurs  just 
before  death,  its  symptoms  are  so  mingled  with  those  of  the  original 
disease  that  they  can  not  be  separated.  In  some  cases  there  may  be 
localized  or  general  convulsions,  or  paralysis,  loss  of  consciousness,  and 
strabismus. 

The  prognosis  is  bad,  cases  generally  proving  fatal  in  the  course  of  a 
few  days.     Tlie  diagnosis  is  so  uncertain  and  obscure  that  the  treatment 


Y68  DISEASES  OF  THE  NERVOUS  SYSTEM. 

must  be  symptomatic,  and  directed  toward  the  general  rather  than  the 
local  condition. 

Inflammatory  Thrombosis — Septic  Thrombosis — Sinus-Phlebitis. — This 
condition  is  most  frequent  in  children  in  connection  with  acute  meningitis. 
It  may  exist  either  with  the  simple  or  the  tuberculous  variety.  It  also  fol- 
lows otitis — especially  old  and  neglected  cases — usually  with  necrosis  of  the 
petrous  bone,  but  sometimes  without  it.  It  is  much  less  frequently  asso- 
ciated with  disease  of  the  ear  in  children  than  in  adults.  It  may  arise 
from  traumatism,  necrosis  of  the  cranial  bones,  or  from  septic  processes 
involving  any  of  the  cavities  or  any  of  the  structures  adjacent  to  the  brain, 
such  as  the  scalp,  orbit,  nasal  fossa,  mouth,  or  pharynx.  Infection  from 
the  mouth  or  pharynx  is  most  frequent  in  children  in  connection  with 
scarlet  fever  or.  diphtheria  ;  while  usually  secondary  to  otitis  it  may  occur 
without  it,  the  infection  being  carried  by  the  blood-vessels.  Infection 
from  the  nose  may  have  its  origin  in  ulceration  from  syphilis  or  tubercu- 
losis.    In  the  orbit,  the  source  may  be  malignant  disease. 

The  seat  of  the  thrombosis  will  depend  upon  the  original  disease.  If 
this  affects  the  cranial  bones  or  the  scalp,  it  will  be  the  longitudinal  sinus ; 
if  the  ear,  the  lateral  sinus ;  if  the  base  of  the  skull,  the  orbit,  the  mouth, 
the  jaw,  or  the  nose  is  affected,  it  will  be  the  cavernous  sinus.  When 
thrombosis  occurs  with  meningitis  the  lesions  are  much  the  same  as  in 
the  cachectic  form,  with  the  exception  that  there  are  sometimes  slight 
changes  in  the  walls  of  the  sinuses.  If  the  patient  has  suffered  from  a 
local  septic  process,  there  may  be  puriform  softening  of  the  clot,  and  gen- 
eral pyaemia,  with  the  development  of  secondary  abscesses  in  the  brain, 
in  the  lungs,  and  in  other  organs.  With  such  cases  there  may  be  asso- 
ciated a  general  or  localized  meningitis. 

Symptoms. — The  symptoms  of  septic  thrombosis  are  more  decided  than 
those  of  the  cachectic  form.  When  occurring  in  the  course  of  meningitis, 
it  usually  adds  no  new  symptoms  to  those  of  the  original  disease.  In  the 
pysemic  form  the  symptoms  are  more  characteristic,  particularly  when 
associated  with  otitis.  There  are  recurring  chills  with  very  high  and 
widely-fluctuating  temperature.  There  is  headache,  and  often  localized 
tenderness  of  the  scalp ;  the  other  symptoms  which  are  present  are  usually 
the  same  as  those  of  meningitis.  If  metastasis  occurs,  there  may  be  evi- 
dences of  abscesses  of  the  brain  or  in  other  organs,  and  sometimes  there 
are  signs  of  suppuration  in  the  jugular  vein. 

The  local  symptoms  of  the  thrombosis  differ  somewhat  according  to 
the  sinus  affected  :  if  its  seat  is  the  superior  longitudinal  sinus,  there  may 
be  cyanosis  of  the  face,  dilatation  of  the  temporal  and  frontal  veins,  and 
sometimes  epistaxis ;  if  the  lateral  sinus  is  involved,  the  process  may  ex- 
tend to  the  jugular  vein,  which  may  be  felt  in  the  neck  as  a  hard  cord, 
and  there  may  be  dilatation  of  the  veins  of  the  mastoid  region,  and  even 
localized  oedema  ;  when  the  cavernous  sinus  is  affected,  there  may  be  pro- 


CEREBRAL  ABSCESS.  769 

trusion  of  the  eyeball  of  the  affected  side,  oedema  of  the  lid,  and  with  the 
ophthalmoscope  the  retinal  veins  appear  enlarged  and  tortuous,  sometimes 
being  the  seat  of  thrombosis.  The  process  may  affect  either  one  or  both 
sides.  The  course  of  septic  thrombosis  is  rather  irregular,  varying  from  a 
few  days  to  three  weeks.  In  fatal  cases  death  takes  place  from  menin- 
gitis, cerebral  abscess,  or  pyaemia.  The  prognosis  is  very  grave,  unless  the 
disease  is  so  situated  that  it  is  accessible  to  surgical  operation. 

Treatment. — The  only  successful  treatment  is  surgical.  Operation 
is  easiest  in  thrombosis  of  the  lateral  sinus,  being  much  more  difficult 
if  involving  the  superior  longitudinal  sinus.  So  many  cases  are  now  on 
record  of  successful  operation  upon  septic  thrombosis  of  the  lateral  sinus, 
that  it  should  always  be  urged  when  the  diagnosis  is  clear.  Eecurring 
chills  and  high,  fluctuating  temperature,  associated  with  disease  of  the  ear, 
either  with  or  without  symptoms  of  meningitis,  are  sufficiently  character- 
istic to  justify  operative  interference. 

CEREBRAL  ABSCESS. 

Cerebral  abscess  is  quite  rare  in  children,  decidedly  more  so  than  is 
cerebral  tumour.  In  Gowers'  collection  of  223  cases,  only  24  were  under 
ten  years  of  age.  In  infants,  abscess  is  one  of  the  least  frequent  diseases 
of  the  brain,  and  up  to  five  years  it  is  exceedingly  rare. 

Etiology. — By  far  the  most  frequent  cause  in  children  is  otitis.  This 
is  the  origin  of  the  great  majority  of  the  cases.  Abscess  rarely  compli- 
cates acute  otitis,  but  is  seen  with  the  chronic  form.  Exactly  how  otitis 
causes  cerebral  abscess  it  is  not  always  easy  to  determine.  Toynbee  was 
the  first  to  call  attention  to  the  fact  that  cerebellar  abscess  was  most 
frequent  with  disease  of  the  mastoid  cells,  and  cerebral  abscess  with  otitiS' 
media.  Usually  there  is  caries  of  the  petrous  bone,  but  there  may  be^ 
none.  The  infection  may  extend  through  the  small  veins  traversing  this 
bone,  or  along  the  lateral  sinuses  to  the  cerebellum.  Abscess  is  often 
attributed  to  the  retention  of  pus  in  the  ear,  but  it  may  occur  when  the 
discharge  is  free. 

Traumatism  is  the  second  important  etiological  factor.  Abscess  may 
be  associated  with  fracture  of  the  skull,  or  follow  simple  concussion.  The 
abscess  is  generally  in  the  neighbourhood  of  the  injury,  but  occasionally 
is  produced  by  contre  coup.  In  one  instance,  reported  by  Wagner,  thrush 
was  believed  to  be  the  cause  of  cerebral  abscess,  the  same  fungus  that 
existed  in  tlio  mouth  being  found  in  the  brain,  which  in  this  case  was 
studded  with  small  abscesses.  Abscess  may  be  the  result  of  infectious 
emboli,  associated  with  general  pyaemia,  though  this  is  rare  in  early  life ; 
and  finally  it  may  occur  without  any  assignable  cause. 

Lesions. — The  most  frequent  seat  of  the  abscess  is,  first,  the  temporo- 
sphenoidal  lobe ;  secondly,  the  cerebellum ;  thirdly,  the  frontal  lobes. 
Other  locations  are  very  rare.     Abscesses  are  usually  single.     In  size  they 


7Y0  DISEASES  OP  THE  NERVOUS  SYSTEM. 

vary  from  that  of  a  small  cherry  to  an  orange.  One  case  was  observed  by 
Meyer,  in  which  an  abscess  occupied  one  entire  hemisphere.  The  con- 
tents are  usually  thick  greenish-yellow  pus,  which  may  be  very  fetid. 
When  abscesses  have  lasted  for  some  time  they  are  usually  surrounded 
by  dense  pyogenic  membrane,  and  may  become  encysted.  The  patho- 
logical process  may  be  slow,  and  often  is  apparently  stationary  for  a  long 
period.  Abscesses  may  rupture  into  the  ventricles,  less  frequently  upon 
the  surface  of  the  brain,  causing  meningitis,  or  the  pus  may  even  escape 
externally  through  the  auditory  meatus,  as  in  Lallemand's  case. 

Symptoms. — These  are  general  and  local.  The  general  symptoms  are 
much  the  more  important  for  diagnosis,  and  often  are  the  only  ones  present. 
The  local  symptoms  are  those  of  a  tumour.  The  clinical  history  of  a  case 
of  abscess  of  the  brain  may  be  divided  into  three  stages :  First,  the  period 
of  onset,  or  early  acute  inflammatory  symptoms,  fever,  etc.,  which  attend 
the  formation  of  pus.  Secondly,  the  latent  period,  or  period  of  remission, 
in  which  very  few  symptoms  are  present.  In  many  acute  cases  this  stage 
is  wanting  altogether ;  in  the  chronic  cases  it  may  last  for  months,  or  even 
years.  Thirdly,  the  final  period,  with  recurrence  of  active  cerebral  symp- 
toms, followed  by  death  in  a  few  days. 

The  onset  may  be  accompanied  by  symptoms  so  slight  as  almost  to 
escape  notice.  In  most  cases,  however,  headache  and  fever  are  present. 
The  headache  is  usually  severe,  and  often  localized  upon  the  affected  side ; 
in  cerebellar  abscess  it  may  be  occipital.  The  fever  is  moderate  in  inten- 
sity, and  continuous.  In  addition  there  may  be  vertigo,  vomiting,  gen- 
eral convulsions,  and  cessation  of  the  aural  discharge,  if  one  has  been 
present.  The  duration  of  this  stage  is  variable ;  it  may  be  only  a  few 
days,  or  several  weeks.  It  is  shorter  in  traumatic  cases,  and  in  those  which 
are  due  to  pyaemia. 

The  latent  stage,  or  period  of  remission  of  symptoms  may  be  quite 
short — only  a  few  days'  duration — and  it  is  often  absent.  During  this 
period  the  temperature  may  fall  quite  to  the  normal,  and  the  headache 
disappear,  or  be  only  occasional  and  slight.  However,  if  any  focal  symp- 
toms halve  been  present  they  remain  unchanged. 

The  symptoms  of  the  terminal  stage  are  due  to  a  rapid  extension  of 
the  inflammatory  process,  with  oedema  and  softening  about  the  abscess, 
sometimes  to  rupture  into  the  ventricle,  and  sometimes  to  meningitis. 
The  fever  now  returns,  and  may  be  high.  There  is  headache,  often 
very  intense  and  continuous ;  there  may  be  delirium  and  convulsions,  and 
the  gradual  development  of  coma.  In  addition  there  may  be  vomiting, 
paralysis,  opisthotonus,  retracted  abdomen,  and  the  other  symptoms  of 
meningitis.  Occasionally  all  the  earlier  symptoms  may  be  latent,  and  the 
terminal  symptoms  may  be  the  only  ones  present.  In  infants,  the  fontanel 
is  usually  large  and  bulging ;  convulsions  are  rather  more  frequent  than 
in  older  children. 


CEREBRAL  ABSCESS.  771 

The  local  symptoms  of  abscess  are  rather  indefinite,  owing  to  its  usual 
situation.  Abscesses  of  considerable  size  may  exist  in  the  temporo-sphe- 
noidal  lobe,  in  the  central  part  of  the  frontal  lobe,  or  in  the  cerebellum, 
without  any  definite  local  symptoms.  If  the  abscess  is  near  the  motor  area, 
there  are  the  usual  symj)toms  of  disease  in  this  location,  spasm,  or  paraly- 
sis of  the  face,  arm,  or  leg.  A  cortical  or  sub-cortical  abscess  is  likely  to 
cause  convulsions.  Cerebellar  abscess  may  give  rise  to  occipital  headache, 
frequent  vomiting,  and  vehen  the  abscess  is  large  enough  to  press  upon 
the  middle  lobe,  there  may  be  inco-ordination  of  the  muscles  of  the 
extremities.  Optic  neuritis  may  be  present,  but  other  symptoms  relating 
to  the  cranial  nerves  are  rare.  Localized  tenderness  over  the  scalp,  when 
persistent,  is  a  symptom  of  importance,  and  may  serve  to  locate  the  ab- 
scess, if  it  is  superficial. 

Diagnosis. — Of  the  general  symptoms,  the  most  important  for  diagnosis 
are  fever,  headache,  delirium,  and  terminal  coma.  These  become  particu- 
larly significant  when  following  otitis  or  traumatism.  The  differential 
diagnosis  of  abscess  is  to  be  made  principally  from  tumour  and  meningitis, 
and  from  these  conditions  more  by  the  history  and  general  course  of  the 
disease  than  by  any  special  symptoms.  The  diagnosis  of  abscess  from 
tumour  is  considered  in  connection  with  the  latter  disease.  It  is  more 
difficult  to  distinguish  between  meningitis  and  abscess,  since  the  two  pro- 
cesses are  often  associated.  With  meningitis  convulsions  are  more  com- 
mon, but  they  are  rarely  localized ;  rigidity  and  the  inflammatory  symp- 
toms are  more  intense ;  the  course  is  usually  more  rapid  and  more  regular, 
being  rarely  interrupted,  as  is  the  course  of  abscess.  From  the  cerebral 
symptoms  occurring  with  otitis  it  is  extremely  difficult  to  distinguish 
abscess,  for,  according  to  Gowers,  optic  neuritis  may  be  present  in  the 
former  as  well  as  in  the  latter  condition.  The  more  intense  and  pro- 
longed are  the  cerebral  symptoms  and  the  more  marked  the  neuritis,  the 
greater  are  the  probabilities  of  abscess. 

Prognosis. — The  prognosis  in  cerebral  abscess  is  always  grave,  unless 
accessible  to  surgical  operation.  The  progress  may  be  slow,  or  rapid,  but 
it  is  inevitably  from  bad  to  worse,  and  sooner  or  later  the  disease,  if  not 
interfered  with,  proves  fatal. 

Treatment. — The  medical  treatment  of  abscess  in  its  active  stage  is 
that  of  any  acute  intracranial  inflammation, — ice  to  the  head,  absolute 
quiet,  free  catharsis,  and  full  doses  of  the  bromides  or  antipyrine  or  mor- 
phine, if  pain  is  intense.  The  absolutely  hopeless  condition  of  these  cases 
when  left  to  themselves,  and  the  recent  brilliant  results  from  surgical 
operations,  should  lead  the  physician  to  urge  operation  in  every  case.* 


*  For  a  discussion  of  the  surgical  aspects  of  this  question,  see  "  Brain  Surgery,"  by 
M.  Allen  Starr,  M.  D.,  and  "  Pyogenic  Infectious  Diseases  of  the  Brain  and  Cord,"  by 
William  McEwen,  M.  D. 


'72  DISEASES   OF   THE  NERVOUS  SYSTEM. 


CEREBRAL  TUMOUR. 

Very  little  has  been  added  to  our  knowledge  of  cerebral  tumour  in 
children  since  the  exhaustive  monograph  of  Starr,  which  appeared  in 
Keating's  Cyclopsedia  in  1890.  It  is  to  this  article  that  I  am  indebted 
for  most  of  the  facts  in  this  chapter. 

Varieties  and  Location. — Tumour  of  the  brain  is  not  very  infrequent, 
and  may  be  seen  even  in  infancy.  From  this  time  up  to  puberty  there  is 
no  period  of  special  susceptibility.  In  two  hundred  and  sixty-nine  of  the 
cases  in  Starr's  collection,  in  which  the  nature  of  the  tumour  was  stated, 
the  following  were  the  varieties : 

Tubercle 152  cases. 

Grlioma 37 

Sarcoma 34 

Glio-sareoma 5 

Cyst 30 

Carcinoma 10 

Gumma 1 

Tuberculous  tumours  are  more  often  multiple  than  are  other  varieties. 
Their  most  frequent  seat  is  the  cerebellum ;  next  to  this  the  pons  and 
crura  cerebri.  They  are  rarely  cortical  or  central.  Glioma  is  most  often 
found  in  the  cerebellum  or  in  the  pons,  and  next  in  the  cortex;  but  it  is 
rarely  central.  Sarcoma  is  most  frequently  in  the  cerebellum ;  next  to 
this,  in  the  order  of  frequency,  in  the  pons,  the  basal  ganglia,  and  the  cor- 
tex. Cystic  tumours  are  either  central  or  cerebellar.  Taking  the  cases 
as  a  whole,  the  most  frequent  seat  of  tumour  in  children  is,  first  the  cere- 
bellum, second  the  pons,  third  the  centrum  ovale. 

Tuberculous  tumours  are  occasionally  seen  in  infancy,  but  they  occur 
most  frequently  between  the  ages  of  five  and  twelve  years.  They  are- 
usually  secondary  to  tuberculosis  elsewhere,  especially  in  the  lungs  and  in 
the  bronchial  lymph  nodes.  They  most  frequently  start  from  the  mem- 
branes, rarely  being  centrally  situated,  and  extend  inward,  infiltrating 
the  superficial  portion  of  the  cerebellum  or  cerebrum.  There  is  almost 
invariably  localized  meningitis  at  the  site  of  the  tumour;  there  maybe 
adhesions  between  the  dura  and  pia  mater,  and  the  disease  may  extend  to 
the  cranial  bones.  In  size,  these  tumours  vary  from  a  small  pea  to  a 
child's  fist.  They  may  be  softened  and  broken  down  at  the  centre,  or 
cheesy  throughout.  They  are  the  result  of  a  localized  tuberculous  in- 
flammation, which  does  not  differ  essentially  from  that  seen  in  other 
parts  of  the  body. 

Glioma  is  not  infrequent  in  infancy.  It  is  probably  connected  in 
every  case  with  the  ependyma  of  the  ventricle.  It  repeats  the  structure- 
of  the  neuroglia,  being  composed  of  connective  tissue  and  branching  cells,. 


CEREBRAL  TUMOUR.  YT3 

Sarcoma  may  be  of  the  spindle-celled  or  the  mixed  variety.  It  grows 
much  more  rapidly  than  glioma.  The  two  varieties  are  not  infrequently 
combined  in  the  same  tumour — glio-sarcoma. 

Cystic  tumours  are  sometimes  sarcomatous  in  origin,  the  wall  of  the 

cyst  containing  sarcoma  cells,  and  they  may  also  be  parasitic,  from  the 

growth  of  the  echinococcus.    They  may  be  found  in  any  part  of  the  brain. 

The  other  varieties  of    sarcoma,  gumma   and  vascular   tumours,  are 

exceedingly  rare  until  after  puberty. 

As  the  tumour  grows,  secondary  lesions  are  produced  in  most  of  the 
cases.  These  are  the  result  of  pressure  upon  arteries,  causing  localized 
anaemia,  or  even  cerebral  softening ;  or  upon  veins,  producing  congestion 
and  oedema.  When  affecting  the  middle  lobe  of  the  cerebellum,  pressure 
upon  the  venas  Graleni  may  lead  to  effusion  into  the  ventricles.  Localized 
meningitis  over  tumours  superficially  situated  is  the  rule,  and  this  may  be 
the  cause  of  some  of  the  symptoms.  Rarely,  cerebral  haemorrhage  may  be 
associated. 

Etiology. — The  causes  of  cerebral  tumours  are  for  the  most  part  un- 
known. In  a  few  instances  there  is  a  history  of  definite  traumatism. 
Sarcoma  or  carcinoma  may  be  secondary,  and  tuberculous  tumours  are 
probably  always  so. 

Symptoms.— These  may  be  divided  into  two  groups :  first,  the  general 
symptoms  which  are  common  to  tumours  of  all  varieties,  and  are  inde- 
pendent of  location ;  secondly,  the  local  symptoms  depending  upon  the 
situation  of  the  growth. 

General  symptoms. — One  of  the  most  frequent  is  headache.  Though 
it  varies  much  in  its  severity,  character,  and  position,  it  is  rarely  absent. 
It  is  apt  to  be  severe,  and  may  continue  for  a  long  period,  or  it  may  be 
intermittent.  The  location  of  the  pain  has  no  definite  relation  to  the  sit- 
uation of  the  tumour.  It  may  be  accompanied  by  sensations  of  tightness, 
compression,  or  tension  in  the  head.  It  may  be  associated  with  localized 
tenderness  of  the  scalp ;  when  this  is  constant  it  is  a  valuable  s3miptom 
for  diagnosis,  as  it  often  occurs  with  tumours  superficially  located. 

General  convulsions  are  frequent  in  the  early  stage,  but  separated  by 
quite  long  intervals ;  they  become  more  frequent  and  more  severe  as  the 
disease  progresses.  All  degrees  of  severity  are  seen,  from  slight  twitch- 
ings  and  temporary  loss  of  consciousness,  to  typical  epileptiform  seiz- 
ures. They  are  most  common  when  the  growth  is  rapid  and  when  com- 
plicating meningitis  is  present.  Attacks  of  vomiting  or  of  localized 
spasm  may  for  a  considerable  time  precede  general  convulsions ;  and  in  a 
single  attack  there  may  be  first  localized  and  then  general  convulsions. 
]\rental  symptoms  are  generally  present  in  great  variety  and  complex- 
ity. There  may  be  only  f retfulness  and  irritabilit}'',  or  a  marked  change  in 
disposition.  These  symptoms  are  so  frequent  from  other  causes  in  chil- 
dren that  they  excite  no  apprehension,  unless  to  them  are  added  dulness, 


774  DISEASES  OP  THE  NERVOUS  SYSTEM. 

apathy,  and  somnolence.  Later  in  the  disease  there  may  be  attacks  of 
hypochondriasis,  or  of  melancholia ;  there  may  be  periods  of  wild,  almost 
maniacal  excitement ;  and,  finally,  the  mental  impairment  may  approach 
a  condition  of  imbecility. 

Optic  neuritis  and  optic-nerve  atrophy  are  very  frequent,  occurring, 
according  to  Starr,  in  eighty  per  cent  of  the  cases.  This  is  only  recog- 
nised by  the  ophthalmoscope,  as  there  may  be  no  disturbance  of  vision. 
The  optic  neuritis  is  generally  double,  appears  earlier,  and  is  more  con- 
stant in  basal  tumours  than  in  those  at  the  convexity,  or  those  centrally 
located. 

Vomiting  is  very  frequent,  but  diagnostic  only  when  it  occurs  sud- 
denly without  assignable  cause,  and  without  nausea  or  other  symptoms 
of  indigestion.  It  is  especially  significant  when  frequently  repeated,  and 
of  more  importance  in  older  children  than  in  infants. 

Vertigo  is  often  associated  with  vomiting.  At  first  it  is  occasional  and 
seen  upon  changing  position,  but  later  it  may  be  quite  constant,  espe- 
cially with  tumours  in  the  posterior  fossa. 

Disturbances  of  sleep  are  frequent.  There  is  usually  insomnia,  but 
sleep  may  be  broken  by  hallucinations,  accompanied  by  attacks  of  scream- 
ing ;  rarely  is  there  persistent  drowsiness  until  toward  the  end  of  the  dis- 
ease. 

Local  symptoms. — These  depend  upon  the  situation  of  the  tumour, 
but  not  at  all  upon  its  anatomical  character.  Local  symptoms  may  be 
wanting  entirely,  and  they  may  vary  much  in  different  cases  even  with 
tumours  in  the  same  situation.  They  are  modified  by  the  size  and  by 
the  rapidity  of  growth,  and  by  the  existence  of  local  meningitis. 

In  tumours  of  the  cortex,  the  meninges  are  likely  to  be  involved,  espe- 
cially with  tuberculous  and  gliomatous  growths.  The  pathological  process 
may  extend  from  within  outward  or  from  without  inward.  The  most 
frequent  general  symptoms  in  such  cases  are  headache,  circumscribed  ten- 
derness of  the  scalp,  convulsions,  and  mental  symptoms.  Optic  neuritis, 
vomiting,  and  vertigo  are  not  so  common.  Tumours  situated  in  the  fron- 
tal lobe,  as  a  rule,  present  few  symptoms  and  may  be  entirely  latent. 
Irritation  of  the  frontal  lobe  may  extend  to  the  motor  area  and  cause 
convulsions  either  local  or  general ;  but  not  often  is  there  paralysis.  Tu- 
mours of  the  left  side  (of  the  right  side  in  left-handed  persons)  in  the 
third  frontal  convolution  may  cause  motor  aphasia. 

Tumours  in  the  motor  convolutions  along  the  fissure  of  Eolando  pro- 
duce the  most  definite  and  uniform  local  symptoms.  When  situated  at 
the  upper  portion  the  leg  is  afl!ected,  at  the  middle  portion,  the  arm, 
and  at  the  lower,  the  face.  Irritative  symptoms,  such  as  rigidity  or  clonic 
spasm,  commonly  precede  for  some  time  the  paralysis  which  results  from 
pressure  or  destruction.  These  attacks  of  localized  convulsions  may  begin 
in  the  face,  arm,  or  leg ;    biit  they  usually  extend  more  or  less  rapidly 


CEREBRAL  TUMOUR.  YY5 

until  all  three  are  involved.  There  is  no  loss  of  consciousness,  but- there 
may  follow  a  slight  transient  paralysis.  Such  attacks  are  known  as  "  Jack- 
eonian  epilepsy,"  and  form  one  of  the  most  diagnostic  symptoms  of  cere- 
bral tumour.  Localized  spasm  may  be  associated  with  anesthesia  or 
other  disturbances  of  sensation.  The  paralysis  generally  first  affects  one 
extremity — the  arm  or  leg,  according  to  the  location  of  the  tumour — and 
afterward  it  may  involve  the  entire  side,  including  the  face. 

If  the  tumour  is  centrally  located,  or  at  the  base,  hemiplegia  may  be  an 
early  symptom  from  pressure  on  the  motor  tract.  With  cortical  paralysis 
there  may  be  associated  ataxia  and  anaesthesia. 

Tumours  of  the  parietal  lobe  may  give  no  local  symptoms.  At  times 
there  are  disturbances  of  muscular  sense,  tactile  sensibility,  or  sensations 
of  pain  and  temperature.  If  the  inferior  parietal  lobule  of  the  left  side 
is  affected,  there  may  be  word-blindness,  or  inability  to  understand  writ- 
ten language. 

Tumours  of  the  occipital  lobe  produce,  as  the  only  constant  local  symp- 
tom, hemianopsia.  This  is  usually  bilateral,  affecting  the  same  side  of 
both  eyes,  being  on  the  side  opposite  to  that  of  the  lesion — i.  e.,  a  tumour 
on  the  right  side  causes  blindness  in  the  left  half  of  both  eyes,  so  that 
the  patient  sees  nothing  to  the  left  of  a  line  directly  in  front  of  him. 
Instead  of  hemianopsia,  there  may  be  only  irritation  and  various  disturb- 
ances of  sight. 

Tumours  of  the  temporo-sphenoidal  lobe  may  be  latent,  or,  if  on  the 
left  side,  may  cause  word-deafness — i.  e.,  inability  to  understand  the  sig- 
nificance of  spoken  language. 

Tumours  in  the  island  of  Eeil  when  situated  upon  the  left  side  (right 
side  in  left-handed  persons)  may  cause  motor  aphasia  or  disturbances  of 
speech.  If  they  are  large  they  may  produce  symptoms  by  pressure  upon 
the  motor  tract, — hemiplegia  or  monoplegia. 

Tumours  of  the  basal  ganglia  cause  marked  general  symptoms,  but 
none  of  a  definitely  local  character.  The  important  symptoms  relate  to  the 
various  tracts  or  bundles  of  fibres  which  pass  from  the  cortex  through  the 
internal  capsule.  These  include  the  motor  and  the  various  sensory  tracts, 
the  olfactory,  auditory,  visual,  and  speech  tracts.  Any  of  these  may  be 
pressed  upon,  and  the  nature  of  tlie  symptoms  will  depend  upon  the  size 
of  the  tumour  and  the  extent  of  the  pressure.  If  only  the  anterior  part 
of  the  capsule  is  affected  there  may  be  no  symptoms ;  if  the  middle 
fibres,  hemiplegia  and  disturbances  of  articulation ;  if  the  posterior  fibres, 
hemian^esthesia.  All  these  may  bo  associated,  and  any  of  them  may  be 
complete  or  partial.  Tumours  in  this  situation  are  apt  to  implicate  the 
cranial  nerves.  Optic  neuritis  is  quite  constant,  and  appears  early.  Lo- 
calized or  general  convulsions  are  rare. 

The  peculiar  symptoms  pointing  to  tumours  of  the  crura  cerebri  are 
nystagmus,  strabismus,  and  loss  of  pupillary  reflex,  sometimes  with  general 


7Y6  DISEASES   OP   THE   NERVOUS  SYSTEM. 

muscular  inco-ordination,  and  a  staggering  gait.  There  is  usually  third- 
nerve  paralysis  on  the  side  of  the  tumour,  and  on  the  side  opposite  to  the 
hemiplegia  with  which  it  is  often  associated.  Tliis  variety  of  crossed 
paralysis  is  quite  diagnostic.  The  symptoms  of  third-nerve  paralysis  are 
external  strabismus,  dilatation  of  the  pupil,  and  ptosis.  In  these  cases 
optic  neuritis  appears  early.  There  may  be  a  complicating  hydrocephalus. 
While  hemiplegia  is  commonly  present  with  large  tumours,  it  may  be  ab- 
sent with  small  ones,  or  may  appear  later  than  paralysis  of  the  third  nerve. 

Tumours  of  the  pons  are  quite  common.  The  diagnostic  symptoms 
consist  in  crossed  paralysis,  the  cranial-nerve  symptoms  being  on  the  side 
of  the  tumour,  and  the  general  motor  and  sensory  symptoms  on  the  oppo- 
site side.  When  the  seat  is  the  upper  half  of  the  pons,  the  third  and  fifth 
nerves  are  apt  to  be  implicated,  giving  rise  to  ptosis,  dilatation  of  the 
pupils,  external  strabismus,  trophic  disturbances  such  as  ulceration  of  the 
cornea,  and  neuralgic  pain  in  the  face.  Tumours  in  the  lower  half  of  the 
pons  involve  the  sixth,  seventh,  and  eighth  nerves,  causing  internal  strabis- 
mus, contracted  pupils,  facial  paralysis,  sometimes  deafness,  and  auditory 
vertigo.  Other  symptoms  associated  with  tumours  of  the  pons  are  head- 
ache, vomiting,  and  optic  neuritis ;  convulsions  being  rare. 

Tumours  of  the  medulla  are  recognised  by  the  involvement  of  the 
glossopharyngeal,  pneumogastric,  spinal  accessory,  and  hypoglossal  nerves. 
There  are  difficulty  of  deglutition,  irregular  respiration,  irregular  pulse, 
and  vaso-motor  disturbances,  such  as  flushing  of  the  face  and  perspiration. 
There  may  be  projectile  vomiting,  polyuria  or  glycosuria,  opisthotonus, 
difficulty  in  articulation  or  in  sucking,  and  in  protrusion  of  the  tongue. 
When  large,  these  tumours  may  produce  symptoms  of  pressure  upon  the 
motor  or  sensory  tracts, — paralysis,  partial  angesthesia,  with  rigidity  and 
exaggerated  reflexes. 

Tumours  of  the  cerebellum  are  especially  important,  this  being  the  most 
frequent  location  in  childhood.  When  only  one  hemisphere  is  affected 
there  may  be  no  local  symptoms.  Tumours  involving  the  middle  lobe,  or 
those  large  enough  to  produce  pressure  upon  the  middle  lobe,  give  rise  to 
vertigo  and  cerebellar  ataxia.  Vertigo  is  especially  frequent ;  it  may 
occur  with  headache.  Cerebellar  ataxia  is  different  from  the  ataxia  due 
to  a  spinal-cord  lesion,  and  strikingly  resembles  that  of  intoxication. 
It  may  increase  until  the  patient  is  unable  to  walk,  although  there  is 
no  loss  of  muscular  power.  Vomiting  is  a  frequent  symptom,  as  are  also 
optic  neuritis,  and  headache  which  is  usually  occipital.  When  there  is 
secondary  hydrocephalus,  as  is  not  uncommon,  mental  symptoms  are 
present,  and  there  may  be  enlargement  of  the  head.  Opisthotonus  is 
occasionally  seen,  but  general  convulsions  are  rare. 

Diagnosis. — The  size  of  the  tumour  is  to  be  determined  mainly  by  the 
general  symptoms,  special  attention  being  given  to  the  order  of  their 
development.     A  diagnosis  as  to  the  nature  of  the  tumour  is  really  not  of 


CEREBRAL   TUMOUR.  YY7 

much  importance ;  but  some  information  upon  this  point  may  be  gained 
from  the  consideration  of  its  etiology,  the  rapidity  of  its  growth,  and  the 
age  of  tlie  patient.  Cerebral  tumour  may  be  confounded  with  abscess,  tuber- 
culous meningitis,  chronic  basilar  meningitis,  and  chronic  hydrocephalus. 
The  symptoms  distinguishing  tumour  from  abscess  are  the  following  :  Tu- 
mour may  occur  at  any  age  ;  without  definite  etiology,  excepting  when 
tuberculous ;  the  progress  is  steady,  but  generally  slow,  new  symptoms  be- 
ing continually  added  ;  headache  is  more  constant  and  more  severe ;  optic 
neuritis  more  frequent;  cranial  nerves  more  often  involved;  mental  dis- 
turbances more  marked ;  focal  symptoms  are  often  definite ;  fever  is  absent ; 
duration,  six  months  to  two  years.  As  compared  with  the  above,  abscess 
is  not  so  frequent,  being  especially  rare  in  infancy ;  there  is  a  definite  his- 
tory of  traumatism  or  ear  disease ;  progress  more  irregular ;  symptoms 
often  intermittent ;  headache  less  severe  ;  mental  symptoms  less  marked ; 
optic  neuritis  and  involvement  of  the  cranial  nerves  less  frequent ;  focal 
symptoms  usually  indefinite ;  localized  tenderness  over  the  scalp  more 
•constant ;  fever  present  except  in  the  latent  period ;  the  most  frequent 
complication  is  acute  meningitis. 

Cases  of  tuberculous  meningitis  which  may  be  confounded  with  tumour 
are  those  of  slow  course  sometimes  seen  in  older  children.  The  diffi- 
culty in  diagnosis  is  increased  by  the  frequent  association  of  tuberculous 
tumours  with  tuberculous  meningitis.  The  main  points  of  difference  are 
that  in  tumour  the  symptoms  are  more  localized  and  the  course  gen- 
erally much  slower.  Almost  every  individual  symptom,  however,  may  be 
present  in  the  two  conditions. 

Chronic  basilar  meningitis  may  produce  symptoms  almost  identical 
Avith  those  of  tumour  in  the  posterior  fossa.  It  is,  however,  confined  to 
infancy,  and  is  frequently  syphilitic.  Hydrocephalus  and  opisthotonus 
are  much  more  marked  than  are  usually  seen  with  tumour. 

Chronic  hydrocephalus  may  resemble  tumour;  this  occurs  so  frequent- 
ly as  a  lesion  secondary  to  tumour  that  the  question  often  arises  whether 
there  is  only  hydrocephalus,  or  there  is  in  addition  a  tumour.  Primary 
hydrocephalus  is  usually  congenital,  and  commonly  attains  to  a  greater 
degree  than  is  seen  in  secondary  hydrocephalus. 

Prognosis. — The  prognosis  in  cerebral  tumour,  while  bad,  is  not  hope- 
less. Cases  are  occasionally  seen  which  exhibit  all  the  characteristic 
symptoms  of  tumour,  even  including  optic  neuritis,  which  recover  per- 
fectly. These  are  probably  syphilitic,  although  often  no  such  history 
can  be  obtained.  In  other  cases,  most  frequently  of  a  tuberculous  na- 
ture, an  arrest  of  the  growth  occurs  and  the  patient  recovers  with  some 
function  of  the  brain  impaired;  usually  there  is  loss  of  vision  or  some 
paralysis.  In  most  cases,  however,  the  progress  is  steadily  downward 
until  death. 

Treatment. — If  there  is  any  reason  to  suspect  syphilis,  the  iodide  of 
potassium  should  be  given  in  large  doses  and  continued  for  a  long  period; 


778  DISEASES  OF  THE  NERVOUS  SYSTEM. 

the  effect  of  this  drug  even  in  tumours  not  syphilitic  is  sometimes  bene- 
ficial. Starr  refers  to  a  case  in  which  symptoms  of  six  months'  duration, 
including  optic  neuritis,  entirely  disappeared  under  the  use  of  mercury 
and  the  iodide.  The  tumour  was  supposed  to  be  gumma,  but  an  autopsy 
obtained  six  months  later  showed  it  to  be  a  sarcomatous  cyst.  For  a 
discussion  upon  the  surgical  aspect  of  the  treatment  of  brain  tumours,  the 
reader  is  referred  to  Starr's  work  on  Brain  Surgery. 

HYDROCEPHALUS. 

Hydrocephalus  or  "  water  on  the  brain,"  consists  in  an  accumulation  of 
serum  in  the  cranial  cavity.  This  may  be  between  the  dura  mater  and 
the  pia  (external  hydrocephalus)  or  in  the  ventricles  of  the  brain  (internal 
hydrocephalus).  The  former  is  secondary  and  is  quite  rare,  while  the  lat- 
ter is  not  uncommon.     Hydrocephalus  may  be  acute  or  chronic. 

Acute  Hydrocephalus  is  secondary  to  basilar  meningitis,  which  is  usu- 
ally of  tuberculous  origin.  The  terms  tuberculous  meningitis  and  acute 
hydrocephalus  are  sometimes  used  synonymously.  A  moderate  distention 
of  the  ventricles  is  frequent  in  all  varieties  of  acute  meningitis.  The 
amount  of  fluid  in  acute  hydrocephalus  is  not  great,  there  being  rarely 
more  than  three  or  four  ounces  present. 

Chronic  External  Hydrocephalus  is  extremely  rare,  and  is  probably 
always  a  secondary  lesion.  It  is  found  with  certain  congenital  malforma- 
tions and  with  atrophy  of  the  brain,  and  it  may  follow  meningeal  haemor- 
rhage or  pachymeningitis.  On  incising  the  dura  mater  a  few  ounces,  or 
sometimes  even  a  pint,  of  serum  may  escape.  The  convolutions  are  some- 
what flattened,  and  may  be  greatly  atrophied.  Other  lesions  are  found 
either  in  the  brain  or  in  the  dura  mater.  There  may  be  some  degree 
of  internal  hydrocephalus  associated.  External  hydrocephalus  may  cause 
enlargement  of  the  head  and  separation  of  the  sutures,  and  in  fact  most 
of  the  symptoms  of  the  internal  variety;  but  usually  it  is  not  severe 
enough  to  give  rise  to  any  decided  symptoms.  It  is  so  rare  that  it  need 
not  be  considered  at  length. 

CHRONIC   INTERNAL   HYDROCEPHALUS. 

This  is  the  important  variety,  and  when  no  qualifying  term  is  men- 
tioned this  is  the  form  of  hydrocephalus  which  is  always  understood. 

Etiology. — This  occurs  both  as  a  primary  and  a  secondary  condition. 
When  secondary  it  is  usually  associated  with  tumours  of  the  base  of  the 
brain  or  with  chronic  basilar  meningitis,  either  simple  or  tuberculous.  It 
is  in  these  cases  a  mechanical  condition  caused  by  pressure  which  oblit- 
erates the  openings  from  the  lateral  ventricles  into  the  fourth  ventricle, 
or  the  foramen  of  Magendie. 

The  causes  of  primary  hydrocephalus  are  as  yet  very  little  understood. 
In  a  large  proportion  of  the  cases  the   disease  is  congenital,  generally 


CHRONIC  INTERNAL   HYDROCEPHALUS.  779 

beginning  in  the  latter  months  of  intra-uterine  life.  Some  of  these  cases 
are  clearly  syphilitic.  D'Astros  *  has  collected  nine  cases  and  added 
three  others,  in  which  hydrocephalus  was  associated  with  lesions  un- 
doubtedly syphilitic.  When  due  to  syphilis,  the  disease  may  at  the  same 
time  be  congenital.  Eickets  and  hydrocephalus  are  occasionally  associ- 
ated, but  so  infrequently  as  to  make  a  definite  etiological  connection  be- 
tween them  very  doubtful.  The  rachitic  head  has  been  so  often  mistaken 
for  hydrocephalus  that  an  erroneous  notion  has  arisen  as  to  the  frequent 
association  of  these  two  diseases.  This  point  will  be  referred  to  more 
fully  under  diagnosis.  Chronic  hydrocephalus  is  often  attributed  to 
tuberculosis,  but  here  again  the  connection  is  a  very  doubtful  one. 
Heredity  is  a  factor  of  some  importance;  numerous  instances  are  on 
record  where  two  children  in  the  same  family  have  been  affected.  Hydro- 
cephalus not  infrequently  develo2:)s  after  successful  operations  upon  spina 
bifida  or  encephalocele. 

Lesions. — The  difference  between  the  primary  and  secondary  cases  is 
chiefly  one  of  degree.  The  amount  of  fluid  in  secondary  cases  is  rarely 
more  than  three  or  four  ounces.  In  primary  cases  it  is  usually  from  half 
a  pint  to  one  pint,  but  it  may  be  very  great.  In  one  of  my  own  cases 
there  was  removed  from  the  head  of  a  child,  who  died  at  four  months,  five 
pints  of  fluid.  Larger  quantities  than  this  have  been  reported,  but  not  at 
so  early  an  age.  In  composition  this  resembles  the  cerebro-spinal  fluid. 
An  examination  in  one  of  my  cases  showed  it  to  be  a  clear,  translucent 
fluid,  slightly  alkaline  in  reaction,  specific  gravity  1005,  containing  sodium 
and  potassium  chlorides,  alkaline  phosphates,  and  a  trace  of  albumin.  In 
some  specimens  sugar  is  found.  In  cases  of  inflammatory  origin  the 
amount  of  albumin  is  generally  larger,  and  the  fluid  may  be  slightly  tur- 
bid. The  effusion  may  become  purulent  from  accidental  infection  re- 
sulting from  operation,  from  rupture,  or,  as  in  one  of  my  cases,  from  in- 
fection through  the  sac  of  a  spina  bifida  with  which  it  was  complicated, 
the  process  extending  to  the  brain  through  the  central  canal  of  the  cord. 

The  changes  in  the  brain  result  from  the  gradual  accumulation  of 
fluid  in  the  ventricles.  The  septum  lucidum  is  usually  broken  down, 
and  all  the  avenues  of  communication  between  the  ventricular  cavities 
are  greatly  enlarged.  The  continuous  distention  results  in  a  gradual 
thinning  of  the  brain  substance  w^hich  forms  the  ventricular  walls ;  often 
these  are  found  only  one  fourth  of  an  inch  in  thickness,  or  even  less 
than  this,  the  cortex  being  a  mere  shell  (Fig.  131).  In  one  of  my 
autopsies  the  ependyma  of  the  ventricle  and  the  pia  mater  were  in 
places  actually  in  contact,  all  of  the  brain  tissue  having  been  absorbed ; 
the  brain  resembled  a  large  double  cyst.  In  a  case  of  Peterson's,  with 
the  exception   of  a  small   portion    of  one    temporo-sphenoidal   lobe,  all 


*  Ilevue  Mcnsuellc  des  Maladies  dc  rEiifance.  ix,  481,  5-13. 


Y80 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


of  both  hemisplieres  had  disappeared,  the  cerebellum  and  basal  ganglia 
alone  being  intact.  The  brain  is  always  anaemic,  and  the  gray  and  white 
substance  may  be  indistinguishable.  The  changes  are  largely  mechanical, 
the  microscope  showing,  in  my  case  just  referred  to,  only  granular  matter 
and  round  nuclei  evidently  from  broken-down  nerve  cells.  In  less  severe 
cases  the  changes  may  be  slight.  It  is,  however,  always  surprising  to  see 
the  amount  of  compression  which  the  cortex  will  tolerate  without  inter- 
ference with  its  functions,  provided  the  pressure  comes  gradually.  The 
ependyma  may  be  normal,  but  it  is  usually  somewhat  thickened  and  pale, 
sometimes  granular,  and  may  be  infiltrated  with  new  cells.  When  infection 
takes  place  an  acute  ependymitis  may  be  set  up.     Chronic  inflammation 

of  the  ependyma  is  thought 
to  be  the  essential  lesion  in 
many  of  the  primary  cases, 
whether  of  simple  or  syphi- 
litic origin. 

The  bones  of  the  skull  are 
markedly  affected;  the  su- 
tures at  the  vault  are  widely 
separated,  and  sometimes 
even  those  at  the  base.  After 
the  removal  of  the  fluid  the 
head  collapses,  giving  an  ap- 
pearance which  has  been  well 
likened  to  a  "bag  of  bones." 
It  should  not  be  forgotten, 
however,  that  hydrocephalus 
may  coexist  with  premature 
ossification,  in  which  case  the 
head  may  be  small.  In  the 
cases  which  recover,  the  wide 
gaps  in  the  skull  may  be  closed  by  the  development  of  wormian  bones ;  but 
ossification  is  often  not  complete  until  the  fifth  or  sixth  year. 

The  most  frequent  lesion  associated  with  congenital  hydrocephalus  is 
spina  bifida,  in  which  cases  there  may  also  be  a  patency  of  the  central 
canal  of  the  spinal  cord ;  more  rarely  meningocele  or  encephalocele  are  met 
with.  Sometimes  there  are  deformities  in  other  parts  of  the  body,  such  as 
club-foot  or  hare-lip. 

Symptoms. — Hydrocephalus  may  exist  with  a  small  head.  In  this 
condition  there  is  usually  premature  ossification  of  the  cranial  bones. 
Four  such  cases  have  come  under  my  notice,  one  child  having  lived  to 
be  fourteen  months  old.  These  children  are  usually  idiotic,  and  die  at  an 
early  age,  often  from  convulsions.  In  such  cases  other  malformations  of 
the  brain  are  frequently  associated. 


Fig.  131.— Vertical  transverse  section  of  a  brain  in  con- 
genital hydrocephalus,  from  a  child  who  died  at  the 
age  of  three  weeks.  A,  distended  lateral  ventricle ; 
JB,  its  descending  horn. 


CHRONIC   INTERNAL   HYDROCEPHALUS. 


^81 


Hydrocephalus,  with  the  exceptions  mentioned,  is  recognised  by  the 
increased  size  of  the  head.  In  order  to  estimate  the  amount  of  enlarsfe- 
ment,  it  must  be  remembered  that  at  birth  the  circumference  of  the 
normal  head  is  about  14  inches,  and  at  one  year  from  18  to  19  inches. 
The  degree  of  enlargement  in  hydrocephalus  may  be  very  great.  In  one 
of  my  cases,  the  head  at  four  months  measured  24^  inches.  In  another  at 
ten  and  a  half  months,  2Gf  inches  (Fig.  132).     Steiner  has  reported  a  re- 


.ri 


Fig.  13-2.— Chronic  li  ydrocupluilus  of  a  severe  type;  head  of  a  globular  shajie;  child,  ten 
and  a  half  molitlis  old. 


markable  case  in  which  the  head  at  eight  months  measured  32^  inches. 
When  the  enlargement  of  the  head  is  not  great  the  diagnosis  is  not  so 
easy.  Hydrocephalic  enlargement  is  commonly  symmetrical  and  in  all 
directions.  The  head  is  sometimes  globular  in  outline  (Fig.  132)  and 
sometimes  pyramidal  (Fig.  133).  The  forelicad  is  exceedingly  high  and 
projecting,  and  there  is  a  prominence  at  the  root  of  the  nose  seen  in  no 
other  form  of  enlargement.  The  sutures  may  be  separated  from  half  an 
inch  to  two  or  three  inches ;  tlie  fontanel  is  very  large,  tense,  and  bulging; 


782 


DISEASES  OP   THE   NERVOUS  SYSTEM. 


the  veins  of  the  scalp  are  enlarged  and  prominent.  In  marked  cases 
fluctuation  may  be  readily  obtained,  and  the  head  may  even  be  distinctly 
translucent. 

In  the  acquired  form  all  these  symptoms  are  less  marked,  and  if  ossi- 
fication of  the  skull  has  taken  place  it  is  often  impossible  to  discover 
any  increase  in  size.  The  rate  of  growth  of  the  head  varies  much  in  dif- 
ferent cases,  and  it  is  the  surest  measure  of  the  progress  of  the  case.  The 
increase  in  circumference  is  usually  from  one  to  three  inches  a  month. 

The  primary  cases  are  for  the  most  part  of  congenital  origin,  and  the 
child  may  die  in  utero.    At  other  times  the  process  may  have  advanced  so 


Fig.  133. — Chronic  hydrocephalus  of  average  severity  ;  head  of  pyramidal  shape ;  showing  char- 
acteristic expression  of  the  eyes. 

far  before  birth  that  puncture  of  the  head  is  necessary  before  delivery  is 
possible.  In  perhaps  the  majority  of  cases  no  symptoms  are  observed  at 
birth,  or  the  head  is  only  slightly  larger  than  normal.  Usually  nothing 
is  noticed  until  the  child  is  two  or  three  months  old,  when  it  is  discov- 
ered that  the  head  is  increasing  in  size  at  an  abnormal  rate.  If  the 
progress  is  rapid,  other  symptoms  are  soon  evident :  the  infant  can  not 
hold  up  its  head  ;  it  is  lethargic,  and  all  its  perceptions  are  dulled,  sight 
and  hearing  included  ;  there  may  be  a  general  flaccid  condition  of  all  the 


CHRONIC   INTERNAL   HYDROCEPHALUS.  783 

muscles  of  the  extremities  due  to  a  slight  general  paresis,  but  more  often 
there  is  rigidity,  which  is  usually  most  marked  in  the  legs,  but  sometimes 
in  the  arms;  the  hands  are  often  clenched,  with  the  thumbs  adducted ; 
the  reflexes  are  exaggerated  ;  the  pupils  are  generally  contracted  and 
equal,  though  they  may  be  dilated ;  nystagmus  and  convergent  strabismus 
are  often  present.  Convulsions  may  occur  from  time  to  time,  or  may  be 
deferred  until  near  the  close  of  the  disease.  As  the  head  enlarges  the 
body  usually  wastes,  and  the  disproportion  between  the  two  may  seem 
greater  than  it  really  is. 

Such  congenital  cases  rarely  see  the  end  of  the  first  year,  and  are  often 
fatal  during  the  first  six  months.  The  causes  of  death  are  marasmus,  con- 
vulsions, and  intercurrent  disease,  rarely  rupture  of  the  head. 

In  the  cases  which  develop  more  slowly,  the  symptoms  are  quite  differ- 
ent. The  head  may  not  attain  at  eighteen  months  the  size  reached  in  the 
other  cases  at  the  third  or  fourth  month.  The  surprising  thing  about  many 
of  these  cases  is  that  the  distinctly  cerebral  symptoms  are  so  few.  Where 
the  pressure  develops  gradually,  the  brain  seems  able  to  tolerate  an  almost 
indefinite  amount  of  it.  The  more  readily  the  bones  of  the  skull  yield  to 
pressure  the  fewer  are  the  nervous  symptoms ;  hence,  other  things  being 
equal,  they  are  less  marked  where  the  disease  begins  before  the  sutures 
are  firmly  ossified  than  in  the  later  cases.  A  comparatively  small  amount 
of  effusion  may  cause  very  marked  symptoms  in  a  child  two  or  three  years 
old,  while  a  much  larger  amount  in  an  infant  of  a  year,  may  produce  much 
less  disturbance.  It  is  for  this  reason  that  secondary  hydrocephalus 
causes  such  striking  symptoms,  although  the  accumulation  of  fluid  is 
small. 

Whether  the  progress  of  these  cases  is  slow  or  rapid,  the  development  of 
the  children  is  greatly  retarded.  Many  are  not  able  to  support  the  head 
until  two  or  three  years  old  ;  frequently  they  do  not  walk  until  five  or  six 
years  old.  The  special  senses  are  generally  not  noticeably  affected,  but  in- 
telligence in  most  cases  is  interfered  with, — in  some  only  slightly,  in  others 
very  markedly,  while  some  are  idiotic.  Contractions  of  the  extremities 
are  occasionally  seen,  but  usually  more  of  the  hands  than  the  legs.  Sen- 
sation is  not  often  affected.  The  course  is  a  very  chronic  one.  From 
time  to  time  there  are  exacerbations  of  the  symptoms,  and  even  inter- 
current meningitis  may  be  excited. 

Prognosis. — Recovery  is  rare.  It  is  quite  exceptional  that  a  hydro- 
cephalic child  reaches  the  age  of  seven  years.  In  some  cases  tlie  process 
goes  on  up  to  a  certain  age  and  then  ceases  spontaneously,  and  the  child 
may  go  through  life  with  a  head  very  much  larger  than  normal,  usually 
with  a  mental  condition  somewhat  impaired.  Retrogression  of  the  symp- 
toms is,  however,  never  to  be  looked  for. 

Diagnosis. — The  most  important  symptom  is  the  enlargement  of  the 
head,  and  this  can  only  be  arrived  at  by  careful  measurement  and  com- 


YSJ:  DISEASES  OP  THE  XERVOUS  SYSTEM. 

parison  with  the  normal  size.  The  rapidity  of  growth  is  quite  as  impor- 
tant for  diagnosis  as  the  fact  of  enlargement.  If  the  head  grows  more 
than  an  inch  a  month  there  can  be  little  doubt.  Hydrocephalus  without 
enlargement  of  the  head  can  not  be  diagnosticated.  The  enlargement 
most  frequently  confounded  with  hydrocephalus  is  that  which  occurs  in 
rickets.  In  the  latter  disease  it  is  almost  invariably  irregular ;  there  are 
prominences  over  the  two  frontal  eminences  and  over  the  parietal  bones, 
often  with  furrows  between  them ;  the  size  of  the  head  is  chiefly  due  to 
thickening  of  the  bones  of  the  skull ;  the  marked  prominence  of  the  fore- 
head is  not  seen,  and  the  increase  in  bi-parietal  diameter  is  not  present ; 
furthermore,  there  are  other  signs  of  rickets. 

Treatment. — Almost  every  sort  of  local  treatment  has  been  adopted  for 
hydrocephalus,  including  incision,  aspiration,  cranial  puncture  with  the 
trocar,  lumbar  puncture,  blisters,  strapping,  and  counter-irritation.  Up 
to  the  present  time  there  does  not  exist  sufficient  evidence  to  show  that 
any  one  of  these  means  is  curative.  If  aspiration  is  done,  the  fluid  reac- 
cumulates  very  quickly,  while  incision  or  cranial  puncture  is  almost  cer- 
tain to  be  followed  by  meningitis.  If  there  is  any  reasonable  suspicion  of 
syphilis,  mercurial  inunctions  to  the  head  should  be  employed,  and  even 
in  other  cases  a  few  favourable  results  have  been  reported.  Convulsions 
and  other  functional  symptoms  are  to  be  treated  upon  general  principles, 
as  they  arise.  At  the  present  time  I  believe  it  is  better  to  refrain  from 
all  operative  measures  unless  rupture  seems  likely  to  occur. 


INFANTILE   CEREBRAL   PARALYSIS. 

Synonyms :  Spastic  diplegia,  paraplegia,  or  hemiplegia. 

Under  the  term  cerebral  paralysis  are  included  several  groups  of  cases 
with  causes  quite  dissimilar,  but  having  certain  definite  clinical  features 
in  common.  While  the  symptomatology  is  quite  clear,  there  are  many 
questions  relating  to  the  pathology  that  are  not  yet  fully  settled,  although 
much  has  been  added  to  our  knowledge  within  the  last  few  years.  Paraly- 
sis depending  upon  cerebral  tumour,  abscess,  or  hydrocephalus  is  not  in- 
cluded in  this  chapter. 

The  cases  of  cerebral  paralysis  may  be  divided  into  three  groups, 
according  as  the  paralysis  depends  upon  conditions  existing  i^rior  to 
birth,  upon  those  connected  with  birth,  or  upon  those  of  subsequent 
development. 

I.  Paralysis  of  Intra-Uterine  Origin. — This  is  the  least  frequent  con- 
dition. In  such  cases  there  is  some  congenital  defect  in  the  brain,  due 
sometimes  to  arrested  development,  at  others  to  such  intra-uterine  lesions 
as  haemorrhage  or  thrombosis.  There  may  be  porencephalus,  or  cysts  ex- 
tending deeply  into  the  substance  of  the  brain,  sometimes  communicating 


INFANTILE   CEREBRAL   PARALYSIS.  785 

with  the  ventricles.  The  origin  of  this  condition  is  for  the  most  part  un- 
known. In  rare  cases  the  paralysis  is  due  to  cortical  agenesis,*  a  condition 
in  which  the  brain  may  seem  normal  to  the  naked  eye,  but  the  microscope 
shows  a  complete  arrest  in  the  develojoment  of  the  cells  of  the  cortex,  usu- 
ally affecting  both  hemispheres.  In  still  other  cases  there  are  found  gross 
defects  in  development  in  the  motor  centres  of  the  cortex.  Such  a  lesion 
is  shown  in  Fig.  139,  page  795.  Cases  in  which  there  is  conclusive  evi- 
dence of  intra-uterine  haemorrhage  are  very  rare. 

SymjJtoms. — In  most  of  the  paralyses  due  to  intra-uterine  lesions,  loss 
of  power  is  only  one  of  the  symptoms,  and  usually  not  the  most  jDromi- 
nent.  It  is  rare  that  there  is  not  some  mental  impairment,  and  usually 
idiocy  is  present.  The  type  of  paralysis  is  nearly  always  diplegic  or  para- 
plegic. Where  this  is  due  to  arrested  cortical  development,  a  general  flac- 
cidity  of  the  muscles  may  be  seen  instead  of  the  rigidity  so  characteristic 
of  the  other  forms  of  cerebral  paralysis. 

II.  Birth-Paralysis. — Cerebral  birth-paralysis  is  due  in  nearly  all  cases 
to  meningeal  htemorrhage.  The  primary  lesions  and  the  early  symptoms 
have  already  been  described  (page  105)  in  connection  with  the  Diseases  of 
the  jSTewly  Born.  The  secondary  lesions  present  considerable  variety. 
There  may  be  found  (1)  meningo-encephalitis,  (2)  atrophy  and  sclerosis 
of  the  cortex,  (3)  cysts  upon  the  surface,  (4)  secondary  degenerations  in 
the  spinal  cord. 

1.  Meningo-encephalitis. — This  lesion  is  often  quite  diffuse.  There 
is  thickening  of  the  pia  mater,  and  it  is  usually  adherent  to  the  brain 
substance.  The  cortex  is  involved  to  a  variable  degree,  depending  some- 
what upon  the  time  which  elapses  between  the  initial  lesion  and  the  au- 
topsy. The  following  were  the  microscopical  changes  found  by  Sachs  f  in 
the  brain  of  a  child  in  my  wards  at  the  Babies'  Hospital,  who  died  at  the 
age  of  one  year  of  measles :  The  lesions  were  found  everywhere  in  the 
cortex.  The  pia  was  universally  adherent,  and  showed  general  cellular 
infiltration ;  its  blood-vessels  showed  marked  cellular  proliferation,  and 
the  veins  in  the  sub-pial  space  were  dilated  and  filled  with  blood.  In  the 
pia  dipping  in  between  the  convolutions  similar  changes  were  present.  In 
the  cortex  few  if  any  normal  pyramidal  cells  were  found,  but  in  the  outer 
layers  were  an  enormous  number  of  small  glia  cells.  Many  of  the 
blood-vessels  showed  a  cell-proliferation  of  their  walls.     There  was  also 


*  For  fuller  (lescrif)tion,  see  Sachs's  Nervous  Diseases  of  Children,  1895,  p.  (iOL 
f  The  clinical  features  of  this  case  are  quite  as  interesting'  as  the  pathological  find- 
ings. The  child  was  a  first-horn,  delivered  after  a  dry  labour  of  forty-eight  hours. 
It  was  asphyxiat-ed,  and  from  the  first  days  of  its  life  it  had  attacks  of  convulsions, 
usually  repeated  many  times  a  day.  During  one  of  these  convulsions  the  photograph 
from  which  Fig.  loO  was  made,  was  taivcn  by  Dr.  Peterson.  The  child  had  the  symp- 
toms of  typical  spastic  pamplegia — the  arms  being,  however,  slightly  involved — retarded 
mental  development,  and  convergent  strabismus. 


786 


DISEASES  OF   THE   NERYOUS  SYSTEM. 


a  degeneration  in  the  pyramidal  tracts  of  the  anterior  cohimns  of  the 
cord. 

2.  Atrophy  and  sclerosis. — These  changes  vary  much  in  extent  and 
degree.  There  may  be  only  a  circumscribed  area  in  which  the  convolu- 
tions are  small,  firmer  than  usual,  and  covered  with  an  adher-ent  pia,  or 
there  may  be  an  atrophy  so  extensive  as  to  involve  a  large  part  of  one  hemi- 
sphere (Figs.  134  and  135),  or  sometimes  of  both  hemispheres.  Usually 
the  lesion  is  somewhat  diffuse  over  the  convexity  of  both  sides,  and  much 
more  frequently  of  the  anterior  than  of  the  posterior  half  of  the  brain. 


Fig.  1-34.— Extensive  atrophy  and  sclerosis  of  the  right  hemisphere,  from  an  infant  seven  and  a 
half  jnonths  old;  probalaly  the  result  of  a  meningeal  haemorrhage  at  birth  (lateral  ^^ewJ. 

History. — Twelve  hours  after  birth  was  seized  with  general  convulsions,  which  continued 
for  three  days,  ^o  other  symptoms  noticed  till  one  month  before  death,  when  weakness  of  left 
arm  was  observed.   Xever  lield  head  erect.    Was  plump  and  well  nourished ;  died  from  erysipelas. 

Autopsy. — Pia  not  adherent;  a  large  cyst  occupied  the  region  of  the  occipital  and  posterior 
part  of  the  parietal  lobes,  showing  in  its  floor  diseolouration'and  pigmentation,  evidently  from 
an  old  hemorrhage.     Eight  optic  nerve,  tract,  and  crus  much  smaller  than  the  left. 


Where  a  depression  of  the  brain  exists  the  space  is  filled  with  cerebro- 
spinal fluid,  and  in  many  cases  there  is  a  deformity  of  the  skull. 

3.  Cysts  upon  the  surface  may  occur  alone  or  in  connection  with  the 
lesions  just  mentioned.  These  are  usually  small,  about  the  size  of  a  wal- 
nut, but  they  may  cover  a  large  part  of  a  hemisphere.  Such  large  cysts 
are  sometimes  classed  as  cases  of  external  hydrocephalus. 

4.  Secondary  degenerations  of  the  internal  caj^sule  and  the  lateral  col- 
umns of  the  cord  are  found  in  most  of  the  cases  associated  with  extensive 
atrophy  and  sclerosis,  and  in  many  of  those  in  which  only  meningo- 
encephalitis is  present. 

Symptoms. — The  type  of  paralysis  will  of  course  depend  upon  the 
extent  and  position  of  the  original  lesion.  A  diffuse  lesion  is  followed  by 
diplegia  ;  one  not  quite  so  extensive  by  paraplegia ;  one  affecting  one  side 
only  by  hemiplegia,  or  even  monoplegia,  though  this  is  very  rare.     The 


INFANTILE   CEREBRAL   PARALYSIS. 


78r 


relative  frequency  of  the  cliiferent  forms  will  vary  according  to  the  age  at 
which  the  patients  come  under  observation.  Thus  in  the  statistics  of 
Sachs  and  Peterson,*  there  were  twenty-seven  cases  of  diplegia  or  para- 
plegia, and  twenty-two  of  hemiplegia.  These  cases  were  drawn  from 
miscellaneous  sources,  chiefly  from  a  general  neurological  clinic.  Ac- 
cording to  my  own  observations,  which  have  been  chiefly  upon  infants, 


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Fig.  1S.J. — Atrophy  ul' right  lieiuisplioru  ;  .suiuc  (J,^sc  as  Fig.  13-1;  superior  viuw. 


the  cases  of  diplegia  and  paraplegia  have  outnumbered  those  of  hemi- 
plegia more  than  four  to  one.  My  belief  is  that  the  great  majority  of 
the  congenital  cases,  or  those  due  to  haemorrhage  occurring  at  birth,  are 
diplegias  or  paraplegias,  and  that  very  many  of  them  succumb  during  the 
first  two  years,  and  never  come  under  the  observation  of  the  neurologist ; 
however,  the  cases  of  hemiplegia,  because  of  the  less  serious  lesion,  live  much 
longer,  and  hence  are  more  likely  to  be  seen  by  the  specialist.     Diplegia 


*  Journal  of  Nervous  and  Mental  Disease,  May,  1890. 


788  DISEASES   OF   THE   NERVOUS   SYSTEM. 

and  paraplegia  will  therefore  be  considered  as  the  characteristic  types  of 
cerebral  birth-palsy,  as  the  cases  of  hemiplegia  do  not  differ  from  those- 
due  to  later  causes — i.  e.,  the  acquired  form. 

In  the  most  severe  cases  that  survive  the  symptoms  of  the  early 
days  of  life  (page  107)  there  remains  some  rigidity  of  the  extremities, 
chiefly  of  the  legs,  which  is  constant  or  intermittent,  slight  or  well  marked. 
There  is  often  spasm  of  the  muscles  of  the  neck  and  trunk,  giving  rise  ta 
opisthotonus.  In  many  cases  there  are  frequent  attacks  of  convulsions- 
(Fig.  136).  The  general  physical  development  of  the  child  is  often  inter- 
fered with,  so  that  it  remains  small  and  delicate,  and  perhaps  dies  of  some 
acute  disease  in  early  infancy,  never  having  been  able  to  sit  erect,  or  even, 
support  its  head.     In  other  cases  the  general  nutrition  is  not  affected, 


Fig.  130. — Convulsions  in  spastic  paraplegia;  from  a  photograph  by  Dr.  Frederick  Peterson 
during  an  attack.     (History  on  page  785.) 

and  life  may  be  prolonged  indefinitely,  but  usually  with  some  degree  of 
mental  impairment.  This  is  seen  in  all  degrees;  it  may  be  so  slight  as- 
not  to  be  noticed  until  the  child  is  two  or  three  years  old,  or  the  child 
may  be  idiotic.  Often  these  children  are  not  able  to  stand  imtil  they 
are  over  three  vears  old,  and  do  not  walk  alone  until  they  are  four  or 
five  years  old,  and  then  Avith  a  peculiar  cross-legged  gait,  owing  to  spasm 
of  the  adductors  of  the  thighs.  This  may  be  so  great  as  to  entirely  pre- 
vent walking,  and  while  sitting  or  lying  the  thighs  may  cross  each  other. 
These  form  the  typical  cases  of  spastic  paraplegia  (Fig.  137).  All  the 
reflexes  are  s:reatly  exaggerated.  The  arms  are  much  less  affected  than 
the  legs  and  in  about  half  the  number  they  are  not  involved  at  all. 

In  the  mild  cases  the  early  symptoms  may  be  overlooked,  and  noth- 
ing excite  suspicion  until  the  infant  is  six  or  eight  months  old.     There 


INFANTILE  CEREBRAL   PARALYSIS. 


Y89 


is  then  discovered  unmistakable  muscular  weakness;  the  child  does  not 
sit  up,  or  even  hold  up  the  head  when  the  trunk  is  supported.  Often 
there  is  observed  before  this  time  a  tendency  to  stiffen  the  body  and  to 
throw  it  backward,  owing  to  spasm  of  the  cervical  or  spinal  muscles. 
The  muscular  weakness  is  often  mistaken  for  rickets,  or  regarded  sim- 
ply as  backwardness.  A  closer  exami- 
nation usually  discloses  the  presence  of 
some  rigidity  of  the  extremities,  par- 
ticularly of  the  legs,  and  exaggeration 
of  the  knee-jerk.  As  the  child  grows 
older  other  symptoms  of  imperfect  de- 
velojoment  become  more  and  more  evi- 
dent. 

There  are  changes  in  the  shape  of 
the  skull,  this  being  usually  smaller 
than  normal  in  all  its  diameters,  or 
there  may  be  asymmetry.  There  is 
an  arrest  of  development  in  the  para- 
Ij'zed  limbs.  These  are  both  smaller 
and  shorter  than  normal.  There  is 
marked  muscular  atrophy.  In  many 
cases  abnormal  movements  are  seen, 
which  may  be  of  an  irregular  choreic 
type,  or  they  may  be  athetoid.  Epi- 
lepsy develops  in  from  33  to  50  per  cent 
of  all  these  patients. 

III.  Acute  Acquired  Paralysis. — 
This  is  usually  of  the  hemijslegic  type, 
although  diplegia  and  paraplegia  may 
in  rare  instances  be  met  with.  This 
group  includes  cases  developing  at  any 
time  after  birth,  but  the  great  majority 
of  those  seen  in  childhood  begin  before 
the  fifth  year. 

Etiology. — The  etiology  is  often  ob- 
scure. The  paralysis  sometimes  follows 
traumatism.  It  is  occasionally  seen  in 
the  course  of  scarlet  fever,  measles,  diphtheria,  variola,  and  pneumouia. 
Much  more  frequently  than  with  any  of  these  diseases  it  occurs  during 
pertus.sis,  being  usually  the  outcome  of  a  severe  paroxysm.  The  fre- 
quency with  which  these  cases  arc  ushered  in  with  convulsions  has  led 
many  to  assign  this  as  the  cause  of  the  jiaralysis.  It  is  possible  that  the 
convulsions  are  sometimes  tlic  result  and  sometimes  the  cause  of  the 
lesion. 


Fig.  137. — Spastic  paraplegia. 

Cliild  two  and  one  half  years  old, 
New  York  Foundlinf;  Hospital,  unable 
to  walk  or  even  to  stand  without  assist- 
ance. The  habitual  position  of  the 
limbs,  which  is  due  to  stronir  adductor 
s[iasiu,  is  shown  in  the  ]iicturc. 


Y90  DISEASES   OF   THE   NERVOUS   SYSTEM. 

Lesions. — The  lesions  of  acute  cerebral  palsy  may  he  grouped  under 
three  heads:  (1)  those  of  the  blood-vessels;  (2)  those  of  the  mem- 
branes;  (3)  those  of  the  brain  substance. 

1.  Lesions  of  the  blood-vessels. — There  may  be  hsemorrhage,  em- 
bolism, or  thrombosis.  HEemorrhage  is  by  far  the  most  important.  It  is 
usually  meningeal,  rarely  cerebral.  It  occurs  more  frequently  at  the  con- 
yexity  than  at  the  base,  and  is  often  diffuse.  Meningeal  heemorrhage 
may  result  from  pachymeningitis.  It  may  be  due  to  traumatism,  where 
it  is  also  from  the  dura  mater;  or  from  the  acute  hypersemia  accompany- 
ing paroxysms  of  pertussis,  where  it  may  be  from  the  dura  or  the  pia; 
or  it  may  be  secondary  to  thrombosis  of  the  superior  longitudinal  sinus. 
The  association  of  haemorrhage  wiili  sinus-thrombosis  is  not  very  in- 
frequent. It  was  found  in  one  of  my  autopsies  upon  a  patient  who  died 
of  pneumonia.  Cerebral  hjemorrhage  is  extremely  rare,  but  it  occurs 
even  in  infants;  I  once  saw  it  in  one  only  two  months  old. 

Embolism  is  rarely  found  unless  associated  with  acute  rheumatic  en- 
docarditis, and  then  usually  in  children  who  are  over  seven  years  old. 
As  in  adults,  the  usual  seat  of  the  embolus  is  a  branch  of  the  middle  cere- 
bral artery.  It  may  be  single  or  multiple.  Thrombosis  has  been  met 
with  in  a  small  number  of  cases,  but  it  is  extremely  rare. 

2.  Lesions  of  the  membranes. — These  are  generally  the  result  of  old 
cerebro-spinal  meningitis ;  sometimes  they  may  be  of  syphilitic  origin. 
In  both,  however,  the  process  is  rarely  confined  to  the  membranes ;  it  is  a 
meningo-encephalitis. 

3.  Lesions  of  the  brain  substance. — Atrophy  and  sclerosis  are  ter- 
minal conditions  found  in  a  large  number  of  the  autopsies  made  upon 
cases  where  the  jDaralysis  has  been  of  long  standing.  They  vary  in  se- 
verity and  extent,  and  are  followed  by  secondar}^  degeneration  in  the 
cord,  as  in  cases  of  birth  paralysis.  There  may  be  the  same  develo])- 
ment  of  cysts  of  the  pia  mater,  or  an  accumulation  of  fluid  in  the  arach- 
noid cavity,  these  taking  the  place  of  the  atrophied  convolutions.  What 
the  primary  lesion  is  in  these  cases  is  still  a  matter  of  debate.  Striimpell 
believes  many  of  them  to  be  due  to  an  acute  polieneephalitis,  analo- 
gous to  acute  poliomyelitis.  Cases  are  not  infrequently  seen  clinically, 
which  this  pathology  seems  to  explain  very  satisfactoril}'-.  However, 
there  is  as  yet  lacking  sufficient  anatomical  evidence. 

In  this  connection  may  be  mentioned  a  case  of  acute  paralysis  in 
which  no  lesion  was  found.  In  the  spring  of  1894,  there  was  admitted 
to  the  Babies'  Hospital,  an  infant  with  pneumonia,  who  had  developed, 
a  few  days  before,  typical  right  hemiplegia.  The  pneumonia  antedated 
the  paralysis  by  several  days.  The  latter  came  on  suddenly,  with  convul- 
sions, and  involved  the  face,  arm,  and  leg.  The  arm  and  leg  appeared 
to  be  completely  paralyzed,  but  in  the  face  the  paralysis  was  incom- 
plete. The  paralysis  had  begun  to  improve  somewhat  at  the  time  of 
the  child's  death,  which  occurred  a  little  over  a  week  after  its  onset. 


INFANTILE   CEREBRAL   PARALYSIS.  791 

At  the  autopsy  no  gross  lesion  could  be  discovered.  A  careful  microscop- 
ical examination  was  made  by  two  expert  pathologists,  Drs.  C.  A.  Herter 
and  J.  S.  Thacher,  who  could  find  no  explanation  of  the  paralysis.  Noth- 
ing abnormal  was  found  except "  a  slight  increase  of  small  spheroidal  cells 
about  some  of  the  meningeal  and  cortical  vessels  of  the  motor  area.  The 
frontal  and  occiiDital  lobes  were  normal." 

Sym2)toms. — While  diplegia  and  paraplegia  are  occasionally  seen,  the 
great  majority  of  cases  of  acquired  cerebral  palsy  are  of  the  hemiplegia 
variety.  When  diplegia  and  paraplegia  occur,  it  is  usually 'in  early  in- 
fancy, and  their  symptoms  and  course  differ  in  no  wise  from  the  birth 
palsies.  We  may  therefore  regard  hemiplegia  as  the  chief  manifestation 
of  acquired  cerebral  palsy. 

The  onset  of  the  paralysis  is  almost  invariably  sudden,  with  convul- 
sions, which  are  usually  repeated,  and  in  severe  cases  followed  by  loss  of 
consciousness.  In  the  secondary  cases  these  are  generally  the  only  symp- 
toms. In  one  of  my  cases  the  patient  went  to  bed  apparently  well,  and 
awoke  in  the  morning  with  hemiplegia.  Such  an  onset,  however,  is  very 
exceptional.  When  the  paralysis  is  apparently  primary,  fever  is  usually 
present,  and  in  addition  to  the  convulsions  there  may  be  vomiting,  de- 
lirium, and  other  symptoms,  strongly  suggestive  of  an  acute  inflammatory 
process  in  the  brain,  which  continue  for  a  variable  time,  usually  two  or  three 
days,  before  paralysis  is  seen.  The  temperature  in  most  cases  is  from 
100°  to  103°  F.,  and  the  rise  of  temperature  follows  more  frequently  than 
precedes  the  convulsions.  After  the  child  recovers  consciousness,  and 
sometimes  before  this,  the  paralysis  is  discovered.  If  there  is  a  very  ex- 
tensive lesion  there  may  be  diplegia,  deep  coma,  and  death,  but  this  is 
very  infrequent.  Usually  the  lesion  is  more  limited,  and  the  symptoms 
are  those  of  typical  hemiplegia.  It  is  rare  that  the  face  is  much  involved, 
and  often  it  escapes  altogether.  The  paralysis  of  the  arm  and  leg  is  at 
first  complete,  but  may  improve  very  rapidly  in  the  course  of  a  few  days. 
Disturbances  of  sensation  are  usually  of  a  transient  character.  After  a 
variable  period,  from  one  to  several  weeks,  the  patient  begins  to  use  the 
paralyzed  extremities,  first  the  leg,  afterward  the  arm,  as  in  adult  hemi- 
plegia. The  convulsions  may  be  repeated  for  the  first  day  or  two.  but 
prolonged  or  continuous  convulsions  are  rare.  With  lesions  of  the  left 
side  of  the  brain,  speech  may  be  aft'ected,  and  not  infrequently  in  young 
children  when  the  lesion  is  upon  the  right  side.  The  reflexes  are  in- 
creased upon  the  affected  side,  and  slight  ankle-clonus  may  l)c  present. 

In  the  course  of  a  few  weeks  the  child  may  be  able  to  walk,  dragging 
the  affected  leg;  the  recovery  in  the  leg  is  sometimes  complete, but  in  most 
cases  a  slight  halt  in  the  gait  remains.  The  arm  usually  recovers  more 
slowly  than  the  leg, and  contractures  are  likely  to  develop  after  a  variable 
time,  generally  two  or  three  years.  In  Fig.  138  is  shown  a  frequent  de- 
formity of  the  upper  extremity.     Contractures  of  the  k'g  lead  to  various 


792 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


forms  of  talipes,  generally  equlnus,  from  shortening  of  the  tendo-Achillis. 
Sometimes  the  arm  or  the  leg  recovers  so  perfectly  that  the  case  may 

be  regarded  as  one  of  monoplegia.  In  old 
cases  the  paralyzed  limbs  are  atrophied; 
there  is  more  or  less  rigidity,  and  the  spas- 
tic condition  may  be  quite  marked.  I  have 
seen  this  limited  to  a  single  grou|)  of  mus- 
cles in  the  leg.  Aphasia  is  common  in 
right  hemiplegias,  and  it  is  not  very  rare 
in  those  of  the  left  side,  because  infants 
appear  to  use  both  sides  of  the  brain  with 
nearly  equal  facility. 

The  mental  condition  of  these  children 
is  usually  normal,  in  striking  contrast  with 
the  cases  of  congenital  diplegia.  The 
earlier  the  paralysis  occurs  the  more  likely 
are  mental  symptoms  to  be  present,  since 
we  have  here  not  only  the  direct  effect  of 
the  lesion,  but  an  arrested  development  of 
some  part  of  the  brain.  Epilepsy  is  not 
an  uncommon  sequel ;  it  may  be  of  the 
Jacksonian  type,  or  there  may  be  attacks 
of  general  convulsions.  In  other  cases 
there  are  post-hemiplegic  movements  of  a 
choreic  or  athetoid  character,  or  irregular 
inco-ordinate  movements. 

Prognosis  of  Infantile  Cerebral  Paraly- 
sis.— In  diplegia  and  paraplegia  the  outlook 
is  always  unfavourable.    A  very  large  num- 
ber of  these  cases  which  are  due  either  to 
intra-uterine  or  birth  lesions,  never  reach 
the  third  year,  but  die  in  infancy  of  maras- 
mus or  acute  intercurrent  disease.     Those  who  survive  usually  show  seri- 
ous mental  defects,  and  many  are  practically  helpless  on  account  of  the 
extreme  spastic  condition  of  the  muscles  of  the  extremities. 

In  hemiplegia  the  prognosis  is  much  more  favourable.  In  most  of 
these  cases  the  paralysis  is  of  the  acute  acquired  variety,  and  the  later  the 
period  of  onset,  the  less  likely  is  the  brain  to  be  seriously  damaged.  In 
some  of  these  patients  complete  recovery  takes  place  ;  in  others  the  residual 
paralysis  is  so  slight  as  to  be  easily  overlooked  except  on  careful  examina- 
tion, the  occurrence  of  epilepsy  being  perhaps  the  first  thing  which  leads 
one  to  suspect  that  a  previous  paralysis  has  existed.  The  great  majority  of 
children  who  have  suffered  from  infantile  cerebral  palsy  have  some  degree 
of  permanent  paralysis  and  usually  some  deformities  from  contractures, 


result  of  contractures  Ibllowing 
an  attack  of  hemiplegia  four 
years  before ;  child  seven  years 
old. 


INFANTILE   CEREBRAL   PARALYSIS.  793 

the  extent  of  both  varying,  of  course,  with  the  severity  of  the  primary 
lesion.  In  all  cases  seen  in  young  infants  it  is  exceedingly  difficult  to 
give  a  prognosis  in  regard  to  future  mental  development.  As  a  rule,  the 
impairment  is  directly  proportionate  to  the  extent  of  the  paralysis  and 
its  intensity ;  although  in  exceptional  cases  we  find  a  good  deal  of  meii- 
tal  disturbance  with  only  moderate  paralysis,  and  vice  versa. 

Diagnosis. — The  diagnosis  between  the  congenital  and  acquired  forms 
of  cerebral  palsy  is  of  no  great  practical  importance,  and  it  may  be  im- 
possible ;  for  the  symptoms  in  congenital  cases  are  often  not  sufficiently 
marked  to  attract  attention  until  children  are  old  enough  to  sit  alone  or 
to  walk. 

It  may  be  quite  difficult  to  distinguish  cerebral  paralysis  from  infantile 
spinal  paralysis.  The  history  of  an  acute  onset,  the  atrophied  limbs,  the 
deformities,  and  the  absence  of  sensory  disturbances,  may  be  found  in  both 
conditions.  Spinal  paralysis  is,  as  a  rule,  monoplegic,  and  often  affects 
but  a  single  group  of  muscles.  Cerebral  paralysis  is  either  diplegic  or 
hemiplegic  in  character,  and  even  though  only  a  leg  or  an  arm  may  seem 
to  be  affected,  a  critical  examination  will  usually  reveal  the  fact  that 
the  other  limb  of  that  side  has  also  suffered.  The  presence  of  rigidity  and 
exaggerated  reflexes  is  quite  as  importaut  evidence  of  this  as  loss  of  power. 
The  electrical  reactions,  however,  are  conclusive;  the  reaction  of  degen- 
eration is  absent  in  cerebral  paralysis,  while  it  is  present  in  sj^inal  paralysis. 

Simple  as  the  differentiation  may  seem  in  most  cases,  the  mistake  is 
frequently  made  of  confounding  cerebral  diplegia,  particularly  of  the 
flaccid  type,  with  rickets.  But  a  careful  history  and  a  thorough  exami- 
nation will  usually  dispel  all  doubt  (see  article  on  Eickets).  Cases  of 
acute  acquired  paralysis  at  the  onset  may  be  mistaken  for  acute  menin- 
gitis, but  early  loss  of  consciousness,  the  early  development  of  the 
paralysis,  its  permanent  character,  and  the  short  duration  of  the  acute 
symptoms,  distinguish  cases  of  haemorrhage  from  those  of  meningitis; 
but  when  it  follows  traumatism,  and  when  it  occurs  in  the  course  of 
some  other  disease  such  as  pneumonia  or  scarlet  fever,  it  may  be  diih- 
cult  or  im])Ossible  to  make  a  diagnosis  between  the  two  conditions. 

Treatment. — The  course  and  the  result  of  cerebral  paralysis  depend 
u]i(»ii  the  extent  of  the  injury  to  the  brain,  its  nature,  and  the  age  at 
which  it  is  inflicted, — all  these  being  conditions  which  are  beyond  the 
power  of  the  physician  to  modify  or  control.  The  treatment  of  cerebral 
palsy  is  therefore  extremely  unsatisfactory.  For  the  congenital  cases 
practically  nothing  can  be  done,  except  for  the  dcformiti(^s  and  compli- 
cations. The  acquired  cases  during  llie  acute  onset  ai'c  lo  lie  managed 
like  all  other  eases  oT  acute  cerebral  congestion  or  iiilhiiiiinai  ioii, — ab- 
solute rest,  ice  to  llic  head,  and  bromides.  Eleelricily  is  lU'Ver  lo  be 
used  in  early  cases,  and  liilli  or  iiolliiiig  is  to  be  expected  from  it  in  the 
l;ilc  OIK'S.     ]\Iucli  can  lie  accoiiipl islicd  in  an  educaliona!  way  for  llie  men- 


794  DISEASES   OF  THE  NERVOUS  SYSTEM. 

tal  derangements  resulting  from  cerebral  palsy.  An  important  part  of 
the  treatment  relates  to  the  deformities.  Many  of  these  may  be  pre- 
vented by  the  early  use  of  orthopaedic  apparatus.  Serious  deformities 
in  old  cases  may  be  greatly  benefited  by  tenotomy  or  myotomy,  followed 
by  the  use  of  suitable  apparatus.  Epilepsy  is  to  be  treated  as  when  it 
depends  on  other  causes. 

FEEBLE-MINDEDNESS,   IDIOCY,   IMBECILITY^ 

By  these  terms  are  designated  the  different  forms  of  mental  impair- 
ment, seen  in  children  as  a  result  either  of  arrested  development  or  dis- 
ease of  the  brain.  They  differ  in  degree  rather  than  in  kind,  and  may  be 
associated  with  a  variety  of  pathological  conditions.  Following  some- 
what the  classification  of  Ireland,  these  cases  may  be  grouped  as  follows: 

1.  Those  depending  upon  the  arrested  development  of  the  brain  as  a 
whole,  or  of  the  frontal  lobes.  An  excellent  example  of  this  class  of  cases 
is  shown  in  Fig.  139.   Another  form  is  "  agnosia  corticalis  "  (page  785). 

2.  Those  associated  with  hydrocephalus. 

3.  Those  associated  with  mierocephalus,  with  or  without  premature 
ossification  of  the  cranial  bones. 

4.  The  paralytic  cases — including  the  varieties  which  occur  in  the 
different  forms  of  cerebral  paralysis,  the  greater  part  of  which  are  due  to 
meningeal  haemorrhage  at  the  time  of  birth,  and  associated  with  spastic 
diplegia  or  paraplegia;  a  smaller  number  are  associated  with  acquired 
palsy,  which  is  most  frequently  due  to  meningeal  hsemorrhage. 

5.  Those  of  inflammatory  origin.  The}'  follow  cerebro-spinal  men- 
ingitis, and  possibly  also  there  may  be  added  a  group  dependent  upon 
poliencephalitis  (Striimpell). 

6.  Those  associated  with  epilepsy,  in  which  the  condition  is  a  result 
of  changes  in  the  brain  produced  by  the  repetition  of  the  epileptic  seiz- 
ures. 

7.  Sporadic  cretinism  (page  798). 

8.  Mongolian  idiocy  *  is  a  form  characterized  b}^  marked  backward- 
ness of  bodily  and  mental  development,  and  by  a  peculiar  Chinese  type 
of  skull  and  face.  The  head  is  flattened  from  before  backward  and  the 
nose  is  broad  and  flat;  but  most  striking  are  the  narrow  palpebral  fis- 
sures slanting  downward  toward  the  nose.  The  infants  are  usually  good- 
natured,  quiet,  and  placid;  dentition  and  muscular  co-ordination  are 
tardy;  walking  and  talking  may  be  delayed  until  between  the  third  and 
fourth  year.  The  vital  resistance  is  feeble,  and  many  die  in  early  child- 
hood. If  they  survive,  these  children  grow  up  feeble-minded.  Little  is 
known  of  the  pathogenesis  of  this  condition,  but  in  many  cases  there  are 
syphilitic  antecedents. 

*  See  Sutherland,  The  Practitioner  (London),  New  Series,  vol.  x,  1899.  p.  633. 


FEEBLE-MINDEDNESS,    IDIOCY,    IMBECILITY. 


795 


9.  Amaurotic  family  idiocy.  This  name,  proposed  by  Sachs  *  (Xew 
York),  indicates  the  prominent  features  of  the  malady,  which  is  not  a 
very  rare  one.  The  first  symptoms  are  usually  noticed  between  the  third 
and  sixth  months  in  apparently  healthy  infants.     It  is  then  discovered 


Fig.  189. — Arrested  development  of  the  frontiil  lobes  of  the  brain,  particularly  of  the  right  side, 
from  an  idiotic  child  twelve  months  old.f 


that  the  infant,  who  before  this  has  seemed  to  see  well,  no  longer  notices 
objects ;  the  expression  becomes  stupid ;  the  infant  docs  not  hold  up  its 
head  and  never  learns  to  sit.  There  is  relaxation  of  the  voluntary  mus- 
cles, es])ecially  those  of  the  trunk.     The  characteristic  features  of  the 


*  New  York  Medical  Jouniivl,  July,  ISOO;  also  Koatiiig's  Cyelo.,  Supplement,  1899. 

f  A  microscopical  examination  by  Dr.  Martlia  Wollstein  showed  the  cortex  in  the 
affected  region  to  be  only  one-third  the  normal  thickness;  the  cortical  layers  were  ill- 
defined  ;  there  was  a  striking  absence  of  the  cliiiracteristic  nerve  cells,  both  the  large 
and  small  pyramidal  cells  being  few  in  nuinlicr.  '{'here  was  no  growth  of  connective^ 
tisj^uo.     The  white  substance  was  normal,  as  were  also  tlic  dura  and  pia. 


796  DISEASES   OF   THE  NERVOUS   SYSTEM. 

disease  are  revealed  by  the  ophthalmoscope.  There  is  a  milk}'  blue  or 
white  optic  disk,  with  bright  cherry-red  centre,  occupying  the  place  of  the 
macula  lutea,  and  atrophy  of  the  optic  disk.  The  ocular  changes  are 
symmetrical.  The  voluntary  muscles  show  more  or  less  reaction  of  de- 
generation. The  disease  is  progressive,  and  usually  fatal  within  a  year; 
but  occasionally  the  blind,  helpless  child  may  live  for  two  or  even  six 
years.  Whether  the  disease  is  a  developmental  degeneration  or  an  in- 
flammation is  not  yet  determined.  The  brain  shows  defective  develop- 
ment, with  degeneration  and  chromatolysis  of  the  nerve  cells,  sclerosis, 
and  thickening  of  the  membranes.  Nearly  all  of  the  reported  cases  have 
heen  in  Hebrews.    The  prognosis  is  at  present  hopeless. 

In  addition  to  the  etiological  factors  belonging  to  the  different  con- 
ditions above  described,  the  influence  of  heredity  is  fo  be  considered: 
there  may  be  nervous  diseases  in  the  family,  alcoholism,  syphilis,  and 
some  other  inherited  vices  of  constitution  in  the  parents,  and  intermar- 
riage among  blood  relations. 

Diagnosis. — In  older  children  it  is  seldom  difficult  to  recognise  an 
abnormal  mental  condition;  but  in  infants,  especially  if  under  one  year 
old,  this  is  not  so  easy  a  matter.  Without  a  considerable  period  of  ob- 
servation it  may  be  impossible  to  decide  whether  an  infant  is  simply 
backward  or  has  some  serious  mental  defect. 

In  the  first  place  one  should  be  familiar  with  the  mental  and  physi- 
cal development  of  healthy  children.  A  normal  infant  of  average  mus- 
cular development  can  usually  support  the  head  steadily  before  it  is 
five  months  old,  often  at  three  months;  it  can  usually  sit  erect  at 
seven  or  eight  months,  and  stand  with  assistance  at  twelve  or  thirteen 
months.  Toys  are  held  and  usually  handled  with  facility  at  five  or  six 
months.  The  recognition  of  the  nurse  or  mother  comes  at  flve  or  six 
months.  Usually  the  first  distinct  words  are  pronounced  about  the  end 
of  the  first  year,  and  at  two  years  most  children  put  words  together  in 
short  sentences.  Variations  of  a  few  months  from  the  averages  above 
mentioned  can  hardly  be  considered  abnormal. 

Marked  backwardness  may  be  the  result  of  inheritance.  On  inves- 
tigation it  may  be  found  that  the  same  thing  was  true  of  one  or  other 
parent  or  of  some  near  relative.  Surroundings  also  have  much  to  do  with 
the  rapidity  of  development.  Infants  are  always  stimulated  by  contact 
with  other  children.  Backwardness  is  often  the  result  of  conditions 
purely  physical;  these  may  be  inherited,  or  the  result  of  some  serious 
derangement  of  nutrition,  which  is  the  consequence  of  severe  acute  dis- 
ease, or  more  often  of  protracted  malnutrition  due  to  improper  feeding. 
From  such  causes  one  often  sees  infants  who  at  two  years  have  not 
reached  a  point  attained  by  an  average  child  at  twelve  months.  To 
determine  whether  the  mental  state  is  simply  the  result  of  the  poor 
general  nutrition,  or  is  dependent  upon  actual  disease  or  imperfect  devel- 


FEEBLE-MINDEDNESS,    IDIOCY,    IMBECILITY.  Y9T 

■opment  of  the  brain,  is  frequently  a  matter  of  the  greatest  clifficult5^  The 
backward  infant  is  usually  distinguished  chiefly  by  the  things  which  he 
■does  not  do ;  while  with  those  who  are  deficient  not  only  are  the  proper 
signs  of  development  wanting,  but  many  new  and  peculiar  symptoms 
may  be  observed.  The  backward  child  mav  not  sit  alone  until  he  is 
twelve  or  fifteen  months  old,  and  may  not  walk  until  he  is  two  and  a 
half  years  old,  but  the  cerebral  development  is  in  most  cases  propor- 
tionate to  the  physical  condition.  Speech  may  be  so  dela5'ed  that  the 
first  words  do  not  come  until  two  years,  and  short  sentences  not  until 
three  years  old,  and  yet  in  understanding  what  is  said  to  and  done  for 
him  the  child  may  seem  bright  and  his  development  steady  and  progres- 
sive, although  slow. 

All  children  whose  development  is  delayed  should  be  examined  for 
local  signs  of  cerebral  disease ;  the  symptoms  mentioned  under  the  vari- 
ous heads  of  early  hydrocephalus,  meningeal  haemorrhage,  and  cretin- 
ism should  be  sought.  Sight  and  hearing  should  be  tested,  and  the  eyes, 
if  possible,  examined  with  an  ophthalmoscope ;  the  co-ordination  of  the 
hands  should  be  tested  in  various  ways ;  the  reflexes  examined,  and  gen- 
eral rigidity  or  slight  paralysis  noted,  also  the  muscular  power  in  the 
trunk,  neck,  and  extremities.  Many  children  who  are  mentally  deficient 
do  not  show  any  disturbances  of  nutrition  during  the  first  year.  The 
^Towth  of  the  body  in  height. and  weight  may  be  quite  normal;  although 
this  is  rarely  true  of  the  muscular  power.  Some  of  them  show  marked 
signs  of  backwardness  in  physical  development,  and  in  nearly  all  there 
are  some  other  striking  symptoms.  Among  the  most  frec{uently  noticed 
are  drooling,  hanging  the  tongue  out  of  the  mouth,  a  fixed  aimless  stare, 
the  production  of  some  inarticulate  sounds,  which  are  usually  peculiar 
to  the  child  and  may  be  repeated  many  times  a  day.  Occasionally  there 
are  sharp  screams  without  any  evident  cause,  also  irregular  aimless 
movements  of  the  hands.  Objects  are  not  properly  held,  and  if  grasped, 
they  are  soon  dropped  by  an  infant  of  twelve  or  fourteen  months  as  by 
a  normal  one  of  three  or  four  months.  The  child  does  not  recognise  its 
bottle  or  its  nurse.  Nystagmus  is  often  present,  and  there  may  be  occa- 
sional convulsions.  The  infant  is  not  attracted  by  bright  colours  or  toys, 
and,  in  short,  seems  dull  and  unresponsive  to  every  mental  iin|)ression. 

Although  one  may  feel  perfectly  sure  from  the  signs  enumerated 
that  mental  deficiency  exists  in  many  cases,  its  degree  can  not  be  deter- 
mined before  the  third  year. 

Most  cases  of  idiocy  exhibit  to  a  greater  or  less  degree  the  stigmata 
of  degeneration  (page  803).  In  an  examination  of  517  idiots  by  Howe, 
there  was  found  blindness  in  21;  deafness  in  13;  some  defect  of  the 
nose  or  mouth,  such  ns  hare-li]i.  high  ]ialatal  arch,  or  cleft  palate,  in  23 
■cases;  and  some  (Icroi-iiiity  of  the  hands  or  feet  in  54  cases;  while  in 
96  there  was  paralysis  of  one  oi'  nioi'e  liniljs. 
52 


T98 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


SPORADIC   CRETINISM. 

Synonyms :  Cretinoid  idiocy,  myxcedematous  idiocy,  idiocy  with 
pachydermatous  cachexia. 

Since  the  early  description  of  this  disease  by  Fagge,  in  1871  and 
1874,  numerous  cases  liave  been  published  in  England,  on  the  continent 
of  Europe,  and  in  America,  showing  that  sporadic  cretinism  is  not  con- 
fined to  any  country.  During  the  last  six  years,  five  cases  have  come 
under  my  own  observation.  While  the  disease  is  rare,  cretins  are  much 
more  common  than  was  formerly  supposed. 

Etiology. — It  is  now  well  established  that  this  condition  depends 
upon  the  absence  of  the  internal  secretion  of  the  thyroid  gland.     In 

a  series  of  sixteen  autopsies 
collected  by  Fletcher  Beach^ 
the  thyroid  gland  was  absent 
in  fourteen  and  the  seat  of 
bronchocele  in  two.  The  symp- 
toms closely  resemble  the 
myxoedema  of  adults  which 
follows  the  removal  of  the  thy- 
roid. Eegarding  the  causes 
which  destroy  the  thyroid 
gland  or  abolish  its  functions 
little  is  as  yet  known.  In 
most  cases  it  is  probably  a  con- 
genital condition.  In  some  in- 
stances it  has  followed  acute 
disease.  In  a  certain  number 
of  cases  sporadic  cretinism  is 
associated  with  goitre.  As  a 
rule,  only  one  case  occurs  in  a 
famil}',  the  other  members  of 
which  present  nothing  abnor- 
mal in  mental  or  physical  de- 
velopment. 

Symptoms. — The  symptoms 
of  cretinism  in  most  cases  make 
their  appearance  during  the 
first  year,  sometimes  not  imtil  children  are  two  or  three  years 
old,  and  occasionally  none  may  be  seen  until  the  seventh  or  eighth 
year.  The  general  appearance  of  the  cretin  is  very  striking,  and  so 
characteristic  that  when  once  seen  the  disease  can  hardly  fail  to  be  rec- 
ognized (Figs.  140  and  141).  The  body  is  greatly  dwarfed,  and  children 
of  fifteen  years  are  often  only  two  and  a  half  or  three  feet  in  height.    All 


Fig.  140. — A  typical  cretin,  nine  years  old ; 
height,  28J  inches.     (After  Bramwell.) 


&^  3 


o  '*- 


i     i^ 


P   P 


fee   bo 


799 


800  DISEASES  OF  THE  NERVOUS  SYSTEM. 

the  extremities,  the  fingers  and  the  toes,  are  short  and  stumpy.  The 
subcutaneons  tissue  seems  very  thick  and  boggy,  but  does  not  pit  upon 
pressure  like  ordinary  oedema.  The  facies  is  extremely  characteristic : 
The  head  seems  large  for  the  body,  the  fontanel  is  open  until  the  eighth 
or  tenth  year,  and  it  may  not  be  closed  even  in  adults ;  the  forehead  is 
low  and  the  base  of  the  nose  is  broad,  so  that  the  eyes  are  wide  apart ;  the 
lips  are  thick,  the  mouth  half  open,  and  the  tongue  usually  protrudes 
slightly ;  the  cheeks  are  baggy,  the  hair  coarse,  straight,  and  generally 
light  coloured.  The  teeth  a.p'pesiv  very  late — in  one  of  my  cases  none  were 
present  at  two  years — and  are  apt  to  decay  early. 

Fatty  tumours  are  quite  constant  in  older  children,  although  they  were 
wanting  in  two  of  my  infantile  cases.  They  are  seen  in  the  supra-clavicu- 
lar region,  just  behind  the  sterno-mastoid  muscle,  sometimes  in  the  axilla, 
or  between  the  scajDula;,  and  sometimes  in  other  jDarts  of  the  body.  In 
distribution  they  are  apt  to  be  symmetrical,  and  are  usually  about  the  size 
of  a  hen's  egg.  The  neck  is  short  and  thick.  In  some  cases  there  is  a 
depression  corresponding  to  the  location  of  the  thyroid  gland.  The  chest 
is  not  deformed.  The  abdomen  is  large,  jjendulous,  and  resembles  that 
of  rickets.  The  skin  is  dry,  perspiration  scanty,  and  eczema  is  common. 
The  voice  is  hoarse  and  rough.  Patients  often  do  not  walk  until  they 
are  five  or  six  years  old,  and  then  they  waddle  in  a  clumsy  way.  All  the 
movements  of  the  body  are  slow  and  lethargic,  and  everything  indicates 
a  mental  and  physical  torpor.  The  rectal  temperature  is  usually  sub- 
normal. I  had  once  an  oiDportunity  to  observe  an  attack  of  acute  broncho- 
pneumonia in  one  of  these  cretins  two  3'ears  old.  The  symptoms  and 
physical  signs  were  typical,  but  during  the  greater  part  of  the  disease 
the  rectal  tem^Derature  fluctuated  between  95°  and  98"5°  F.  Only  once 
was  a  temperature  above  99°  F.  recorded.  On  account  of  their  low  tem- 
perature and  tor^oid  condition  these  patients  are  very  sensitive  to  cold. 
The  mental  condition  is  always  impaired,  and  they  are  usually  idiotic. 
Speech  is  acquired  late,  and  in  some  cases  not  at  all.  Cretins  are  dull, 
placid,  and  good-natured,  rarely  troublesome  or  excitable ;  and  when 
fifteen  or  eighteen  years  old  they  appear  like  children  of  two  or  three 
years.  There  is  an  absence  of  development  of  the  sexual  organs,  and 
almost  invariably  they  suffer  from  chronic  constipation. 

Diagnosis. — The  diagnosis  is  usually  easy,  although  the  early  cases 
are  sometimes  miscalled  rickets.  The  low  temperature,  the  facial  ex- 
pression, the  torjDor,  and  the  fatty  tumours  are  enough  to  differentiate 
the  two  diseases. 

Prognosis  and  Treatment. — There  is  no  tendency  to  spontaneous 
improvement.  Many  of  these  cases  die  in  childhood,  but  a  few  live 
to  adult  life.  Until  within  the  last  few  years  they  have  been  con- 
sidered hopeless.  The  improvement  which  followed  the  use  of  the 
thyroid  extract  in  cases  of  adult  myxoedema  has  led  to  a  trial  of  this 


INSANITY.  801 

remedy  in  sporadic  cretinism.  A  sufficient  number  of  cases  have  now 
been  recorded  to  establish  the  fact  that  the  thyroid  extract  is  a  specific 
remed}^  for  this  disease.  Peterson  and  Bailey  *  have  collected  forty 
cases  treated  in  this  manner.  No  case  failed  to  improve  when  the  ex- 
tract was  properly  given.  In  twentj^-five  cases  the  improvement  was 
very  striking.  In  many  cases  it  is  truly  remarkable  (Figs.  1-il-l-i-i). 
After  a  few  months'  treatment  the  entire  appearance  of  the  child  is  in 
most  cases  changed:  The  idiotic  expression  of  the  features  is  lost;  the 
thickening  of  the  skin  and  subcutaneous  tissues  disappears;  there  is  a 
marked  increase  in  height,  and  in  the  circumference  of  the  head;  mus- 
cular power  is  rapidly  developed,  so  that  many  soon  become  able  to  walk ; 
and  progress  is  seen  in  dentition,  and  in  some  older  girls  in  the  establish- 
ment of  menstruation.  Intellectual  progress  is  much  slower  than  phys- 
ical changes ;  however,  nearly  all  the  children  become  brighter  and  more 
intelligent,  and  a  few  learn  to  talk.  In  the  cases  thus  far  reported  the 
treatment  has  hardly  been  continued  long  enough  to  enable  one  to 
speak  definitely  regarding  the  ultimate  outcome  of  this  condition.  Osier 
refers  to  one  case  in  which  recovery  seems  to  have  been  complete.  In 
all  cases  the  thyroid  extract  must  be  given  indefinitely,  for  otherwise 
improvement  ceases  at  once,  and  cases  may  even  relapse.  The  earlier 
the  treatment  is  begun  the  more  marked  is  the  improvement  usually 
noticed. 

The  preparation  most  used  in  i\.merica  is  Parke,  Davis  &  Co.'s  desic- 
cated extract,  prepared  from  the  thyroid  gland  of  the  sheep.  Of  this; 
half  a  grain  may  Idc  given  once  or  twice  a  day  at  first;  after  becoming 
somewhat  accustomed  to  the  drug  the  child  may  take  one  grain  three 
times  a  day,  or  even  more.  Some  disturbances  are  often  seen  at  the 
beginning  of  the  treatment — perspiration,  fretfulness,  and  sometimes  a 
rise  in  temperature — but  these  soon  pass  off. 

INSANITY. 

Insanity  is  so  special  a  subject,  that  all  that  will  l)e  attenijitcd  liere 
will  be  to  mention  the  most  frequent  varieties  seen  in  early  life,  with  the 
important  etiological  factors  which  operate  at  this  period.  For  a  rnll 
discussion  of  the  subject  the  reader  is  referred  to  works  upon  insanity. 
and  to  Sachs,  in  whose  book  f  will  l)e  found  (|uiit'  a  full  l)il)liogrniiliy  of 
this  aspect  of  the  subject. 

Insanity  is  distinguisliid  fi'diii  idiocy  in  lliat  il  alTrcIs  ;i  miiid  pi'cxi- 
ously  sound;  however,  the  two  conditions  may  l)c  associatcil.  ['ndoiiWlcd 
cases  of  mental  disease  have  been  observed  before  the  seventh  year,  but 

*  Paediatrics,  May  1,  1896.  See  also  Osier.  American  Journal  of  the  Medical  Sci- 
ences, 1897,  cxiv,  No.  4,  and  Bramwell's  Monof^raph  on  Cretinism. 

t  Nervous  Diseases  of  Children,  New  York,  180.5.  See  also  IMills.  in  American 
Text-Book  of  Diseases  of  Children,  Philadelphia.  1898. 


802  DISEASES  OF  THE  NERVOUS  SYSTEM. 

they  are  extremely  rare.  From  this  time  up  to  puberty,  however,  nearly 
all  the  varieties  seen  in  adult  life  occasionally  occur,  but  they  are  very  in- 
frequent even  at  this  period.  The  form  which  insanity  in  childhood  most 
frequently  assumes  is  mania. 

Etiology. — Insanity  is  sometimes  seen  as  a  sequel  of  one  of  the  infec- 
tious diseases,  more  often  typhoid  fever  than  any  other,  although  it  may 
follow  measles,  scarlet  fever,  diphtheria,  or  variola.  Another  cause  is 
masturbation,  although  its  effect  is  much  more  frequently  seen  after 
puberty  than  before.  Hereditary  syphilis  is  sometimes  the  cause  of  de- 
mentia, which  comes  on  about  the  fourth  or  fifth  year,  or  even  later. 
Alcoholism,  epilepsy,  insanity,  or  other  nervous  diseases  in  the  parents 
are  important  causes.  Prolonged  or  continuous  mental  strain,  the  result 
of  overwork  in  school,  is  a  cause  of  considerable  importance,  especially  in 
girls  about  the  time  of  puberty.  As  exciting  causes  may  also  be  men- 
tioned various  reflex  conditions,  such  as  intestinal  worms,  phimosis,  delay 
in  the  establishment  of  menstruation,  and  abnormal  conditions  of  the  nose 
and  throat ;  these,  however,  can  not  have  much  influence  except  where  the 
predisposition  is  a  strong  one.  Insanity  may  be  associated  with  or  may 
follow  hysteria,  chorea,  or  epilepsy.  It  has  sometimes  followed  injury  to 
the  brain,  acute  meningitis,  and  occasionally  other  forms  of  brain  disease. 

Symptoms. — Certain  forms  of  insanity  are  practically  never  seen  in 
children,  such  as  j^aranoia  or  primary  delusional  insanity,  acute  demen- 
tia, paretic  dementia,  periodic  or  circular  insanity,  and  cataleptic  insanity. 

Mania  is  one  of  the  most  frequent  forms,  aud  is  the  most  common 
variety  of  post-febrile  insanit3^  Its  symptoms  may  be*  quite  intense,  but 
are  usually  of  short  duration,  lasting  but  a  few  days  or  weeks.  In  rare 
cases  it  may  continue  for  months,  and  it  may  even  be  permanent. 

Melancholia  is  not  uncommon.  It  is  seen  as  a  result  of  prolonged 
mental  strain  in  school,  it  may  be  due  to  fear  of  punishment,  and  some- 
times may  follow  masturbation.  It  is  usually  associated  with  some  very 
marked  disturbance  of  the  general  health.  It  shows  itself,  as  in  the  adult, 
by  fits  of  depression,  self-mutilation,  and  even  by  suicidal  tendencies. 

Epileptic  insanity  may  follow  epilepsy  in  children  who  were  previously 
mentally  sound,  where  it  may  take  the  form  of  true  epileptic  dementia, 
or  there  may  be  attacks  of  mania  which  occur  in  the  place  of  an  ejjileptic 
seizure  or  follow  such  a  seizure.  Transitory  attacks  of  fury  or  frenzy 
coming  on  without  apparent  cause  should  always  suggest  the  possibility 
of  epilepsy. 

Other  forms  which  insanity  assumes  in  early  life  are :  transitory  psy- 
choses, such  as  delirium,  night-terrors,  attacks  of  sobbing  or  weeping, 
sometimes  from  fright ;  moral  insanity,  as  shown  by  perversion  of  the 
moral  sense  from  injury  or  disease,  and  by  various  vicious  tendencies; 
morbid  impulses,  which  may  be  homicidal  or  sexual,  or  a  disposition  to 
thieving,  lying,  pyromania,  etc. ;  morbid  fears,  of  which  there  may  be  an 


THE   STIGMATA   OF   DEGENERATION.  803 

almost  endless  variety.  These  are  sometimes  associated  with  a  low  state 
of  physical  health ;  this,  however,  is  usually  not  the  case. 

Prognosis. — On  the  whole,  insanity  in  childhood  has  a  better  progno- 
sis than  in  the  adult.  In  most  of  the  cases  of  mania,  melancholia,  the 
various  transitory  psychoses,  or  the  choreic  and  hysterical  forms,  recovery 
occurs  with  proper  treatment.  The  outlook  for  the  other  varieties  is 
much  worse,  especially  in  those  in  which  there  is  a  strong  hereditary 
tendency  to  mental  disease. 

The  treatment  is  to  be  conducted  along  the  same  general  lines  as  in 
adults. 

THE   STIGMATA  OF  DEGENERATION. 

These  marks  are  of  much  importance  in  relation  to  the  different  forms 
of  nervous  disease  in  children,  especially  epilepsy,  idiocy,  and  insanity. 
They  are  of  great  value  in  determining  existing  nervous  disease,  or  as 
showing  latent  neuropathic  tendencies. 

The  physician  should  be  familiar  with  these  various  signs  in  order  that 
he  may  connect  them  with  each  other  and  refer  them  to  their  proper 
.source,  and  at  the  same  time,  by  appreciating  their  significance,  be  able 
to  advise  parents  with  regard  to  the  care,  education,  mode  of  life,  and 
occupation  of  children,  in  whom  to  a  greater  or  less  degree  these  signs 
may  be  present.  These  stigmata  are  not  of  equal  importance  as  marks  of 
degeneration.  Some  of  them,  such  as  facial  asymmetry  and  most  of  the 
deformities  of  the  palate,  are  always  to  be  so  regarded ;  the  speech  defects 
are  often  so,  while  many  of  the  others  may  or  may  not  be,  according  to 
their  association.  The  stigmata  are  divided  into  anatomical,  physiological, 
and  psychical.     The  following  is  the  classification  given  by  Peterson  :  * 

Anatomical  Stigmata. — Cranial  anomalies  :  Facial  asymmetry ;  de- 
formities of  the  palate  ;  anomalies  of  the  teeth,  tongue,  lips,  or  nose. 

Anomalies  of  the  eye  :  Flecks  on  the  iris ;  strabismus ;  chromatic 
asymmetry  of  the  iris ;  narrow  palpebral  fissure  ;  albinism ;  congenital 
cataract ;  pigmentary  retinitis. 

Anomalies  of  the  ear. 

Anomalies  of  the  limbs  :  Polydactyly;  syndactyly;  ectrodactyly ;  sym- 
elus  ;  ])hocomelus  ;  excessive  length  of  the  arms. 

Anomalies  of  the  trunk  :  Hernias ;  malformation  of  the  breasts  and 
thorax;  dwarfishness  ;  giantism;  infantilism;  femininism;  masculinism ; 
spina  bifida. 

Anomalies  of  the  genital  organs. 

Anomalies  of  the  skin  :  Polysarcia  ;  hypertrichosis  ;  absence  of  hair  ; 
premature  grayness. 

*  Deformities  of  the  Hard  Palate  in  Degenerates,  by  Frederick  Peterson,  M.  D., 
International  Dental  Journal,  Dccoinber,  1805. 


804  DISEASES   OF  THE  NERVOUS  SYSTEM. 

Physiological  Stigmata. — Anomalies  of  motor  function :  Walking  late  j 
tics  ;  tremors  ;  nystagmus  ;  epilepsy. 

Anomalies  of  sensory  function  :  Deaf-mutism  ;  neuralgia  ;  migraine  ; 
hypersesthesia  ;  anaesthesia  ;  blindness ;  myopia ;  liypermetropia ;  astig- 
matism ;  Daltonism ;  hemeralopia ;  concentric  limitation  of  the  visual 
field. 

Anomalies  of  speech  :  Mutism  ;  defective  speech  ;  stuttering ;  stam- 
mering. 

Anomalies  of  genito-urinary  function  :  Enuresis ;  sexual  irritability  ;. 
impotence  ;  sterility. 

Anomalies  of  the  instinct  or  apjoetite  :  Merycism  ;  uncontrollable  ap- 
petites for  food,  liquor,  drugs,  etc. 

Diminished  resistance  to  external  influences  and  diseases. 

Eetardation  of  puberty. 

Psychical  Stigmata. — Insanity;  idiocy;  imbecility;  feeble-mindedness; 
eccentricity  ;  moral  delinquency  ;  sexual  perversion. 

DEAF-MUTISM. 

Excluding  the  cases  in  which  idiocy  is  present,  which  are  not  con- 
sidered in  this  chapter,  deaf-mutism  may  be  due  either  to  congenital  or 
acquired  conditions  ;  the  larger  proportion  of  the  cases  belong  in  the  lat- 
ter class.  When  congenital,  deaf-mutism  may  result  from  ostitis,  or  peri- 
ostitis of  the  temporal  bone,  encroaching  upon  the  cavity  of  the  middle 
ear,  from  ankylosis  of  the  ossicles,  from  absence  of  the  internal  ear  or 
any  of  its  parts.  There  may  also  be  colloid  degeneration  of  the  labyrinth. 
It  may  result  from  atrophy  of  the  auditory  nerve,  and  it  may  be  due  to  a 
lesion  of  the  brain.  These  congenital  conditions  are  often  hereditary. 
Acquired  deaf-mutism  is  most  frequently  the  result  of  scarlet  fever,  and 
is  due  to  otitis.  The  second  important  cause  is  cerebro-spinal  meningitis,, 
where  it  may  be  due  to  a  lesion  of  the  brain,  the  auditory  nerve,  or  the- 
ear.  It  occasionally  follows  mumps,  diphtheria,  measles,  and  other  infec- 
tious diseases.  It  may  result  from  repeated  attacks  of  acute  otitis  associ- 
ated with  adenoid  growths  or  chronic  rhino-pharyngitis. 

The  younger  the  child  at  the  time  the  deafness  occurs  the  sooner  the 
power  of  speech  is  lost.  In  most  of  the  infectious  diseases,  if  the  attack 
occurs  before  the  fifth  year  speech  is  lost.  According  to  Love,*  total  deaf- 
ness is  rare  among  deaf-mutes;  hearing  for  speech  is  present  to  a  useful 
degree  in  about  twenty-five  per  cent  of  the  cases,  while  hearing  by  cranial 
conduction  exists  in  nearly  all  cases.  Deaf-mutism  should  be  suspected 
if  a  child  not  idiotic  shows  at  the  end  of  two  years  no  signs  of  beginning 
to  talk.  A  careful  distinction  should  be  made  between  deaf-mutism  and 
idiocy  resulting  either  from  congenital  conditions  or  acquired  disease. 

*  Deaf-Mutism,  by  James  K.  Love.     Macraillan  &  Co..  1896. 


MALFORMATIONS   OP   THE   SPINAL   CORD.  805 

It  is  necessary  that  this  condition  be  recognised  as  early  as  possible,  in 
order  that  the  child  may  have  the  advantages  of  proper  training  during 
its  early  years.  The  physician  should  insist  upon  the  child  being  sent  to 
an  institution  where  it  may  be  taught  to  speak  as  early  as  the  third,  and 
certainly  by  the  fourth  year. 

The  treatment  is  mainly  prophylactic.  The  most  important  relates  to 
the  care  of  the  ears  in  scarlet  fever,  and  the  removal  of  adenoid  vegeta- 
tions of  the  pharynx  and  other  causes  which  produce  attacks  of  acute  or 
chronic  otitis.  For  the  condition  itself  education  is  the  only  thing  to  be 
considered. 


CHAPTER   IV. 

DISEASES  OF  THE  SPINAL  CORD. 

MALFORMATIONS, 

MALFORMATiO]srs  of  the  cord  are  very  frequently  associated  with  those 
of  the  brain,  and  bear  a  certain  degree  of  resemblance  to  them.  (1)  The 
cord  may  be  absent  (amyelia)  ;  this  condition  may  exist  alone  or  with  ab- 
sence of  the  brain.  (2)  The  lack  of  development  may  be  only  partial 
(atelomyelia),  as  where  some  of  the  tracts  are  wanting.  The  most  impor- 
tant one  is  defective  development  of  the  lateral  tracts,  which  may  be  a 
cause  of  spastic  paraplegia  (Charcot).  (3)  There  may  be  a  malposition  of 
some  of  the  gray  matter  (heterotopia).  (4)  There  may  be  a  double  cord 
(diplomyelia) ;  the  division  is  generally  incomplete,  and  is  attributed  to  an 
abnormal  development  of  the  central  canal ;  it  is  usually  associated  with 
other  deformities.  All  of  these  malformations  are  extremely  rare  and  of 
very  little  practical  interest. 

There  remains  to  be  mentioned  the  only  one  which  is  really  impor- 
tant—spina  bifida. 

Spina  Bifida. — This  is  a  malformation  of  the  vertebral  canal  with  a 
protrusion  of  some  part  of  its  contents  in  the  form  of  a  fluid  tumour.  The 
tumour  is  elastic,  compressible,  usually  increased  by  crying,  and  sometimes 
by  pressure  upon  the  anterior  fontanel.  The  contained  fluid  is  clear  serum, 
resembling  in  all  respects  the  cerebro-spinal  fluid.  It  is  one  of  the  most 
frequent  congenital  deformities. 

According  to  ITiuiiphrey,  spina  bifida  is  due  to  an  early  failure  in 
development, — in  most  cases  before  the  cord  is  segmentated  from  the  epi- 
blastic  layer  frotn  which  it  is  developed.  Hence  it  remains  adherent  to 
the  epiblastic  covering,  and  the  structures  which  should  be  formed  between 
the  cord  and  the  skin  are  undeveloped.  For  this  reason  we  have  in  the 
wall  of  the  sac  a  fusion  of  the  elements  of  the  cord,  nerves,  meninges,  ver- 
tebral arches,  muscles,  and  integument.     If  the  error  in  development  occurs 


806 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


Fig.  145.  —  Meningo- 
cele (partially  dia- 
grammatic). A,  the 
membranes ;  £,  the 
spinal  cord  ;  G,  the 
integument.  The 
accumulation  of 
fluid  is  behind  the 
cord,  which  does 
not  enter  the  sac. 


later,  the  cord  and  nerves  may  be  attached  to  the  sac,  but  not  intimately 
fused  with  it ;  in  still  other  cases  the  cord  does  not  enter  the  sac  at  all. 
The  malformation  may  occur  before  the  central  canal 
is  closed ;  or,  if  closed,  it  may  reopen  from  the  accu- 
mulation of  fluid.  It  is  probable  that  the  accumula- 
tion of  fluid  first  occurs,  and  that  this  prevents  the 
union  of  the  parts  of  the  vertebral  arches. 

Although  the  tumour  is  generally  associated  with  a 
bifid  spine,  this  is  not  necessarily  the  case.  The  pro- 
trusion may  take  place  through  the  intervertebral 
notch  or  foramen,  or  there  may  be  a  fissure  of  the 
bodies  of  the  vertebrae,  and  an  anterior  tumour  project- 
ing into  the  cavity  of  the  thorax,  abdomen,  or  pelvis, — 
spina  bifida  occulta.  The  principal  anatomical  varie- 
ties are  meningocele,  meningo-myelocele,  and  syringo- 
m.yelocele.* 

Menmgocele. — In  this  form  there  is  a  protrusion 
of  the  membranes  only  (Fig.  145).    The  accumulation 
of  fluid  is  either  in  the  arachnoid  cavity  or  the  subarachnoid  space  poste- 
rior to  the  cord.     The  opening  of  communication  between  the  tumour  and 

the  spinal  canal  is  small  in  this  variety, 
usually  being  about  one  twelfth  to  one 
sixth  of  an  inch  in  diameter.  There  may, 
however,  be  no  communication.  The 
skin  is  usually  fully  developed  (Fig.  146). 
The  tumour  is  frequently  globular,  some- 
times pedunculated,  and  may  attain  a 
very  large  size,  being  as  much  as  five  or 
six  inches  in  diameter.  This  is  because 
spontaneous  rupture  is  not  likely  to  oc- 
cur, and  the  tumour  does  not  become  in- 
fected except  by  operative  interference. 
With  such  tumours  patients  may  live  to 
adult  life.  This  variety  is  most  frequent- 
ly seen  in  the  cervical  region.  It  has 
the  best  chance  of  natural  recovery,  and 
in  it  operation  gives  the  best  results. 

Meningo-myelocele. — This  is  by  far  the 
most  frequent  variety  of  spina  bifida,  oc- 
curring in  thirty-five  of  the  fifty-seven 
cases  reported  by  Demme.  It  is  the  form 
usually  seen  in  the  sacro-lumbar  region. 


Fig.  146.' 


-Meningocele,  in  a  child  one 
year  old. 


*  See  Report  of  London  Clinical  Society,  1885 :  and  Humphrey,  Lancet,  March  28, 
1885. 


SPINA   BIFIDA. 


807 


The  accumulation  of  fluid  takes  place  in  the  anterior  subarachnoid  space, 
less  frequently  in  the  anterior  arachnoid  cavity  (Fig.  147).  In  this  form 
the  cord  is  contained  in  the  sac,  and  usually  forms  a  part  of  its  wall. 
The  tumour  is  smaller  than  the  meningocele,  the  usual  size  being  that  of 
a  mandarin  orange.  It  is  sessile,  never  pedunculated.  As  a  rule  it  is  only 
partly  covered  by  skin,  but  has  a  central  area,  elliptical  in  shape,  where 
there  is  only  a  thin,  translucent  membrane.  This  sur- 
face, which  is  known  as  the  central  cicatrix,  is  some- 
times covered  with  granulations,  and  frequently  ulcer- 
ates. The  tumour  often  has  a  vertical  furrow  or  a  cen- 
tral umbilication,  corresponding  to  the  attachment  of 
the  cord  on  its  inner  surface.  The  usual  relation  of 
the  parts  is  for  the  cord  to  run  horizontally  across 
the  upper  part  of  the  tumour  to  the  central  cicatrix, 
with  which  it  becomes  blended,  and  from  which  again 
the  nerves  arise.  These  re-enter  the  canal  at  the  lower 
part  of  the  tumour,  and  are  distributed  below  as  usual. 
In  other  cases  the  cord  joins  the  wall  of  the  sac  soon 
after  its  entrance,  and  its  attenuated  fibres  are  found 
spread  out  all  over  the  sac,  coming  together  again  be- 
low and  entering  the  spinal  canal. 

The  following  case,  upon  which  I  recently  made  an 
autopsy,  is  a  good  example  of  the  common  variety : 
The  child  died  on  the  third  day  after  birth  from  rup- 
ture of  the  sac.  The  tumour  occupied  the  sacral  region.  The  first 
sacral  vertebra  was  normal,  and  beneath  this  the  cord  passed,  termina- 
ting in  the  cauda  equina  soon  after  entering  the  sac,  and  continued 
back  to  the  central  cicatrix.  Here  nerve  filaments  blended  with  the 
other  tissues  in  an  indefinite  structure,  from  which  again,  with  toler- 
able distinctness,  they  could  be  seen  to  pass  over  the  wall  of  the  sac  and 
return  to  the  canal.  The  afferent  and  efferent  nerves  and  the  part  of  the 
membranes  they  carried  with  them  formed  several  septa,  making  a  smaller 
separate  sac  within  the  larger  one.  The  large  sac  was  clearly  a  dilatation 
of  tlie  anterior  subarachnoid  space,  and  communicated  freely  with  the 
same  space  in  the  cord  above. 

Syringo-7nyelocele. — In  this  variety  the  accumulation  of  fluid  is  in  the 
central  canal  of  the  cord,  the  lining  of  the  sac  being  here  the  attenuated 
and  atrophied  cord  elements.  This  is  the  rarest  form  of  tumour,  but  the 
one  most  frequently  associated  with  hydrocephalus,  and  consequently  hav- 
ing the  worst  prognosis.  It  is  usually  found  in  the  dorsal  or  dorso-lumbar 
region,  rarely  in  the  lum])o-sacral  (Fig.  118). 

With  spina  bifida  other  deformities  are  frecjuently  associated,  the  most 
common  being  club-foot,  hydrocephalus,  more  rarely  encephalocele  or 
cerebral  meningocele,  and  hure-lip.     If  hydrocephalus  exists,  there  is  in 


Fig.  147. —  Meninjjo- 
myelocele  (partially 
diagrammatic).  A, 
the  membranes  ;  £, 
the  cord  ;  C,  the  in- 
tegument. The  ac- 
cumulation of  fluid 
is  in  front  of  the 
cord,  the  tikuuents 
of  which  are  spread 
out,  forming  a  part 
of  the  wall  of  the 
sac. 


DISEASES  OF   THE  NERVOUS   SYSTEM. 


i'lG.  14s. — tivringo-myeloeele  of  the  niid- 
dorsal  region,  in  a  child  four  months 
old,  who  also  had  hydrocephalus. 


most  cases  a  dilatation  of  the  central  canal  of  the  cord  and  a  direct  com- 
munication between  the  tumour  and  the  lateral  ventricles  of  the  brain. 

Pressure  upon  the  anterior  fontanel 
causes  an  increase  in  the  size  of  the 
tumour,  and  conversely.  Club-foot  is 
usually  double,  most  frequently  tal- 
ipes equino-varus.  In  a  number  of 
cases  there  is  a  history  of  some  de- 
formity in  other  members  of  the  fam- 
ily. I  once  saw  two  successive  chil- 
dren in  the  same  family  with  spina 
bifida. 

Symptoms. — The  tumour  is  pres- 
ent at  birth,  and  is  most  frequently 
situated  just  above  the  sacrum.  Pa- 
ralysis is  frequent  in  myelocele  and 
syringo-myelocele,  but  is  not  seen  in 
meningocele  ;  its  degree  and  its  loca- 
tion depend  upon  the  situation  of  the 
tumour  and  the  extent  to  which  the 
cord  is  involved.  It  is  rare  in  cervi- 
cal tumours,  and  most  marked  in  those  situated  in  the  lumbo-sacral  re- 
gion. In  the  worst  cases  there  is  complete  paraplegia,  with  paralysis  of 
the  bladder  and  rectum.  If  the  tu- 
mour is  sacro-lumbar  or  sacral,  only 
the  Cauda  equina  is  likely  to  be  in- 
volved, and  this  but  partially,  so 
that  the  paralysis  of  the  extremities 
is  incomplete,  and  the  bladder  and 
rectum  may  escape. 

In  Fig.  149  is  shown  a  very  re- 
markable case  of  sacral  spina  bifida 
in  a  boy  of  five  years,  who  came 
under  observation  for  incontinence 
of  faeces.  The  tumour  was  a  little 
more  to  the  left  than  to  the  right 
side,  and  had  been  overlooked.  It 
had  evidently  pressed  upon  the  lower 
branches  of  the  sacral  plexus,  so  as 
to  involve  the  sphincter  and  the 
gluteal  muscles  of  the  left  side.  The 
atrophy  was  very  marked,  as  sliown 
in  the  illustration. 

The  natural  course  of  spina  bifida  Fig.  149.— Sacral  spina  bifida. 


SPINA  BIFIDA. 


809 


is  to  increase  steadily  in  size ;  and  if  the  tumour  is  covered  by  skin, 
its  growth  may  be  ahnost  unlimited.  It  has  been  known  to  attain  a  cir- 
cumference of  twenty-two  inches.  If  the  integument  is  wanting,  and  the 
sac  wall  is  very  thin,  rupture  is  pretty  certain  to  take  place,  either 
spontaneously  or  by  some  accident,  in  the  course  of  the  first  few  months  • 
death  then  results  from  convulsions  owing  to  the  rapid  draining  away  of 


.x^^' 


Fig.  150.— Spina  bifida,  with  dilatation  of  the  central  canal  of  the  cord,  and  spinal  meningitis. 
ihe  central  canal  is  filled  with  round  cells,  among  which  are  many  cocci.  XX  is  the  pelli- 
cle of  fibrin  upon  the  posterior  surface  of  the  pia  mater,  also  containing  many  cocci.  The 
pia  IS  every wliere  infiltrated  with  cells,  even  to  the  bottom  of  the  anterior  fissure.  Tlie 
gray  matter  of  the  cord  is  much  congested.  PR  is  the  posterior  nerve  root.  The  section  is 
from  the  dorsal  region  of  the  cord. 


\\\  a  large  number 


the  cerebro-spinal  fluid,  or  from  secondary  infection ^ .._ 

of  cases  death  is  due  to  marasmus  dependent  upon  the  associated  condi- 
tions. Infection  of  the  tumour  may  take  place  witliout  rupture,  the  germs 
passing  through  the  wall  of  the  sac.  If  the  opening  communieating  with 
the  spinal  canal  is  small,  this  infection  may  excite  an  inflammation  limited 
to  tlie  wall  of  the  sac,  and  i-csiilt  in  a  cure  of  the  spina  bifida,  usually  with 


810  DISEASES   OP    THE   NERVOUS  SYSTEM. 

sloughing.  I  have  now  under  observation  a  girl  ten  years  old  in  whom 
this  occurred  in  infancy.  The  site  of  the  former  tumour  is  marked  by  a 
large  dense  cicatrix,  and  there  still  remains  partial  paralysis  of  the  legs. 
If  the  opening  into  the  spinal  canal  is  large,  inflammation  of  the  sac  is 
usually  followed  by  spinal  meningitis,  which  may  extend  upward  and  in- 
volve also  the  meninges  of  the  brain.  In  a  case  published  by  Van  Gieson 
and  myself,*  in  which  there  was  dilatation  of  the  central  canal  of  the 
cord  and  hydrocephalus,  bacteria  penetrated  the  wall  of  the  sac  and  trav- 
elled up  the  central  canal  of  the  cord  (Fig.  150),  finally  exciting  a  sup- 
purative inflammation  in  the  ventricles  of  the  brain,  in  addition  to  a 
spinal  meningitis.  Sections  of  the  wall  of  the  sac  and  of  the  cord  at 
various  levels  showed  the  same  cocci.  The  child  died  at  the  age  of  three 
weeks. 

Prognosis. — This  depends  chiefly  upon  the  anatomical  variety  and  the 
existence  of  complications.  Simple  meningocele,  when  covered  by  integu- 
ment, gives  the  best  prognosis,  and  complete  recovery  may  occur.  In 
meningo-myelocele,  if  complete  paralysis  exists,  the  prognosis  is  bad  ;  and 
if  there  is  hydrocephalus,  the  case  is  hopeless.  In  quite  a  number  of 
cases  in  which  cure  has  followed  operation,  hydrocephalus  has  subse- 
quently developed.  Of  fifty-seven  cases  reported  by  Demme,  twenty-five 
were  operated  npon,  with  seven  recoveries  and  fifteen  deaths,  while  three 
were  unimproved;  of  the  thirty-two  cases  not  operated  upon,  twenty- 
eight  died  within  the  first  month,  and  not  one  lived  over  two  years — 
the  causes  of  death  being  marasmus,  rupture  of  the  sac,  and  meningitis. 

Diagnosis. — It  is  usually  easy  to  recognize  spina  bifida,  but  it  is  often 
difficult  to  distinguish  between  the  different  varieties.  The  absence  of 
a  palpable  fissure  in  the  spine,  perfect  translueency,  and  a  pedunculated 
tumonr,  all  point  strongly  to  meningocele.  Paralysis  of  the  sphincters 
and  lower  extremities,  umbilication  of  the  centre  of  the  tumour,  a  sessile 
tumour,  a  palpable  bony  fissure,  and  a  large  central  cicatrix,  point  to 
meningo-myelocele.  The  coexistence  of  hydrocephalus  points  to  syringo- 
myelocele. 

Treatment. — In  all  cases  the  tumour  should  be  protected  from  pres- 
sure, and  care  taken  where  it  is  not  covered  by  integument,  that  the 
surface  is  kept  absolutely  clean  and  aseptic.  It  should  be  covered  with 
some  antiseptic  powder  and  surrounded  by  a  large  pad  of  absorbent  cot- 
ton, or  a  rubber  ring-cushion.  Complete  paraplegia  with  involvement  of 
the  bladder  and  rectum,  hydrocephalus,  or  extreme  marasmus — all  con- 
tra-indicate  operative  interference.  If  these  are  absent,  operation  should 
be  considered.  The  time  of  operation  will  depend  somewhat  upon  the 
nature  of  the  tumour.  If  it  is  covered  by  integument  and  growing  slowly, 
it  is  well  to  wait  until  the  child  is  at  least  six  months  old.    In  other  cases 

*  Journal  of  Nervous  and  Mental  Diseases,  December,  1890. 


SPINAL  MENINGITIS.  Sll 

delay  is  dangerous,  because  of  the  liability  to  spontaneous  or  accidental 
rupture. 

Nothing  is  to  be  expected  from  simple  aspiration  and  compression. 
The  methods  of  treatment  which  have  been  successfully  employed  are 
ligation,  aspiration  and  injection,  and  excision  of  the  sac.  Ligation  is 
admissible  only  where  there  is  a  pedunculated  tumour;  and  even  for 
these  cases  some  surgeons  prefer  the  clamp.  The  treatment  by  aspira- 
tion and  injection  has  been  Avidely  used  in  Europe,  but  is  not  so  highly 
esteemed  in  America.  The  tumour  having  been  aspirated  and  about  one 
half  of  its  contents  evacuated,  there  is  injected,  without  removing  the 
needle,  a  drachm  of  Morton's  fluid  (iodine,  gr.  x ;  iodide  of  potassium, 
gr.  XXX ;  glycerin,  jj)-  If  the  tumour  is  pedunculated,  pressure  should 
be  made  at  its  neck  to  prevent  the  entrance  of  fluid  into  the  canal.  In 
all  cases  the  child  should  be  kept  in  a  recumbent  position  for  several 
hours.  The  operation  is  not  entirely  free  from  danger,  as  in  some  cases 
it  has  been  followed  by  convulsions  and  death  in  a  few  hours.  Consid- 
erable inflammatory  reaction  usually  occurs,  lasting  from  two  to  four 
days.  After  this  period  there  is,  in  a  favourable  case,  a  subsidence  of  the 
swelling,  with  a  gradual  contraction  and  finally  obliteration  of  the 
tumour.  The  mortality  of  cases  treated  by  this  method  is  from  forty  to 
fifty  per  cent.*  My  own  experience  includes  four  cases,  with  two  re- 
coveries. 

The  dangers  of  this  operation  and  the  uncertainty  as  to  its  results 
'  have  led  many  surgeons  to  discard  it  altogether  in  favour  of  excision, 
which  with  the  technique  of  modern  surgery  is  almost  devoid  of  risk. 
For  a  description  of  this  and  the  various  plastic  operations  that  have 
been  proposed  in  connection  with  complete  or  partial  excision  of  the  sac, 
the  reader  is  referred  to  works  upon  operative  surgery.  In  operating,  it 
should  not  be  forgotten  that  in  the  great  proportion  of  the  cases  (ninety- 
five  per  cent,  according  to  the  Clinical  Society's  Eeport,  which,  however, 
refers  only  to  fatal  cases)  some  part  of  the  cord  is  in  the  sac.  The  cord 
is  often  present  in  tumours  situated  below  the  third  lunil)ar  vc'rtel)ra, 
owing  to  its  attachment  to  the  sac. 

Although  recovery  may  follow  operation,  in  a  very  large  number  of 
cases  it  is  incomplete ;  some  degree  of  paralysis,  with  atrophy,  contrac- 
tures, and  deformities,  remaining  because  of  the  implication  of  cord  ele- 
ments in  the  sac.  In  a  considerable  proportion  of  cases  hydrocephalus 
subsequently  develops,  as  after  similar  operations  u})()n  cerebral  uiciiin- 

gocele. 

SPINAL   MENINGITIS. 

In  acute  meningitis  usnallyouly  Ibc  ]i^a  uiater  is  involved.  Thisrarely 
occurs  alone,  unless  it  is  due  to  trauuuitism.  It  is  most  frequently  asso- 
ciated with  inflammation  of  the  pia  of  the  brain,  and  may  occur  either  with 

*  Report  of  the  London  Clinical  Society. 


812  DISEASES  OF   THE   NERVOUS  SYSTEM. 

the  simple  or  the  tuberculous  variety.  A  certain  amount  of  acute  in- 
flammation of  the  pia  mater  accompanies  most  of  the  cases  of  acute  my- 
elitis. 

Chronic  spinal  meningitis  in  children  usually  involves  the  dura  only. 
Inflammation  of  the  external  layer  (external  pachymeningitis)  is  usually 
secondary  to  caries  of  the  vertebras.  This  is  considered  in  the  article 
on  Compression-Myelitis. 

Symptoms. — The  symptoms  of  inflammation  of  the  s|)inal  membranes, 
no  matter  with  what  pathological  condition  it  may  be  associated,  are  due 
to  irritation  of,  or  pressure  upon,  the  cord  or  nerve  roots.  Those  which 
are  most  common  are :  pain  in  the  back,  which  is  increased  by  move- 
ment, and  usually  by  pressure  upon  the  sjjinous  processes  ;  radiating  pains 
following  the  course  of  the  spinal  nerves,  felt  in  the  extremities  or  in 
the  trunk ;  rigidity  of  the  spinal  column  due  to  spasm  of  the  spinal  mus- 
cles, or  rigidity  of  the  muscles  of  the  extremities ;  and  hyperesthesia 
along  the  spine,  which  may  be  quite  acute.  When  pressure  upon  the  cord 
is  added,  there  is  paralysis  or  paresis,  sometimes  muscular  atrophy  and 
anaesthesia.  Any  of  the  above  symptoms  may  be  acute  or  chronic,  accord- 
ing to  the  nature  of  the  primary  disease. 

The  diagnosis  between  spinal  meningitis  and  myelitis  is  often  not  easy, 
for  except  in  acute  cases  the  two  processes  are  usually  associated ;  and  in  a 
given  case  it  may  be  difficult  to  decide  whether  the  lesion  of  the  cord  or 
of  the  membranes  is  the  more  important  one.  In  meningitis,  pain,  ten- 
derness, spasm,  and  irritative  symptoms  are  generally  more  prominent, 
while  loss  of  power  and  anaesthesia  are  usually  partial.  In  myelitis  the 
pain,  tenderness,  and  other  irritative  symptoms  are  less  marked,  while 
paralysis  and  anaesthesia  may  be  complete. 

Treatment. — This  is  first  of  the  disease  with  which  it  is  associated  ;  in 
addition,  counter-irritation  by  means  of  the  Paquelin  cautery,  rest  in  bed, 
and  in  severe  cases  even  immobilization  of  the  spine  by  a  mechanical  sup- 
port.    Iodide  of  potassium  is  often  useful. 

MYELITIS. 

Myelitis  is  a  rare  disease  in  children,  with  the  exception  of  two  varieties 
which  are  discussed  under  separate  heads,  viz.,  compression-myelitis  and 
acute  poliomyelitis.  Otherwise  myelitis  usually  results  from  injury,  but 
it  may  occur  as  a  complication  of  any  of  the  acute  infectious  diseases,  es- 
pecially typhoid  or  scarlet  fever,  and  diphtheria,  and  even  as  a  primary 
disease,  where  it  is  attributed  to  exposure  or  cold,  but  where  it  is  probably 
infectious.     Chronic  myelitis  may  be  due  to  hereditary  syphilis. 

Myelitis  usually  occurs  in  children  over  ten  years  of  age.  In  situation, 
it  may  be  transverse,  diffuse,  or  disseminated ;  the  process  may  be  acute, 
subacute,  or  chronic.  The  lesions  and  the  symptoms  are  essentially  the 
same  as  when  the  disease  occurs  in  the  adult. 


MYELITIS.  813 

Symptoms. — Myelitis  usually  comes  on  rather  gradually,  with  only 
local  symptoms;  but  the  onset  may  be  quite  acute,  with  severe  general 
symptoms, — fever,  pain,  prostration  and  localized  or  general  convulsions. 
The  local  symptoms  vary  with  the  seat  and  the  extent  of  the  disease. 

In  transverse  myelitis  loss  of  power  and  anassthesia  are  present  below 
the  level  of  the  lesion  ;  either  of  these  may  be  partial  or  complete.  At  the 
level  of  the  lesion  there  is  a  zone  of  hyjoeraesthesia  and  "  girdle-pains." 
All  the  reflexes  below  the  seat  of  the  lesion  are  exaggerated.  Those  at 
the  level  of  the  lesion  are  lost.  There  may  be  loss  of  control  of  the 
sphincters,  bed-sores,  degenerative  changes  in  the  paralyzed  muscles,  con- 
tractures, and  vaso-motor  disturbances.  The  paralyzed  muscles  may  be 
rigid  or  flaccid  according  to  the  seat  and  extent  of  the  lesion. 

When  transverse  myelitis  is  situated  in  the  cervical  region  there  are 
paralysis  and  anaesthesia  of  the  arms,  legs,  and  trunk.  All  the  reflexes  are 
exaggerated,  and  there  is  general  rigidity  of  the  paralyzed  muscles.  There 
are  incontinence  of  fseces  and  retention  of  urine,  followed  by  incontinence 
from  overflow.  The  pupils  are  frequently  contracted,  and  there  may  be 
optic  neuritis.  Atrophy,  when  present,  usually  affects  the  muscles  of  the 
arms,  and  indicates  that  the  cord  to  a  considerable  extent  is  involved. 
There  is  great  danger  to  life,  owing  to  paralysis  of  the  muscles  of  respiration. 

When  the  seat  of  disease  is  the  dorsal  region,  the  symptoms  are  similar 
to  those  above  described,  with  the  exception  that  the  arms  escape,  and 
that  the  eye-symptoms  are  usually  wanting.  This  is  the  most  favourable 
seat  of  the  disease. 

When  the  disease  is  situated  in  the  lumbar  region,  in  addition  to  para- 
plegia and  anaesthesia  of  the  legs,  there  is,  from  the  beginning,  inconti- 
nence of  urine  and  fasces.  The  knee  reflexes  are  lost ;  the  muscles  atrophy, 
and  usually  give  the  reaction  of  degeneration.     Bed-sores  are  frequent. 

In  diffuse  myelitis  the  symptoms  are  a  combination  of  the  above 
groups.  If  a  large  part  of  the  cord  is  involved,  there  are  general  paraly- 
sis and  ansesthesia,  loss  of  reflexes,  marked  trophic  disturbances,  bed- 
sores, etc. 

The  course  of  myelitis  is  slow,  and  it  usually  progresses  steadily  from 
bad  to  worse.  Death  is  due  to  exhaustion  or  complications — cystitis,  bed- 
sores, or  hypostatic  pneumonia — or  to  some  intercurrent  disease.  In  a 
small  proportion  of  the  cases  there  may  be  partial  recovery,  but  very 
rarely  is  this  complete.  The  diagnosis  is  to  be  made  from  spinal  menin- 
gitis, tumours,  and  haemorrhage. 

Treatment. — The  treatment  of  the  early  stage  consists  in  the  use  of  ice 
to  the  spine,  or  counter-irritation  by  means  of  dry  cups,  mustard,  or  the 
Paquelin  cautery.  Later,  the  iodide  of  potassium  should  be  given  in  all 
cases ;  improvement  may  follow  its  use,  even  when  there  is  no  suspicion 
of  syphilis,  but  large  doses  are  required,  and  for  a  long  period.  Electricity 
is  contra-indicated  except  in  chronic  cases,  and  then  but  little  improvement 
53 


814  DISEASES   OP   THE  NERVOUS  SYSTEM. 

is  likely  to  result  from  its  use.  In  these  patients  the  most  important 
thing  is  careful  attention  to  cleanliness  and  to  posture,  in  order  to  pre- 
vent bed-sores,  cystitis,  and  pneumonia. 

COMPRESSION-MYELITIS. 

Synonyms :  Pressure-paralysis  of  the  spinal  cord ;  Pott's  paraplegia. 

Compression-myelitis  is  sometimes  traumatic,  but  usually  follows 
caries  of  the  spine.  It  most  frequently  complicates  this  disease  when  the 
cervical  or  upper  dorsal  vertebrse  are  involved,  rarely  when  the  lower  half 
of  the  spinal  column  is  affected.  This  difference  is  probably  due  to  the 
smaller  size  of  the  spinal  canal  in  its  upper  portion.  According  to  Gib- 
ney,*  paraplegia  is  seen  in  fifty  per  cent  of  the  cases  of  caries  of  the  upper 
half  of  the  spine.  Essentially  the  same  condition,  so  far  as  the  cord  is  con- 
cerned, may  result  from  tumours  of  the  spinal  cord,  or  from  anything  else 
causing  pachymeningitis.  These,  however,  are  exceedingly  rare  in  child- 
hood. 

Lesions. — In  spinal  caries  there  occurs  as  a  result  of  tuberculous  dis- 
ease a  softening  of  the  bodies  of  the  vertebrae,  which  fall  together  from  the 
pressure  due  to  the  superincumbent  weight  of  the  body.  This  causes  a 
backward  projection  known  as  the  kyphosis,  or  angular  deformity.  The 
spinal  canal  is  encroached  upon  by  the  remains  of  the  vertebral  bodies 
whose  ligamentous  attachments  have  been  loosened,  and  also  by  inflam- 
matory products  the  result  of  periostitis,  and  localized  inflammation  of  the 
dura  mater,  chiefly  of  the  external  layer,  but  which  sometimes  affects  the 
internal  layer  also.  All  these  conditions  lead  to  the  production  of  a  mass 
of  inflammatory  material,  often  containing  tuberculous  deposits,  which  is 
chiefly  in  front  of  the  cord,  but  may  surround  it.  The  compression  takes 
place  slowly  in  most  of  the  cases,  from  the  gradual  progress  of  the  lesions 
mentioned.  In  a  small  number  of  cases  there  may  be  a  sudden  pressure 
from  the  slipping  backward  of  one  of  the  vertebral  bodies. 

In  recent  cases  the  cord  at  the  seat  of  compression  is  a  little  smaller 
than  normal.  It  is  usually  involved  to  the  extent  of  from  half  an  inch 
to  two  inches.  Paraplegia  may  have  existed  where  the  changes  found  in 
the  cord  are  very  slight,  and  sometimes  where  no  changes  are  visible  to 
the  naked  eye.  In  more  protracted  and  more  severe  cases,  the  cord  is 
much  smaller  at  the  point  of  disease,  and  under  the  microscope  shows  the 
changes  of  interstitial  myelitis  (Gowers)  with  meningitis.  In  old  cases 
there  are  degeneration  of  the  nerve  elements,  atrophy,  and  sometimes  dis- 
appearance of  the  ganglion  cells,  with  more  or  less  destruction  of  the  nerve 
fibres ;  sometimes  all  distinction  between  the  gray  and  white  substance  is 
lost.  In  addition  to  these  marked  changes  at  the  point  of  pressure,  there 
may  be  ascending  or  descending  degeneration,  as  from  other  focal  lesions.. 

*  Journal  of  Mental  and  Nervous  Diseases,  April,  1897. 


COMPRESSION-MYELITIS.  815 

There  is  usually  inflammation  of  the  nerve  roots,  which  have  also  suffered 
compression.  It  is  in  many  cases  surprising  to  see  to  what  degree  the 
cord  may  be  compressed  and  still  preserve  its  functions. 

Symptoms. — In  caries  of  the  cervical  region  the  symptoms  of  com- 
pression-myelitis not  infrequently  precede  the  deformity,  and,  in  fact,  the 
other  objective  symptoms  of  bone  disease.  The  earliest  symptoms  of 
caries  usually  arise  from  irritation  of  the  nerve  roots,  and  consist  of 
acute  pains  not  often  referred  to  the  spine,  but  radiating  to  the  differ- 
ent regions  to  which  these  nerves  are  distributed.  They  are  felt  in  the 
neck,  in  the  chest,  in  the  epigastrium,  and  sometimes  in  the  loins.  Such 
symptoms  indicate  the  presence  of  pachymeningitis,  and  may  be  present 
whatever  the  location  of  the  vertebral  caries.  Accompanying  these  pains, 
there  is  noticed  a  gradual  weakness  in  the  lower  extremities,  and  some- 
times also  in  the  arms,  according  to  the  location  of  the  disease.  This 
may  steadily  increase  for  several  weeks  until  there  is  complete  paralysis. 
Other  symptoms  are  then  commonly  present.  There  is  usually  some  degree 
of  anaesthesia,  but  in  many  cases  there  is  none,  and  there  may  be  numbness, 
tingling,  formication,  and  pain.  The  sphincters  are  not  often  involved. 
When  the  disease  is  in  the  upper  half  of  the  cord,  there  are  rigidity  of  the 
extremities  and  great  exaggeration  of  all  the  reflexes,  with  marked  ankle- 
clonus.  In  the  rare  cases  in  which  the  lumbar  enlargement  is  involved, 
there  may  be  loss  of  reflexes,  paralysis  of  the  sphincters  and  bed-sores. 

The  distribution  of  the  paralysis  will  depend  upon  the  point  of  com- 
pression. If  this  is  in  the  cervical  region,  all  four  extremities  will  be  para- 
lyzed ;  if  in  the  dorsal  region,  only  the  legs.  In  rare  cases  the  paralysis. 
is  unilateral,  and  if  there  is  no  spinal  deformity  the  condition  may  be  a 
most  puzzling  one.  According  to  the  extent  of  the  secondary  lesions  in 
the  cord,  there  may  occur  muscular  atrophy  and  contractures.  With  dis- 
ease in  the  upper  cervical  region,  death  may  result  from  sudden  pressure 
upon  the  cord,  owing  to  a  dislocation  of  the  odontoid  process,  which  hap- 
pened, in  one  of  Gribney's  cases ;  or  there  may  be  vomiting,  pupillary 
symptoms,  irritation  of  the  phrenic  nerve  causing  hiccough,  or  pressure 
causing  paralysis  of  the  diaphragm. 

Course  and  Prognosis. — These  depend  much  upon  the  treatment  of  the 
case.  In  many  cases  of  paralysis  occurring  early  in  caries,  complete  re- 
covery takes  place  in  the  course  of  a  few  weeks,  sometimes  in  a  feAV  days, 
after  the  application  of  a  proper  mechanical  support.  This  may  be  true 
even  where  the  paralysis  has  continued  for  three  or  four  months.  In  tlie 
cases  which  have  been  long  neglected,  or  those  in  which  the  paralysis  de- 
velops while  proper  mechanical  treatment  is  being  carried  out,  the  chances 
of  improvement,  or  at  least  of  rapid  improvement,  are  not  nearly  so  good. 
Gibney  gives  the  following  statistics  of  one  hundred  and  thirty-three 
cases  under  his  personal  observation  :  thirty-one  proved  fatal;  nine  dyino- 
from  myelitis,  fourteen  from  other  diseases  subsequent  to  recovery  from 


816  DISEASES   OP  THE  NERVOUS  SYSTEM. 

the  paralysis,  and  sis  from  tuberculosis  before  complete  recovery;  sev-- 
entj-f our  recovered  from  the  paraplegia ;  twenty-seven  were  recorded  as 
improved  or  still  under  treatment.  Kelapses  occurred  in  about  fifteen 
per  cent  of  the  cases;  nearly  all  of  these,  however,  subsequently  recov- 
ered. The  usual  duration  of  the  disease  is  from  three  months  to  two 
3'ears.  Complete  recovery  has  often  taken  place  in  cases  that  have  per- 
sisted for  four  or  five  years.  Ko  case  should  be  considered  hopeless  no 
matter  how  long  the  symptoms  have  lasted,  unless  there  is  marked  atro- 
phy with  loss  of  electrical  reactions,  and  contractures  have  taken  place. 

Diag-nosis. — This  is  rarely  difficult.  Spinal  caries  should  be  suspected 
in  every  case  where  the  symptoms  point  to  transverse  myelitis  coming 
on  without  definite  cause.  The  gradual  onset,  the  radiating  pains,  the 
stiffness  of  the  spine  in  walking,  the  gradual  loss  of  power,  the  increased 
reflexes  and  ankle-clonus — all  are  usually  present  and  characteristic. 
They  are  sufficient  to  warrant  the  diagnosis  of  spinal  caries,  even  when 
no  deformity  exists.  When  there  is  deformity,  the  symptoms  are  un- 
mistakable. 

Treatment. — The  most  important  indications  are  the  removal  of 
pressure  and  the  fixation  of  the  spine  by  a  proper  mechanical  support. 
The  best  results  are  secured  by  the  recumbent  position,  the  child  being 
fixed  upon  a  frame,  continuous  traction  being  made  upon  the  head. 
Other  measures  to  be  advised  are  the  Paquelin  cautery,  and  the  internal 
Tise  of  potassium  iodide.  From  his  very  extensive  experience,  Gibney 
has  more  confidence  in  this  drug  than  in  all  else  except  mechanical  treat- 
ment. Large  doses  are  required,  often  from  sixty  to  ninety  grains  being 
given  daily  for  months.  From  personal  observation  of  many  of  Gibney's 
eases  I  can  bear  testimony  both  to  the  beneficial  effect  of  the  iodide,  and 
to  the  ease  with  which  it  is  generally  borne  by  children  in  the  doses 
mentioned.  Very  often  patients  gained  steadily  in  weight  while  taking 
the  drug,  and  acne  was  the  exception.  The  iodide  should  always  be 
largely  diluted.  In  all  cases  patients  should  be  carefully  watched,  kept 
scrupulously  clean,  and  the  position  changed  frequently  to  prevent  the 
formation  of  bed-sores.  Electricity  is  contra-indicated.  "When  the  pa- 
ralysis develops  rapidly  or  occurs  suddenly,  relief  may  sometimes  be  ob- 
tained by  the  operation  of  laminectomy ;  but  little  is  to  be  expected  from 
this  in  the  slow  cases. 

ACUTE   POLIOMYELITIS. 
Synonyms :  Infantile  spinal  paralysis,  acute  atrophic  paralysis. 

This  disease  is  characterized  by  an  acute  onset,  generally  with  febrile 
symptoms,  by  an  early  and  usually  extensive  loss  of  power,  and  by  a  con- 
siderable degree  of  spontaneous  improvement  except  in  certain  groups  of 
muscles  which  remain  permanently  paralyzed,  and  undergo  a  very  rapid 
and  marked  atrophy.  A  chronic  form  of  the  disease  is  described  in 
adults,  but  this  is  rarely,  if  ever,  seen  in  children. 


ACUTE   POLIOMYELITIS.  81Y 

Aciite  poliomyelitis  is  the  most  frequent  cause  of  paralysis  in  early  life 
and  it  is  often  designated  simply  as  infantile  'paralysis. 

Etiology. — In  566  *  cases  the  age  at  which  the  paralysis  developed  was 
as  follows : 

During  the  first  year 20  per  cent. 

"         "    second  year 38       " 

"         "    third  year 22       " 

"         '•    fourth,  and  fifth  years 15       " 

After       "    fifth  year 5       " 

From  this  table  it  will  be  seen  that  the  great  proportion  of  cases  develop 
before  the  fifth  year,  and  that  eighty  per  cent  of  them  begin  during  the 
first  three  years,  the  most  frequent  period  being  the  second  year. 

Boys  are  rather  more  frequently  affected  than  girls.  In  the  series  re- 
ferred to,  fifty-five  per  cent  were  males  and  forty-five  per  cent  were 
females.  Hereditary  influences  seem  to  have  but  little  effect  in  the  pro- 
duction of  this  disease.  It  is  rare  to  find  several  cases  in  the  same  family, 
or  to  trace  any  relation  to  nervous  antecedents.  The  onset  of  the  great 
proportion  of  the  cases  is  in  summer.  Of  Sinkler's  cases,  eighty  per  cent 
began  during  the  five  warm  months.  This  fact  is  decidedly  against  the 
theory  so  often  advanced,  that  the  disease  results  from  exposure  to  cold. 
There  are,  however,  a  few  cases  in  which  the  connection  between  exposure 
and  the  disease  seems  to  be  a  close  one.  On  account  of  the  time  of  on- 
set— most  frequently  in  the  second  year — the  disease  is  often  ascribed 
to  dentition.  In  my  series  this  was  given  as  the  cause  in  one  fifth  of 
the  cases.  The  connection  is  at  most  merely  a  coincidence.  Traumatism 
is  sometimes  given  as  a  cause,  but  the  proportion  of  cases  in  which  the 
paralysis  can  be  fairly  attributed  to  injury  is  very  small,  yet  there  are  a 
few  in  which  a  definite  injury  of  considerable  severity  has  immediately  pre- 
ceded the  onset.  In  about  twelve  per  cent  of  the  cases  above  mentioned 
the  paralysis  came  on  as  a  sequel  to  some  other  acute  disease ;  this  list  in- 
cludes nearly  all  the  diseases  of  infancy,  those  most  frequently  noted  being 
diarrhoea,  scarlet  fever,  and  measles  ;  but  in  the  great  proportion  of  the 
cases  the  patient  was  in  good  health  at  the  time  of  the  attack. 

The  essential  cause  of  the  disease  is  as  yet  unknown.  On  account  of 
the  close  relation  of  the  lesion  to  the  distribution  of  the  blood-vessels, 
many  recent  writers  believe  poliomyelitis  to  be  of  infectious  origin,  the 
cord  changes  being  the  result  of  infectious  embolism  or  thrombosis. 
The  occasional  occurrence  of  small  epidemics  strengthens  this  opinion. 

Lesions. — Infantile  spinal  paralysis  is  due  to  an  acute  inflammation 
of  the  gray  matter  of  the  anterior  portion  of  the  spinal  cord.    The  late 

*  These  statistics  and  those  which  follow  in  this  article  are  derived  from  the  follow- 
ing sources:  Sinklcr,  in  Kcating's  Cyelopivdia,  vol.  iv,  355  cases;  Galbraith,  American 
Journal  of  Obstetrics,  1894,  75  cases;  the  remaining  146  arc  personal  cases  and  others 
taken  from  the  records  of  the  Hospital  for  Kupturi'il  and  f'rijipled,  New  York. 


818  DISEASES  OP   THE  NERVOUS  SYSTEM. 

changes  which  occur  in  the  cord  as  a  result  of  this  process  have  for 
many  years  been  well  established ;  but  the  early  changes  are  even  yet  a 
matter  of  dispute,  owing  to  the  lack  of  opportunities  of  examining  the 
cord  during  the  stage  of  acute  inflammation. 

In  autopsies  made  upon  cases  of  long  standing,  the  part  of  the  cord 
affected  is  distinctly  smaller  than  normal.  One  lateral  half  is  usually 
involved.  The  microscope  shows  that  the  ganglion  cells  are  few  in 
number  or  that  they  have  entirely  disappeared.  Those  that  remain  are 
shrunken  and  deformed  and  scarcely  recognisable  as  ganglion  cells.  The 
entire  gray  horn  is  much  smaller  than  that  of  the  opposite  side,  and  many 
of  its  normal  elements  have  disappeared.  The  white  matter  also  is 
smaller  than  in  the  sound  half  of  the  cord.  The  anterior  nerve-roots 
of  the  affected  side  are  smaller  than  normal,  and  are  degenerated  quite 
to  the  muscles.  The  general  changes  in  the  cord  are  of  a  sclerotic  char- 
acter. The  affected  muscles  are  degenerated,  and  there  may  be  in  ex- 
treme cases  a  complete  disappearance  of  muscle  fibres,  their  place  being 
taken  by  adipose  and  fibrous  tissue.  In  places  where  the  lesion  is  less 
severe  the  fibres  are  small.  The  affected  limb  is  shorter  and  the  bones 
smaller  than  upon  the  sound  side.  These  lesions  are  all  secondary  to 
those  of  the  anterior  ganglion-cells. 

The  most  recent  observations  upon  the  early  stage  of  the  process  by 
Siemerling,  Goldscheider,  and  others,  tend  to  show  that  primarily  the 
lesion  is  an  interstitial  inflammation,  and  not  a  parenchymatous  one,  as 
was  formerly  believed.  Goldscheider's  *  theory  of  the  disease  is  that  the 
first  changes  are  in  the  blood-vessels,  from  which  the  process  extends  to 
the  neuroglia  and  produces  a  proliferation  of  cells ;  the  changes  in  the 
ganglion  cells  are  degenerative  in  character,  and  are  secondary  to  those 
just  described ;  the  same  is  true  of  the  changes  in  the  nerve  fibres. 
Accompanying  the  process  in  some  cases  small  heemorrhages  have  been 
observed. 

The  region  of  the  cord  most  frequently  involved  is  the  lumbar  en- 
largement, but  there  may  be  more  than  one  focus  of  disease.  Usually 
only  one  lateral  half  of  the  cord  is  affected,  but  it  is  not  rare  for  both 
sides  to  be  involved.  In  such  cases  the  lesions  are  generally  more  ad- 
vanced upon  one  side  than  the  other. 

Symptoms. — A  frequent  form  of  onset  is  for  a  child  to  be  taken  quite 
suddenly  ill  with  vomiting,  pains  in  the  legs,  or  general  hypersesthesia,  and 
a  temperature  of  from  101°  to  103°  F.  After  these  symptoms  have  lasted 
a  variable  time,  usually  from  one  to  four  days,  the  paralysis  is  discov- 
ered. In  a  smaller  number  of  cases — about  ten  per  cent  of  the  entire 
number — the   attack  is  ushered  in  by  more  severe  constitutional  symp- 

*  Goldscheider,  Zeitschrift  fur  klin.  Med.,  1893,  p.  494.  See  also  Sachs,  Nervous 
Diseases  of  Children,  1895,  p.  310. 


ACUTE   POLIOMYELITIS.  819 

toms.  There  are  convulsions,  delirium,  a  temperature  of  103°  or  104°  F., 
marked  general  prostration,  constipation,  severe  pains  in  the  back  and 
extremities, — in  short,  all  the  symptoms  of  a  severe  acute  inflammation. 
These  symptoms  last  from  two  days  to  a  week,  often  engrossing  the 
attention  of  the  physician,  so  that  the  paralysis  may  not  be  noticed  until 
the  patient  has  been  sick  for  some  time,  or  possibly  not  until  the  be- 
ginning of  convalescence.  In  quite  a  large  number  of  cases  the  general 
symptoms  are  very  slight,  and  they  may  be  absent  altogether.  A  not 
infrequent  history  is  that  the  child  went  to  bed  apparently  well ;  during 
the  night  Avas  noticed  only  to  be  a  little  restless,  and  that  the  next  morn- 
ing the  paralysis  was  discovered.  In  two  cases  of  my  series  the  paralysis 
came  on  quite  suddenly  while  the  child  was  walking  in  the  street,  and 
was  able  to  reach  home  only  with  considerable  difficulty.  In  such  cases 
it  is  not  improbable  that  previous  symptoms  were  present,  but  were  so 
slight  as  to  have  escaped  notice. 

In  most  of  the  cases  there  are  pains  in  the  back,  in  the  muscles  of  the 
extremities,  or  along  the  course  of  the  spinal  nerves.  With  these  pains 
general  hypersesthesia  is  commonly  associated,  and  there  may  be  other 
disturbances  of  sensation  such  as  numbness  and  tingling.  The  develop- 
ment of  the  paralysis  is  quite  rapid,  it  often  attaining  its  maximum  in 
twenty-four  hours ;  although  sometimes  it  will  be  two  or  three  days,  or 
even  a  week,  before  its  full  extent  is  seen. 

Extent  and  distribution  of  the  primary  paralysis. — In  560  cases  in 
which  this  point  was  noted  the  distribution  was  as  follows : 

One  lower  extremity 229  cases. 

Both  lower  extremities l'^6     " 

General  paralysis  of  all  extremities,  and  more  or  less  of  trunk      79     " 

One  lower  and  one  upper  extremity 36 

Both  lower  extremities  and  one  upper  extremity 16     " 

One  upper  extremity  alone 14 

Both  upper  extremities 2 

All  other  varieties 8 

In  paralysis  of  the  trunk,  the  diaphragm  and  other  respiratory  muscles 
are  very  rarely  affected.  In  combinations  of  an  upper  and  a  lower  ex- 
tremity, the  limbs  are  more  frequently  affected  upon  opposite  sides  than 
upon  the  same  side.     The  sphincters  almost  invariably  escape. 

Course  of  the  disease.— The  rapid  development  of  the  paralysis  is  fol- 
lowed by  a  period  of  from  one  to  four  weeks'  duration  in  which  but  little 
change  is  seen  in  the  affected  muscles.  This  is  followed  by  spontaneous 
improvement,  which,  according  to  Gowers,  begins  in  the  muscles  last 
affected,  and  generally  reaches  its  limit  in  about  three  months.  After 
this  time  but  little  spontaneous  improvement  is  to  be  looked  for,  and  the 
residual  paralysis  is  likely  to  be  permanent.  By  the  end  of  two  months 
marked  atrophy  is  present  in  the  paralyzed  muscles.  The  affected  limb 
is  distinctly  smaller   than  its  fellow,  this  being  quite  apparent  even  in 


820 


DISEASES   OP   THE  NERVOUS  SYSTEM. 


infants.  Except  at  the  onset,  sensory  disturbances  are  absent ;  the  knee> 
jerk  is  lost  in  paraplegic  cases,  and  in  those  in  which  the  extensors  of 
the  thigh  are  paralyzed.  There  is  arrested  growth  in  the  whole  limb 
(Fig.  151).  It  becomes  much  smaller  and  shorter  than  its  fellow.  The 
great  relaxation  of  the  ligaments  at  the  joints  may  allow  subluxation, 
especially  at  the  knee  and  at  the  shoulder.  The  circulation  in  the  af- 
fected limb  is  poor ;  it  is  often  blue  and  cold,  but  bed-sores  are  never 
seen. 

Electrical  reactions. — Very  early  in  the  disease  the  atrophied  muscles 

begin  to  lose  their  power 
to  respond  to  faradism. 
In  the  muscular  groups 
which  are  to  be  perma- 
nently paralyzed,  the  fara- 
dic  response  may  be  lost 
in  a  week.  The  muscles 
in  which  recovery  is  to 
take  place  often  preserve 
a  certain  degree  of  con- 
tractility, although  this  is 
less  than  normal,  and  im- 
proves later.  The  response 
to  the  galvanic  current 
may  be  increased  for  a  few 
months,  and  then  slowly 
fail  as  the  muscular  fibres 
themselves  degenerate,  and 
at  the  end  of  two  or  three 
years  it  may  disappear  al- 
together. The  reaction 
of  degeneration  is  present 
with  great  uniformity  in 
the  atrophied  muscles,  but 
in  them  alone. 
Residual  paralysis  and  deformity. — Only  one  lower  extremity  is  in- 
volved in  half  the  cases,  and  the  paralysis  is  usually  incomplete  and  con- 
fined to  certain  groups  of  muscles.  The  extensors  both  of  the  thigh  and 
of  the  leg  are  nearly  always  involved  to  a  greater  degree  than  the  flexors, 
and  in  very  many  cases  only  the  extensor  groups  are  paralyzed.  The 
muscles  most  frequently  affected  are  the  anterior  tibial  group,  and  next 
the  peroneal  group.  The  most  frequent  deformity  resulting  from  this 
paralysis  is  talipes  valgus,  and  next  to  this  talipes  varus,  both  of  these 
being  usually  associated  with  a  certain  amount  of  equinus.  In  very  rare 
cases  there  is  talipes  calcaneus.     Most  children  with  paralysis  of  only  one 


Tic.  i.,i.— All  iil'l  ■■;!--(■  i>i  iiilantile  spinal  paralysis  of  the 
entire  left  lower  extremity,  showing  extreme  atrophy 
of  the  thigh  and  leg,  and  a  very  characteristic  deform- 
ity of  the  foot. 


ACUTE   POLIOMYELITIS. 


821 


lower  extremity  are  able  to  walk  alone,  or  with  the  assistance  of  a  steel 
brace. 

Paralysis  of  both  lower  extremities  is  the  next  in  frequency.  This 
also  is  rarely  complete.  In  forty-three  cases  of  my  series  there  was 
originally  complete  paraplegia,  but  it  was  permanent  in  only  three.  The 
extent  of  recovery  varies  much  in  different  cases.     Usually  one  leg  re- 


FiG.  152. — An  old  case  of  infantile  spinal  paralysis  of  the  left  arm  and  shoulder  muscles,  with 
resulting  lateral  curvature.  The  spinal  deformity  is  increased  by  the  fact  tliat  the  patient 
had  also  suifered  from  empyema  of  the  left  side. 


covers  to  a  much  greater  degree  than  the  other.  Most  of  these  patients 
are  able  to  walk  with  the  assistance  of  braces,  a  few  only  by  the  aid  of 
crutches.  Some  walk  while  they  are  young,  but  are  unable  to  do  so 
when  fully  grown,  because  the  disproportion  between  the  size  of  the  body 
and  the  limbs  is  then  much  greater. 


822  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Paralysis  of  one  upper  extremity  rarely  occurs  alone,  but  is  associated 
with  paralysis  of  one  or  both  lower  extremities.  Complete  paralysis  of 
an  arm  is  rarely,  if  ever,  seen.  The  muscular  groups  affected  may  be  the 
small  muscles  of  the  hand,  the  muscles  of  the  forearm, — especially  the 
extensors, — or  the  shoulder  group.  Of  single  muscles,  the  one  most 
frequently  involved  is  the  deltoid ;  this  may  result  in  subluxation  of  the 
shoulder.  From  paralysis  of  the  muscles  of  the  trunk  or  shoulder  of  one 
side,  lateral  curvature  may  develop  (Fig.  152).  If  the  serratus  magnus  is 
affected  the  scapula  stands  out  prominently,  giving  rise  to  the  so-called 
"  angel-wing  "  deformity. 

Diagnosis. — The  general  symptoms  of  the  onset  have  nothing  charac- 
teristic about  them,  and  no  diagnosis  can  be  made  until  the  paralysis  has 
taken  place.  The  acute  onset,  the  rapid  wasting,  the  spontaneous  im- 
provement in  certain  groups  of  muscles,  the  absence  of  sensory  symptoms, 
and  finally  the  reaction  of  degeneration, — all  constitute  a  type  which  it  is 
difficult  to  confound  with  any  other  disease. 

At  the  onset  this  paralysis  may  resemble  that  resulting  from  acute 
transverse  myelitis.  In  the  latter,  however,  we  get  anesthesia,  exagger- 
ated knee-jerk,  ankle-clonus,  generally  involvement  of  the  sphincters, 
a  tendency  to  bed-sores,  slight  wasting,  and  no  reaction  of  degeneration. 
It  is,  besides,  extremely  rare. 

Multiple  neuritis  is  in  most  cases  easily  distinguished  from  poliomye- 
litis by  its  gradual  onset,  by  the  presence  of  pain  and  other  sensory  symp- 
toms as  well  as  loss  of  power,  and  by  the  fact  that  spontaneous  recovery 
generally  occurs  within  two  or  three  months.  Besides,  there  is  usually  a 
history  of  antecedent  diphtheria.  But  multiple  neuritis  sometimes  begins 
suddenly  with  febrile  symptoms,  and  paralysis  may  occur  early,  precisely 
as  it  does  in  poliomyelitis.  Furthermore,  in  some  cases  of  neuritis,  the 
sensory  symptoms  are  not  marked,  and  they  may  have  entirely  disappeared 
before  the  patient  is  seen.  In  such  cases  the  diagnosis  from  poliomyelitis 
may  be  difficult  or  even  impossible  except  by  the  course  of  the  disease ; 
for  atrophy  is  common  to  both  conditions,  and  even  the  electrical  reac- 
tions may  be  identical.  There  is  no  doubt  that  some  cases  formerly  re- 
ported as  examples  of  poliomyelitis  terminating  in  complete  recovery  were 
really  cases  of  multiple  neuritis. 

The  diagnosis  from  acute  cerebral  palsy  is  chiefly  difficult  when  the 
spinal  paralysis  has  been  hemiplegic  or  diplegic  in  type,  or  when  after 
cerebral  hemiplegia  the  leg  or  the  arm  has  recovered  so  completely 
that  the  case  resembles  monoplegia.  In  cerebral  palsies  there  is  usually 
rigidity ;  there  is  no  reaction  of  degeneration  ;  other  cerebral  symptoms 
are  commonly  present,  or  there  is  a  history  of  an  onset  with  cerebral 
symptoms;  and  the  atrophy  is  less  marked.  The  most  diagnostic  point 
is  the  electrical  reactions. 

Acute  poliomyelitis  may  be  mistaken  for  other  than  nervous  diseases. 


ACUTE   POLIOMYELITIS.  823 

In  the  early  stage  it  may  be  confounded  with  the  pseudo-paralysis  of 
scurvy.  I  have  several  times  seen  the  mistake  made  of  diagnosticating 
paralysis  where  scurvy  was  present.  In  scurvy,  however,  there  is  seen 
excessive  tenderness  and  hyperesthesia,  pain  upon  motion,  especially 
about  the  knees,  spongy  gums,  and  sometimes  ecchymoses  about  the 
joints.  The  muscular  weakness  of  rickets  is  sometimes  mistaken  for  in- 
fantile paralysis.  However,  in  rickets  the  symptoms  are  always  bilat- 
eral, the  electrical  reactions  are  normal,  and  other  signs  of  rickets  are 
present.  In  all  doubtful  cases  the  chief  reliance  for  the  diagnosis  of 
paralj^sis  should  be  placed  upon  the  character  of  the  electrical  reactions. 
The  lameness  resulting  from  paralysis  may  resemble  somewhat  that  due 
to  hip-disease ;  but  with  a  careful  examination  there  can  rarely  be  any 
difficulty  in  making  the  differential  diagnosis. 

Prognosis. — Poliomyelitis  is  accompanied  by  little,  if  any,  danger  to 
life.  It  is  possible  that  death  may  take  place  during  the  stage  of  acute 
inflammation,  but  this  is  certainly  extremely  rare.  The  most  important 
question  in  early  prognosis  is  whether  there  will  be  any  permanent  pa- 
ralysis, and,  if  so,  what  will  be  its  extent.  The  important  symptoms  for 
prognosis  are  the  amount  of  wasting  and  the  condition  of  the  electrical 
reactions.  Muscles  which  in  ten  days  have  lost  completely  their  faradic 
contractility  are  almost  certain  to  waste  rapidly  and  severely.  The  best 
indication  of  coming  improvement  is  the  return  of  faradic  contractility. 
If  this  is  completely  lost  for  six  months,  recovery  is  doubtful;  if  for 
one  year,  improvement  in  these  muscles  is  not  to  be  expected.  If  faradic 
contractility  has  never  been  lost,  very  great  and  early  improvement  in 
the  paralyzed  muscles  may  be  confidently  predicted.  After  three  months 
but  little  spontaneous  improvement  is  to  be  looked  for,  and  after  two 
years  none  at  all.  Complete  recovery  is  possible  only  with  a  lesion  of 
very  limited  extent;  and  while  it  may  occur,  it  is  so  infrequent  that  it 
should  not  be  expected. 

Treatment. — Unfortunately,  most  of  the  cases  do  not  come  under  ob- 
servation during  the  acute  stage,  or  the  nature  of  the  disease  is  overlooked 
until  the  paralysis  has  occurred.  In  the  early  stage  the  indications  are,  to 
induce  free  perspiration  by  hot  baths,  to  keep  the  patient  in  a  prone  or 
lateral  position,  and  to  use  counter-irritation  to  the  spine  by  means  of 
dry  cups,  mustard,  or  the  Paquelin  cautery,  or  an  ice-bag  may  be  placed 
along  the  spine.  The  natural  course  of  the  disease  is  to  be  kept  in  mind, 
for  the  tendency  is  to  overestimate  the  elfect  upon  the  paralysis  of  the 
drugs  used  in  the  early  stage.  On  theoretical  grounds,  ergot  is  indicated, 
but  it  is  doubtful  whether  any  drugs  have  much  elfect. 

After  all  acute  symptoms  have  subsided,  or  at  the  end  of  two  or  three 
weeks,  electricity  may  be  used,  but  its  curative  effects  have  been  very 
greatly  overestimated.  The  object  in  using  electricity  is  to  keep  up  the 
nutrition  of  the  muscles  until  the  cord  has  recovered,  which  it  is  almost 


824  DISEASES  OF  THE  NERVOUS  SYSTEM. 

certain  to  do  to  a  considerable  degree.  But  no  amount  of  electrization 
can  preserve  muscles  whose  ganglion  cells  have  completely  disappeared. 
These  continue  to  waste  and  lose  their  faradic  contractility,  no  matter 
how  early  electricity  is  begun  nor  how  faithfully  it  is  continued.  Faradism 
may  be  used  for  such  groups  as  respond  to  it ;  otherwise  galvanism  should 
be  employed.  The  beneficial  results  from  electricity  are  to  be  obtained 
in  the  first  year,  chiefly  in  the  first  six  months.  Too  much  can  not  be 
said  against  the  routine  use  of  electricity  in  cases  which  have  been  para- 
lyzed three  or  four  years,  with  the  vain  hope  that  some  good  may  be  done, 
even  though  there  is  no  response  to  either  current.  Strychnine  may  be 
used  in  conjunction  with  electricity  after  all  symptoms  of  central  irrita- 
tion have  subsided,  but  there  is  still  great  diversity  of  opinion  regarding 
its  effect. 

Friction  and  massage  are  of  undoubted  value  in  improving  the  circula- 
tion and  the  nutrition  of  a  limb,  and  should  be  continued  regularly  twice 
a  day  for  a  long  period. 

Mechanical  Treatment. — The  first  use  of  mechanical  appliances  is  the 
prevention  of  deformity.  All  cases  of  paralysis  should  be  carefully 
watched,  and  braces  applied  as  soon  as  any  tendency  to  deformity  from 
muscular  contraction  shows  itself.  This  is  much  easier  than  to  overcome 
deformities  which  have  been  allowed  to  develop,  and  quite  as  important 
for  the  patient.  The  second  use  of  apparatus  is  to  furnish  support  to  the 
limb  in  order  to  enable  the  child  to  walk.  By  such  means  many  get 
about  with  tolerable  comfort,  for  whom  locomotion  without  apparatus 
is  impossible  except  with  crutches.  The  third  purpose  of  apparatus  is,  to 
overcome  existing  deformities  in  neglected  cases.*  Braces  are  generally 
used  in  conjunction  with  myotomy  or  tenotomy  of  the  various  shortened 
tendons,  excision  of  portions  of  elongated  tendons,  and  the  production 
of  artificial  anchylosis  in  cases  of  "  flail  joints."  By  these  means  the 
orthopaedic  surgeon  is  able  to  give  a  great  deal  of  relief  to  these  unfortu- 
nate and  sometimes  helpless  patients. 

On  the  whole,  the  treatment  is  extremely  unsatisfactory,  and  the  result 
depends  upon  the  severity  and  extent  of  the  original  disease,  rather  than 
upon  the  particular  line  of  treatment  adopted  or  the  time  at  which  it  is 
begun. 

TUMOURS  OF   THE  SPINAL  CORD. 

Tumours  of  the  cord  are  exceedingly  rare  in  childhood,  and  almost 
unknown  in  infancy.  The  most  common  varieties  seen  in  early  life  are 
glioma,  sarcoma,  and  tuberculous  tumours.  Eisenschitz  has  reported  a 
case  of  tuberculous  tumour  in  the  dorsal  region  occurring  in  a  child  of 

*  See  G-ibney,  New  York  Medical  Journal,  April  3,  1886,  On  the  Limitation  of 
Therapeutics  in  Infantile  Paralysis. 


SYRINGO-MYELIA.  825 

three  and  a  half  years.    There  was  a  similar  growth  in  the  cerebellum. 
The  symptoms  were  essentially  those  of  compression-myelitis. 

In  my  service  at  the  Babies'  Hospital  I  have  had  a  case  of  glioma 
of  the  cord  in  a  child  onl}^  one  year  old,  which  was  in  many  respects 
unique.  The  early  symptoms  were  gradual  paralysis  of  the  upper  ex- 
tremities, to  which  were  added  later,  stiffness  of  the  neck,  and  finally  im- 
mobility of  the  head — the  position  being  that  of  typical  cervical  caries. 
During  the  sixteen  days  of  observation  there  was  high  fever,  from  101°  to 
104°  F.  There  were  no  pupillary  or  vaso-motor  symptoms.  At  the  au- 
topsy the  cord  was  found  to  be  the  seat  of  a  diffuse  gliosis.  In  the  cer- 
vical region  there  was  marked  enlargement,  the  cord  being  fully  four  times 
its  natural  size.  A  microscopical  examination  by  Dr.  C.  A.  Herter  showed 
that  the  growth  apparently  began  in  the  vicinity  of  the  central  canal, 
and  that  the  gliomatous  process  involved  the  entire  length  of  the  cord.* 

A  somewhat  similar  case  has  been  reported  by  Miura  in  a  boy  of 
eight  years. 

The  diagnosis  of  tumours  of  the  spinal  cord  in  infancy  is  practically 
impossible.  In  later  childhood  they  are  most  apt  to  be  mistaken  for 
Pott's  disease,  but  the  symptoms  are  the  same  as  those  seen  in  tumours  of 
adult  life. 

SYRINGO-MYELIA. 

Syringo-myelia,  although  a  rare  disease,  is  sometimes  seen  in  early  life. 
The  term  is  applied  to  a  condition  in  which  there  is  a  cavity  in  the  cord 
the  result  of  a  pathological  process,  in  contradistinction  to  the  cases  in 
which  a  cavity  is  the  result  of  a  malformation,  or  hyclromyelus,  although 
it  is  not  infrequent  for  the  two  conditions  to  be  associated.  The  patho- 
logical process  which  precedes  the  cavity  formation  is  now  thought 
to  be,  in  most  cases  at  least,  an  infiltration  of  the  substance  of  the 
cord  with  gliomatous  cells.  The  process  is  somewhat  similar  to  that  just 
described  in  the  case  of  tumour  of  the  spinal  cord,  with  the  exception 
that  where  it  results  in  cavity  formation  it  is  slower.  The  infiltration  in 
these  cases  usually  begins  near  the  central  canal.  It  is  followed  by  a  de- 
generation and  breaking  down  of  the  infiltrated  areas,  beginning  at  the 
centre.  As  the  cavity  forms  it  extends,  and  usually  first  invades  the  gray 
matter  of  the  commissure,  later  the  posterior  gray  horns,  the  posterior 
columns,  or  the  anterior  horns.  The  resulting  cavity  is  usually  irregu- 
lar in  shape,  and  may  be  very  small,  or  may  extend  through  a  large  part 
of  the  length  of  the  cord.  It  is  most  frequently  situated  in  the  lower 
cervical  and  upper  dorsal  regions.  It  is  filled  with  fluid,  and  surrounded 
by  gliomatous  tissue. 

*  For  a  full  report  of  this  case  by  Dr.  Herter  and  myself,  see  American  Journal  of 
the  Medical  Sciences,  April,  1895.  See  also  Kohts,  Beitrag  zur  Diagnostik  der  RQck- 
^nmarkstumoren  im  Kindesalter,  Dresden,  1886. 


826  DISEASES  OP  THE   NERVOUS  SYSTEM. 

According  to  Starr,  tlie  essential  symptoms  are  of  three  kinds :  (1) 
There  is  progressive  muscular  atrophy,  with  paralysis  of  some  or  all  the 
muscles  of  one  limb,  usually  extending  to  the  opposite  limb  and  to  the 
trunk,  sometimes  accompanied  by  the  reaction  of  degeneration  ;  (2)  vaso- 
motor and  trophic  disturbances  in  the  affected  limb,  such  as  cyanosis, 
coldness,  bullous  eruptions,  ulceration,  abscesses,  atrophy,  and  sometimes 
fragility  of  the  bones  and  diminution  of  perspiration  ;  (3)  sensory  dis- 
turbances, which  are  probably  the  most  characteristic  symptoms  of  the 
disease, — there  is  loss  of  the  sense  of  pain  and  of  temperature  in  the  atro- 
phied part,  while  the  sense  of  touch  and  of  location  may  be  preserved. 
The  extent  and  distribution  of  these  symptoms  will  of  course  depend 
upon  the  position  of  the  disease. 

The  course  of  syringo-myelia  is  essentially  chronic,  the  duration  being 
usually  several  years ;  and  although  spontaneous  arrest  sometimes  occurs 
the  disease  is  in  most  cases  steadily  progressive. 

The  cause  is  unknown,  and  it  is  not  influenced  by  any  form  of 
treatment. 

FRIEDREICH'S   ATAXIA. 

This  is  a  chronic  disease  of  the  spinal  cord  and  medulla,  which  begins 
most  frequently  in  childhood  or  about  puberty.  The  lesion  affects  first 
the  posterior  columns,  afterward  the  crossed  pyramidal  tracts,  the  direct 
cerebellar  tracts  in  the  lateral  columns,  and  Clarke's  vesicular  columns 
in  the  gray  matter  of  the  cord.  There  is  probably  some  disease  of  the 
medulla,  the  pons,  and  possibly  of  the  cerebellum  and  the  posterior 
nerve-roots.  In  advanced  cases  other  j)arts  of  the  cord  may  be  involved. 
The  disease  is  seen  in  certain  families,  often  affecting  several  mem- 
bers in  succession  at  about  the  same  age.  It  occurs  particularly  in 
families  where  alcoholism,  insanity,  and  other  nervous  diseases  are  fre- 
quent. 

Bramwell,  in  his  monograph  upon  this  disease,  gives  the  following  as 
the  characteristic  symptoms  :  There  is  ataxia,  first  of  the  lower  extremities, 
but  gradually  extending  to  the  upper  extremities  and  the  face.  Early  in  the 
disease  there  is  some  weakness  in  the  legs,  especially  in  the  anterior  group 
of  muscles.  In  the  late  stages  this  is  marked  and  accompanied  by  atrophy. 
The  gait  is  peculiar,  like  that  of  ordinary  ataxic  patients,  the  difficulty  in 
walking  being  due  to  the  ataxia  and  not  to  the  paresis.  After  a  time  there 
is  produced  a  characteristic  deformity  of  the  foot, — it  is  shortened,  as  if 
from  pressure  against  the  toes  and  the  heel,  the  instep  is  high,  and  the  ex- 
tensor tendon  of  the  great  toe  stands  out  prominently.  This  deformity  is 
seen  quite  early  in  the  disease.  There  is  often  lateral  curvature  of  the 
spine.  The  knee-jerk  is  absent.  Unprovoked  and  uncontrollable  laughter 
is  quite  a  characteristic  symptom  of  the  disease.  The  patient  is  unable  to 
stand  with  his  eyes  closed.     There  are  palpitation,  occipital  headache,  and 


THE   MUSCULAR  ATROPHIES.  827 

sometimes  vertigo.  In  the  later  stages  speech  is  slow  and  difficult,  and 
the  patient  talks  like  one  intoxicated.  The  expression  of  the  face  is 
vacant,  and  often  nystagmus  is  present.  There  may  be  choreic  move- 
ments. The  symptoms  steadily  progress  until  the  patient  may  be  help- 
less, although  the  general  health  may  remain  good  for  years. 

The  disease  is  distinguished  from  locomotor  ataxia  by  the  absence  of 
the  "  lightning  pains,"  and  of  the  bladder,  rectal,  or  genital  symptoms,  the 
pupillary  changes,  the  optic-nerve  atrophy,  and  the  trophic  changes  in  the 
bones  and  joints.  It  is  distinguished  from  cerebral  tumour  by  the  absence 
of  headache,  vomiting,  and  optic  neuritis,  and  by  its  longer  course.  The 
progress  of  the  disease  is  slow  but  steady.  It  may  last  from  twenty  to 
thirty  years.     It  is  incurable. 

LANDRY'S  PARALYSIS  (ACUTE  ASCENDING  PARALYSIS). 

This  rare  disease  is  occasionally  seen  in  early  life.  In  regard  to  its  eti- 
ology but  little  is  definitely  known,  the  usual  causes  assigned  being  the 
same  as  those  of  myelitis. 

It  is  characterized  by  a  paralysis — sometimes  preceded  by  general 
symptoms  of  malaise,  fever,  etc. — which  begins  in  the  legs  and  spreads 
rapidly  to  the  muscles  of  the  trunk  and  upper  extremities ;  finally  it  may 
involve  the  neck,  diaphragm,  and  muscles  of  articulation.  The  paralysis 
develops  quite  rajaidly,  often  attaining  its  height  in  from  twenty-four  to 
forty-eight  hours,  sometimes  even  proving  fatal  within  this  time.  In 
other  cases  it  comes  on  gradually,  and  may  be  two  or  three  weeks  in  reach- 
ing its  maximum.  There  is  dyspnoea  from  involvement  of  the  muscles  of 
respiration.  The  paralyzed  muscles  are  flaccid.  There  is  hypersesthesia, 
followed  by  partial  or  complete  ansesthesia  and  loss  of  reflexes.  There  are 
no  changes  in  the  electrical  reactions,  no  atrophy,  no  bed-sores,  and  usually 
no  involvement  of  the  sphincters.  Occasionally  the  arms  may  be  afi'ected 
before  the  legs,  and  even  the  bulbar  symptoms  may  be  the  first  noticed. 
Death  is  the  most  frequent  termination,  and  in  fatal  cases  the  disease  lasts 
from  two  days  to  a  week.  If  recovery  takes  place,  it  is  after  two  or  three 
months  of  illness. 

The  pathology  of  the  disease  is  as  yet  unknown.  The  indications  for 
treatment  are  the  same  as  in  acute  myelitis,  for  in  the  beginning  the  two 
diseases  can  not  usually  be  distinguished  from  each  other. 

THE  MUSCULAR  ATROPHIES. 

These  cases  may  be  broadly  divided  into  two  groups,  following  in  the 
main  the  classification  of  Sachs:*  (1)  Those  dependent  upon  disease  of 
the  spinal  cord, — the  spinal  atrophies;  (2)  those  which  are  primarily  dis- 
eases of  the  muscles  themselves, — the  idiopatliic  atrophies. 

*  New  York  Medical  Journal,  December  15,  1888. 


828  DISEASES  OF  THE  NERVOUS  SYSTEM. 

In  tlie  group  of  atrophies  of  spinal  origin  belong  (1)  the  "hand  type  " 
of  Aran  and  Duchenne,  which  has  been  shown  to  be  dependent  upon  a 
lesion  of  the  spinal  cord  ;  (2)  the  "  peroneal  type  "  of  Charcot,  Marie,  and 
Tooth,  which  as  yet  lacks  positive  pathological  proof  of  its  spinal  origin, 
although  its  etiology,  symptoms,  and  course  leave  but  little  doubt  that  it 
belongs  in  the  same  category  with  the  hand  type. 

In  the  second  (idiopathic)  group  are  included  (1)  muscular  pseudo-hy- 
pertrophy, and  (2)  the  so-called  "  juvenile  atrophy "  of  Erb,  which  is  a 
much  less  frequent  condition.  These  two  varieties  have  the  following  fea- 
tures in  common  :  There  is  progressive  wasting,  beginning  early  in  child- 
hood, and  associated  at  some  period  with  hypertrophy  of  certain  muscles. 
There  are  no  fibrillary  contractions,  no  reaction  of  degeneration,  and  no 
lesions  in  the  cord.  Erom  a  pathological  point  of  view  these  diseases 
might  be  more  properly  considered  elsewhere,  but  they  are  so  closely  asso- 
ciated clinically  with  the  spinal  atrophies  that  it  has  seemed  better  to  de- 
scribe them  in  this  connection. 

Progressive  Muscular  Atrophy  of  the  Hand  Type. — This  disease  is  char- 
acterized by  a  very  slow  but  progressive  wasting,  which  usually  begins  in  the 
muscles  of  the  ball  of  the  thumb  of  one  or  both  hands.  Then  the  palmar 
group  of  muscles  belonging  to  the  little  finger  are  affected,  and  later  the 
interossei.  When  the  wasting  has  reached  a  certain  degree,  there  is 
produced  a  peculiar  and  characteristic  deformity  of  the  hand  known  as 
main  en  gt^iffe,  or  "  claw-hand."  Following  these  muscles,  those  of  the 
forearm  may  be  affected.  At  this  point  the  disease  is  sometimes  arrested, 
or  the  atrophy  may  extend  to  the  muscles  of  the  arm  and  shoulder,  espe- 
cially the  deltoid,  and  finally  to  those  of  the  back.  Exceptionally,  the 
atrophy  begins  in  the  muscles  of  the  shoulder  group  or  even  in  those  of 
the  leg.  The  wasting  takes  place  very  slowly,  the  muscles  disajDpearing 
fibre  by  fibre,  but  the  degree  which  may  be  reached  is  often  extreme. 
The  only  other  characteristic  symptoms  are  fibrillary  contractions  in  the 
muscles  which  are  soon  to  atrophy.  The  patient  is  not  conscious  of  them, 
but  they  are  visible.  The  faradic  contractility  is  preserved  just  in  propor- 
tion to  the  amount  of  muscle  remaining.  If  the  atrophy  is  complete,  it  is 
entirely  lost. 

The  course  of  the  disease  is  a  very  chronic  one,  covering  many  years. 
It  is  incurable.  In  rare  cases  the  process  may  extend  to  the  muscles  of 
the  tongue,  affecting  deglutition  and  articulation,  and  death  may  occur 
from  interference  with  respiration ;  otherwise  the  disease  does  not  tend  to 
shorten  life. 

In  this  form  of  atrophy  heredity  is  an  important  etiological  factor. 
The  disease  may  occur  in  children,  but  very  often  does  not  begin  until 
after  puberty.  The  lesion  consists  in  an  atrophy  of  the  ganglion  cells  of 
the  anterior  horns  of  the  spinal  cord,  followed  by  secondary  degeneration 
of  the  anterior  nerve-roots. 


THE   MUSCULAR   ATROPHIES.  829 

Progressive  Muscular  Atrophy  of  the  Peroneal  Type. — This  is  much  less 
frequent  than  the  variety  just  described.  In  this  form,  the  first  to  waste 
are  the  anterior  muscles  of  the  leg,  especially  the  extensor  longus  hallucis 
and  extensor  communis  digitorum,  afterward  the  peroneal  group.  The 
small  muscles  of  the  foot  are  next  affected,  and  the  disease  may  then  go 
on  to  involve  the  muscles  of  the  calf.  At  this  point  it  may  be  arrested 
permanently,  or  for  several  years,  after  which  the  thigh  muscles  may  waste 
like  those  of  the  leg.  After  many  years  the  hands  are  in  some  cases  involved 
as  in  the  type  previously  described,  and  even  the  muscles  of  the  forearm. 
As  a  rule,  the  supinator  longus,  the  muscles  of  the  shoulder,  neck,  trunk, 
and  face,  escape  altogether.  The  atrophy  is  generally  symmetrical,  but 
not  invariably  so.  The  cutaneous  reflexes  are  usually  present.  There  is 
no  pain.  The  reaction  of  degeneration  is  present  in  some  of  the  muscles, 
and  fibrillary  contractions  are  frequent,  but  not  always  seen. 

In  this  variety  also  the  influence  of  heredity  may  often  be  traced.  It 
is  said  that  boys  usually  inherit  the  disease  through  the  mother.  Like 
the  previous  type,  it  begins  late  in  childhood  or  not  until  after  puberty. 

As  stated  above,  positive  proof  that  this  disease  is  due  to  a  central 
lesion  in  the  cord  is  as  yet  lacking.  Analogy,  however,  leads  to  the  belief 
that  it  dejDends  upon  changes  in  the  ganglion  cells  of  the  anterior  horns 
in  the  lumbar  region,  similar  to  those  found  in  the  cervical  region  in  the 
hand  type.  The  course  of  the  disease  is  very  chronic,  and  it,  too,  is  incur- 
able. The  resulting  deformity  resembles  that  seen  after  poliomyelitis,  and 
may  require  the  same  mechanical  treatment,  with  similar  operations  for 
relieving  contractions. 

Muscular  Pseudo-Hypertrophy  (Pseudo-Hypertrophic  Paralysis). — This 
is  the  most  frequent  and  best-known  variety  of  the  idioj^athic  atrophies. 
It  is  a  disease  of  certain  families,  often  three  or  four  children  being  af- 
fected, the  boys  much  more  frequently  than  the  girls.  The  symptoms  as 
a  rule  come  on  early  in  childhood,  nearly  always  before  the  tenth  year. 
The  earlier  symptoms  relate  to  a  general  weakness  of  the  lower  extremities, 
which  is  accompanied  by  a  marked  increase  in  the  size  of  certain  muscular 
groups,  usually  those  of  the  calves,  but  sometimes  more  of  the  thighs  or 
the  gluteal  regions.  Children  walk  late  and  unsteadily,  and  fall  very  easily. 
They  have  special  difficulty  in  rising  from  the  floor  and  in  mounting 
stairs.  The  method  of  rising  is  quite  characteristic :  the  patient  lifts  his 
body  until  he  touches  the  floor  only  with  the  hands  and  feet ;  then  he 
proceeds  to  "climb  up  himself"  by  putting  first  one  hand  upon  the 
knee,  and  then  the  other,  gradually  moving  his  hands  higher  and  higher 
up  the  thighs  until  the  erect  position  is  attained.  This  is  seen  in  most 
of  the  cases,  but  not  in  all. 

The  size  attained  by  the  calves  is  sometimes  very  great.  Gowers  men- 
tions a  case  in  which  a  boy  of  twelve  had  calves  measuring  fourteen  and  a 
half  inches  in  circumference.  The  enlargement  may  affect  almost  any 
54 


830 


DISEASES  OP   THE  NERVOUS  SYSTEM. 


muscular  group  of  the  lower  extremity.  In  the  upper  extremity,  the  in- 
fra-spinatus  is  most  frequently  enlarged,  next  the  supra-spinatus  and  the 
deltoid.  The  pectorals  and  latissimus  dorsi  are  never  enlarged,  but  are 
generally  markedly  wasted.  Most  of  these  patients  exhibit  while  standing 
a  marked  degree  of  lumbar  lordosis,  due  to  the  weakness  of  the  extensors 
of  the  hip.     This  is  well  shown  in  Fig.  153.     The  patient  may  be  so  weak 

upon  his  legs  that  the  slightest  touch 
will  cause  him  to  fall,  even  with  his 
apparently  immense  muscular  devel- 
opment. The  small  muscles  are  gen- 
erally weaker  than  those  which  are 
enlarged. 

Later  in  the  disease  marked  atro- 
phy occurs  with  a  corresponding 
weakness  of  all  the  affected  groups, 
and  the  patient  may  be  unable  to 
walk  or  even  stand.  With  the  ex- 
ception of  the  use  of  his  hands,  he 
may  be  absolutely  helpless.  The 
knee-jerk  is  at  first  normal,  but  grad- 
ually diminishes  until  it  is  finally 
lost.  The  electrical  reactions  are 
normal  until  marked  wasting  occurs, 
when  there  is  a  lessened  response  to 
faradism  and  galvanism,  but  never 
the  reaction  of  degeneration.  There 
are  no  fibrillary  contractions,  and  no 
sensory  disturbances.  The  progress 
of  the  disease  is  generally  slow,  and 
sometimes  irregular.  It  is  often  more 
rapid  in  early  childhood,  and  slower 
after  puberty. 

The  lesions  are  confined  to  the 
muscles.  At  autopsy  they  appear 
yellow,  and  microscopically  there  is 
found  very  marked  atrophy  of  the 
muscle  fibres,  which  in  places  have 
been  almost  entirely  replaced  by  fat ; 
there  may  be  no  trace  of  muscle  left, 
the  structure  resembling  adipose  tissue.  In  other  places  there  is  an  accu- 
mulation of  fat  between  the  atrophied  muscle  fibres,  and  a  very  great 
increase  of  the  interstitial  tissue. 

The   prognosis   is    grave,   most   patients   dying   before    adult   life   is 
reached.      The  diagnosis  is  generally  easy  from  the  apparent  hypertro- 


l.j:J. — Muscular  pseudo-iiyiKirtrophy, 
showing  to  a  moderate  degree  the  large 
calves  and  gluteal  regions  with  a  mai-ked 
lordosis.  (From  a  photograph  by  Dr.  M. 
A.  Starr.) 


MULTIPLE  NEURITIS.  831 

phy  and  actual  weakness  of  the  muscular  groups.  The  disease  is  incur- 
able. 

The  Juvenile  Form  of  Muscular  Atrophy. — This  is  much  less  frequent 
than  the  form  just  described,  but,  like  it,  begins  in  childhood  or  early 
youth.  It  is  characterized  by  progressive  wasting  of  certain  muscular 
groups,  especially  those  about  the  shoulders  and  pelvis,  and  hypertrophy  of 
others.  Of  the  shoulder  and  upper  extremity,  the  muscles  affected  are  the 
pectorals,  the  trapezius,  the  latissimus  dorsi,  the  serrati,  the  rhomboidei, 
the  muscles  of  the  upper  arm,  and  the  subscapularis.  The  deltoid,  infra- 
spinatus and  supra-spinatus  for  a  long  time  escape,  and  may  be  hyper- 
trophied.  The  hand  and  forearm  are  not  involved.  In  the  lower  extrem- 
ity, the  muscles  of  the  pelvis,  thighs,  and  gluteal  regions  are  affected, 
while  those  of  the  leg  and  foot  escape.  With  this  atrophy  there  may  be 
associated  a  true  or  pseudo-hypertrophy  of  certain  muscular  groups.  In 
this  disease  there  are  no  fibrillary  contractions,  no  reaction  of  degenera- 
tion, and  no  sensory  disturbances.  The  course  and  result  of  this  form 
are  essentially  the  same  as  in  the  preceding  variety.  It  is  now  generally 
regarded  as  closely  allied  to  it  in  its  pathology,  the  most  important  dif- 
ference being  that  of  localization. 

There  has  been  described,  chiefly  by  Landouzy  and  Dejerine,  another 
form  of  atrophy  known  as  the  infantile  facial  tyjje.  In  this,  wasting  be- 
gins in  the  muscles  of  the  face ;  the  lips  are  thickened,  but  all  the  rest  of 
the  facial  muscles  are  markedly  atrophied,  giving  a  peculiar  expression  to 
the  mouth  known  as  "  the  tapir  mouth."  Later,  the  atrophy  extends  to 
the  shoulders  and  arm,  but  does  not  involve  the  supra-spinatus  or  infra- 
spinatus, or  the  flexors  of  the  hand  and  forearm.  This  is  sometimes  de- 
scribed as  beginning  in  the  shoulders,  or  even  in  the  legs.  The  descrip- 
tion therefore  corresponds  to  the  juvenile  form  of  Erb,  with  the  addition 
of  facial  symptoms,  and  it  is  probably  a  variety  of  the  same  disease. 


CHAPTER   V. 
DISEASES  OF  THE  PERIPHERAL  NERVES. 

MULTIPLE  NEURITIS. 

UxDER  the  term  multiple  neuritis  are  included  those  cases  in  which 
several  nerves  are  involved  in  an  inflammatory  process,  which  may  at  times 
be  general.  In  its  distribution  multiple  neuritis  is  usually  symmetrical, 
but  it  is  not  necessarily  so. 

Etiology. — The  chief  cause  of  multiple  neuritis  in  children  is  diph- 
theria, although  it  is  occasionally  seen  after  other  infectious  diseases, 
especially  malaria,  typhoid  or  scarlet  fever,  and   measles.     In  diphtheria 


832  DISEASES  OF   THE   NERVOUS  SYSTEM. 

the  inflammation  is  due  to  the  direct  action  of  the  toxines  upon  the  nerve 
structures,  since  it  can  be  induced  in  animals  by  injecting  toxines  into 
the  circulation.  There  is  little  doubt  that  in  all  infectious  diseases  the 
inflammation  is  excited  in  a  similar  way.  The  metallic  poisons,  lead  and 
arsenic,  are  rarely  the  cause  of  multiple  neuritis  in  early  life,  and  the 
same  is  true  of  alcohol,  although  a  marked  case  from  this  cause  has 
recently  come  under  my  observation  in  a  child  only  three  years  old.* 
Lastly,  there  are  cases  in  which  the  cause  assigned  is  simply  exposure  to 
cold,^those  classed  as  rheumatic. 

Lesions. — Almost  any  nerves  in  the  body  may  be  affected,  although 
the  distribution  varies  somewhat  with  the  cause  of  the  disease.  The 
musculo-spiral  and  the  anterior  tibial  nerves  are  most  frequently  involved, 
but  the  inflammation  may  affect  any  of  the  spinal  nerves,  including  the 
phrenic,  and  occasionally  the  cranial  nerves,  especially  the  pneumogas- 
tric,  hypoglossal,  oculomotor,  and  abducens.  Several  nerves  in  different 
parts  of  the  body  are  usually  affected,  the  lesion  being  in  most  cases  sym- 
metrical. 

The  affected  nerve  is  sometimes  red  and  swollen,  owing  to  acute  conges- 
tion and  oedema  or  a  sero-fibrinous  exudation.  In  other  cases  the  changes 
are  almost  entirely  degenerative.  The  microscope  shows  the  changes 
sometimes  to  be  chiefly  interstitial  and  sometimes  chiefly  parenchymatous. 
There  is  an  exudation  of  cells  into  the  sheath,  between  the  sheath  and 
the  nerve  fibres,  and  even  between  the  nerve  fibres  themselves.  The 
myeline  breaks  up  into  granules,  and  in  places  may  completely  disappear. 

*  This  case  was  in  many  respects  a  remarkable  one.  The  boy  completely  emptied  a 
decanter  containing  twelve  ounces  of  whisky,  but  almost  immediately  vomited  the 
greater  part  of  it.  He  soon  after  showed  the  symptoms  of  alcoholic  intoxication,  and 
in  a  few  hours  became  comatose,  in  which  condition  he  continued  for  twelve  hours. 
After  this  he  gradually  lost  power  in  his  legs,  and  at  the  end  of  a  week  was  unable  to 
walk  at  all.  He  had  convulsions,  and  after  this  there  developed  the  usual  symptoms 
of  meningitis  at  the  convexity,  with  which  he  was  admitted  to  the  Babies'  Hospital, 
December  13,  1895,  three  weeks  after  drinking  the  whisky.  The  child  was  then  un- 
conscious and  there  was  present  incomplete  paralysis,  affecting  all  four  extremities, 
with  anaesthesia  of  the  arms.  The  active  inflammatory  symptoms  continued  for  six 
weeks  longer,  during  which  time  there  were  repeated  convulsions,  continuous  stupor, 
fever,  gradually  increasing  deformities,  marked  atrophy,  loss  of  reflexes,  and  great  dimi- 
nution in  the  faradic  contractility  of  all  the  paralyzed  muscles ;  in  the  thighs,  left  leg, 
and  abdominal  muscles  there  were  no  responses  to  a  strong  current,  but  there  was  no- 
where the  reaction  of  degeneration.  The  child  was  at  death's  door  for  three  or  four 
weeks.  Three  months  after  the  attack  the  first  signs  of  improvement  were  observed  in 
the  cerebral  symptoms.  Shortly  afterward  he  began  to  use  his  hands,  and  at  the  end 
of  six  weeks  he  was  walking  alone  and  talking  freely.  The  improvement  was  very 
rapid,  and  eight  weeks  from  the  date  of  the  first  change  for  the  better,  and  five  months 
from  the  time  of  taking  the  whisky,  he  was  as  well  as  ever.  The  diagnosis  was  mul- 
tiple alcoholic  neuritis,  with  a  convexity  meningitis.  (Fig.  154  is  from  a  photograph 
taken  while  the  symptoms  were  at  their  height.) 


MULTIPLE   NEURITIS. 


833 


The  late  changes  are  those  of  subacute  or  chronic  degeneration  of  the 
nerve  fibres.* 

With  these  changes  in  the  nerves  there  are  associated,  in  some  cases, 
inflammatory  and  degenerative  changes  in  the  ganglion  cells  of  the  spinal 
cord,  although  they  are  much  less  severe  than  are  the  lesions  in  the  nerves. 
However,  they  were  once  regarded  as  the  explanation  of  some  of  these 
cases,  particularly  of  diphtheritic  jaaralysis. 

Syinptoiiis. — The  onset  of  multiple  neuritis  is  in  most  cases  a  grad- 
ual one,  it  being  usually  from  two  to  four  weeks  before  the  paralysis 
reaches  its  height.  Very  exceptionally  the  onset  may  be  abrupt,  with 
fever,  and  marked  paralysis  in  a  few  days.  It  is  characteristic  of  this 
disease  that  both  motor  and  sensory  symptoms  are  present,  and  that  they 


-Alcoholic  neuritis,  showingr  characteristic  dropping  of  the  feet.     This  position  of  the 
lower  extremities  was  maintained  for  over  a  month.     Boy  three  years  old. 


are  the  same  in  their  distribution.  The  symptoms  are  usually  symmet- 
rical. There  is  first  noticed  a  general  weakness  in  the  affected  muscles, 
which  slowly  increases  to  complete  paralysis.  As  the  extensor  groups 
of  the  hands  and  feet  are  apt  to  be  affected,  there  are  Avrist-drop  and 
foot-drop  (Fig.  154:).  The  paralysis  may  begin  in  the  feet  and  hands, 
and  gradually  extend  until  it  involves  not  only  the  four  extremities,  but 
even  the  muscles  of  the  trunk  and  the  neck,  although  this  is  rare.  The 
child  may  then  be  absolutely  helpless,  unable  to  sit  up,  or  even  to  support 
its  head.  In  such  cases  the  head  seems  loosely  attached  to  the  body,  and 
rolls  about  on  the  shoulders  like  a  ball.  Weakness  of  the  spinal  muscles 
leads  to  deformities  (Fig.  lo,")),  which  I  have  seen  mistaken  for  Pott's  dis- 


*  For  a  full  description  of  the  lesions,  consult  Starr's  Middleton-Goldsmith  Lectures, 
New  York  Medical  Record,  1887. 


834: 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


ease,  even  by  experienced  observers.  In  most  of  the  muscular  groups 
the  paralysis  is  incomplete.  The  symptoms  which  relate  to  the  phrenic 
and  the  cranial  nerves  will  be  described  with  Diphtheritic  Paralysis,  for 
they  are  rarely  seen  in  any  other  form.  It  is  characteristic  of  multiple 
neuritis  that  the  bladder  and  rectum  escape. 

The  sensory  symptoms  are  marked  only  in  the  early  stage  of  the  dis- 
ease, while  the  paralysis  is  increasing ;  they  improve  so  much  more  rap- 
idly than  the  motor  symptoms,  that  they 
may  be  altogether  wanting  at  the  time 
that  the  paralysis  is  at  its  height.  In 
some  cases  they  are  so  slight  as  to  be 
overlooked.  There  is  usually  pain  along 
the  course  of  the  affected  nerves,  which 
is  sharp  and  neuralgic  in  character,  and 
generally  associated  with  acute  tender- 
ness of  the  nerve  trunks  and  of  the  mus- 
cles. Often  there  is  a  general  hyperses- 
thesia  in  the  early  part  of  the  attack, 
followed  by  partial  anajsthesia.  The 
sensations  of  touch,  pain,  temperature, 
and  the  muscular  sense  are  all  about 
equally  affected. 

Ataxia  is  not  uncommon,  and  may 
be  a  more  striking  symptom  than  the 
loss  of  power.  All  the  reflexes  are  di- 
minished or  lost,  especially  the  knee-jerk, 
as  the  legs  are  usually  most  affected. 
Sometimes,  particularly  after  diphtheria, 
there  is  loss  of  the  knee-jerk,  when  there 
is  no  other  symptom  of  neuritis.  In  the 
severe  cases  muscular  tremor  is  frequent. 
Atrophy  is  a  prominent  symptom  of 
neuritis,  and  it  is  evident  early  in  the 
disease,  often  being  quite  as  rapid  as  in 
poliomyelitis.  The  electrical  reactions 
are  altered, — every  grade  of  reduction  in 
the  responses  being  seen,  from  a  slight 
diminution  in  the  reaction  to  farad  ism 
to  the  complete  reaction  of  degeneration.  Vaso-motor  symptoms,  such  as 
oedema  of  the  affected  parts,  glossiness  of  the  skin,  etc.,  are  often  present. 
Deformities  from  muscular  contraction  occur  early  ;  they  may  be  severe, 
and  in  some  cases,  permanent. 

Course  and  Prognosis. — The  usual  course  of  the  disease  is  for  the  symp- 
toms gradually  to  increase  for  three  or  four  weeks  and  then  improve, 


Fig.  155. — Multiple  neuritis  after  diph- 
theria in  a  child  four  years  old.  The 
position  of  the  head  and  spine  are 
due  to  partial  paralysis  of  the  trunk 
and  neck.  The  legs  were  also  af- 
fected. 


MULTIPLE   NEURITIS.  835 

sometimes  rapidly,  but  more  ofteu  slowly,  the  case  usually  going  on 
to  complete  recovery  in  the  course  of  a  few  months.  Exceptionally 
the  paralysis  may  be  permanent.  The  sensory  symptoms  always  disap- 
pear before  the  motor  ones.  Multiple  neuritis  may  prove  fatal,  from  pa- 
ralysis of  the  heart  or  the  muscles  of  respiration,  or  death  may  be  due  to 
asphyxia  from  the  entrance  of  food  or  foreign  bodies  into  the  air  passages, 
owing  to  anesthesia  of  the  epiglottis  and  paralysis  of  the  muscles  of 
deglutition.  Death  sometimes  follows  from  complications,  especially 
pneumonia.  The  electrical  reactions  are  of  much  prognostic  value  in 
regard  to  the  persistence  of  the  paralysis.  If  the  reaction  of  degeneration 
is  present  the  paralysis  is  certain  to  last  many  months,  and  some  muscles 
are  sure  to  be  permanently  affected.  Where  there  is  simply  a  diminution 
in  the  faradic  responses,  even  though  accompanied  by  marked  atrophy, 
complete  recovery  may  be  expected,  although  it  is  often  slow. 

Diagnosis. — The  diagnostic  features  of  multiple  neuritis  are  the  com- 
bination of  motor  and  sensory  symptoms  with  the  same  distribution,  the 
occurrence  of  atrophy,  and  the  diminution  in  the  electrical  responses,  even 
the  reaction  of  degeneration.  The  gradual  onset  and  the  wide-spread 
distribution  of  the  paralysis  are  also  characteristic.  If  all  four  extremities 
are  paralyzed,  it  is  altogether  the  probable  disease ;  and  if  to  this  is  added 
paralysis  of  the  neck  and  spinal  muscles,  the  diagnosis  is  almost  certain. 
The  facts  that  the  paralysis  is  often  incomplete,  and  that  it  involves  parts 
distant  from  each  other,  are  also  important.  It  may  be  mistaken  for 
poliomyelitis  (page  822),  for  Landry's  paralysis,  or  for  Pott's  paraplegia ; 
an  important  diagnostic  point  from  the  last  mentioned  is  the  condition 
of  the  reflexes, — being  greatly  exaggerated  in  Pott's  paraplegia,  while  they 
are  diminished  or  lost  in  multiple  neuritis. 

Treatment. — As  this  disease  tends  in  the  great  majority  of  cases  to 
spontaneous  recovery,  it  is  difficult  to  estimate  the  value  of  any  method 
of  treatment.  Causes,  such  as  lead,  arsenic,  alcohol,  and  malaria,  are  to 
be  sought  and  removed  as  the  first  step.  During  the  acute  stage  the  pain 
may  be  so  severe  as  to  require  relief,  which  is  best  accomplished  by  the 
application  of  heat.  In  using  counter-irritation  care  is  necessary,  and 
such  active  measures  as  cauterization  should  not  be  employed,  for  trouble- 
some ulceration  may  follow.  After  the  acute  stage  has  passed,  or  at  the  end 
of  three  or  four  weeks,  electricity  should  bo  begun,  faradism  being  used  if 
the  muscles  respond  to  a  moderate  current,  otherwise  galvanism.  This 
should  be  continued  daily  until  recovery.  Strychnine  is  much  used  in 
these  cases,  but  it  is  doubtful  whether  it  has  any  specific  influence,  al- 
though as  a  tonic  it  is  valuable.  Other  tonics,  such  as  iron,  quinine, 
and  most  of  all  cod-liver  oil,  should  be  given  in  every  case.  Massage  is 
also  beneficial.  The  special  treatment  of  cardiac  and  respiratory  paralysis 
will  be  discussed  in  the  following  article. 


836  DISEASES  OF  THE  NERVOUS  SYSTEM. 


DIPHTHERITIC   PARALYSIS. 

This  is  not  only  the  most  frequent  variety  of  multiple  neuritis,  but  it 
has  some  peculiarities  which  make  a  separate  consideration  of  it  desirable. 

Frequency. — According  to  the  statistics  of  various  observers,  paralysis 
including  all  varieties,  occurs  after  diphtheria  in  from  5  to  15  per  cent 
of  the  cases.  Sanne  gives  11  per  cent  in  2,448  cases;  Lennox  Browne,  14 
per  cent  in  1,000  cases ;  the  Report  of  the  Collective  Investigation  by  the 
American  Psediatric  Society,  9-7  per  cent  of  3,384  cases  which  were  treated 
by  antitoxine. 

It  is  as  yet  too  soon  to  state  to  what  degree  the  frequency  of  para- 
lytic sequelae  after  diphtheria  is  to  be  affected  by  the  antitoxine  treat- 
ment; but  the  figures  above  given  would  indicate  that  the  protective 
power  of  the  serum  over  the  nervous  tissues  is  not  so  great  as  is  seen 
elsewhere,  and  that  unless  administered  very  early  it  may  have  little  or  no 
influence. 

Being  one  of  the  direct  effects  of  the  diphtheria  toxine,  neuritis  is 
much  more  likely  to  follow  severe  than  mild  cases ;  however,  its  occur- 
rence after  some  very  mild  attacks  shows  how  great  is  the  susceptibility 
of  the  nervous  tissues  to  the  action  of  this  poison.  Sometimes  the  throat 
symptoms  have  been  entirely  overlooked,  and  the  development  of  paraly- 
sis has  been  the  first  thing  to  arouse  a  suspicion  of  previous  diphtheria. 

Time  of  Occurrence. — During  the  second  week,  and  sometimes  even 
during  the  latter  part  of  the  first  week,  the  early  paralysis  occurs,  affecting 
the  palate,  and  in  some  cases  the  heart.  The  most  frequent  and  most 
characteristic  paralysis — that  affecting  the  throat,  eyes,  extremities,  heart, 
or  respiration — begins  at  a  later  period,  usually  from  one  to  three  weeks 
after  the  throat  has  cleared  off,  and  sometimes  even  later  than  this. 

Extent  and  Distribution  of  the  Paralysis. — Ross  *  gives  the  following 
statistics  of  171  collected  cases  of  diphtheritic  paralysis :  Palate  affected 
in  128 ;  eyes  in  77,  in  54  of  which  the  muscles  of  accommodation  were 
involved ;  lower  extremities  in  113 ;  upper  extremities  in  60 ;  trunk  or 
neck  in  58 ;  muscles  of  respiration  in  33.  I  do  not  think  this  repre- 
sents the  actual  frequency  of  the  different  varieties  so  truly  as  do  the 
American  Paediatric  Society's  figures,  which  give  the  forms  of  paralysis 
noted  in  a  series  of  cases  collected  for  another  purpose.  In  328  cases  of 
paralysis,  the  variety  was  mentioned  in  189  :  in  124  the  throat  was  af- 
fected; in  22  the  extremities;  in  11  the  eyes;  in  5  the  muscles  of  respi- 
ration ;  in  32  the  heart ;  in  1  the  neck  only ;  in  8  the  paralysis  was 
"general." 

Symptoms. — In  the  great  majority  of  cases  the  throat  is  affected,  and 
usually  the  paralysis  is  first  noticed  there.      It  may  involve  the   palate 

*  The  Medical  Chronicle,  December,  1890. 


DIPHTHERITIC   PARALYSIS.  837 

alone,  or  the  muscles  of  the  pharynx  or  larynx  in  addition.  The  muscles 
of  the  extremities  or  of  the  eye  are  often  next  attacked.  In  severe  cases 
there  may  also  be  involved  the  muscles  of  the  trunk  and  neck,  and  some- 
times the  diaphragm.  Cardiac  paralysis  not  infrequently  occurs  where 
no  other  parts  have  been  previously  affected,  but  in  nearly  all  the  other 
forms,  the  throat  symptoms  have  preceded.  It  is  this  which  distinguishes 
diphtheritic  paralysis  from  other  forms  of  multiple  neuritis.  Whatever  the 
extent  or  situation  of  the  paralysis,  the  knee-jerk  is  nearly  always  lost.  The 
symptoms  in  the  extremities  and  the  trunk  do  not  differ  from  those  of 
multiple  neuritis  from  other  causes.  The  throat  paralysis  shows  itself  by 
a  nasal  voice  and  by  regurgitation  of  fluids  through  the  nose,  sometimes 
by  difficulty  in  swallowing  or  the  entrance  of  food  into  the  larynx,  owing 
to  anaesthesia  of  the  epiglottis  and  paralysis  of  the  muscles  of  deglutition. 
There  may  be  difficulty  in  protruding  the  tongue  or  in  articulation. 
Paralysis  of  the  vocal  cords  may  cause  hoarseness,  aphonia,  or  attacks  of 
spasmodic  dyspnoea.  Facial  paralysis  is  very  rare.  On  the  part  of  the 
eye  there  is  most  frequently  seen  inability  to  read,  owing  to  paralysis  of 
the  muscles  of  accommodation ;  there  may  be  dilatation  of  the  pupils, 
rarely  strabismus  or  ptosis. 

Next  to  that  of  the  throat,  paralysis  of  the  muscles  of  respiration  and  the 
heart  are  the  most  characteristic  forms  of  diphtheritic  neuritis.  Eespir- 
atory  paralysis  may  be  due  to  involvement  of  the  phrenic  or  the  intercostal 
nerves,  more  frequently  the  former.  Extensive  paralysis  of  other  parts — 
the  throat,  extremities,  or  trunk — usually  precedes.  The  first  warning  is 
generally  in  the  form  of  occasional  attacks  of  dyspnoea,  sometimes  ac- 
companied by  cough.  Gradually  these  attacks  increase  in  frequency  and 
severity.  The  voice  is  reduced  to  a  whisper.  As  the  diaphragm  is  usu- 
ally affected,  the  breathing  is  entirely  thoracic.  The  respiratory  move- 
ments are  rapid,  but  irregular,  shallow,  and  ineffectual.  There  is  cyanosis, 
also  great  subjective  as  well  as  objective  dyspnoea.  The  anxiety,  distress, 
and  apprehension  of  the  patient  are  sometimes  terrible.  There  is  a  con- 
stant dread  of  impending  suffocation,  and  the  respiratory  movements  are 
continued  only  by  the  patient's  constant  efforts,  otherwise  they  may  cease 
altogether.  After  a  few  hours  these  severe  symptoms  may  subside,  to  re- 
turn after  a  short  respite.  There  may  be  several  such  attacks  during  two 
or  three  days,  in  each  of  which  death  seems  imminent.  Unfortunately,  this 
is  the  most  frequent  termination.  Of  thirty-three  such  cases  collected  by 
Ross,  only  eight  recovered.  Associated  with  these  respiratory  symptoms 
others  may  be  present,  indicating  that  the  pneumogastric  is  involved. 
There  may  be  attacks  of  abdominal  pain,  vomiting,  and  disturbance  of 
the  heart's  action, — usually  an  irregular  or  intermittent  pulse,  which  may 
be  either  unnaturally  slow  or  very  rapid.  In  many  cases  the  heart  con- 
tinues to  beat  normally,  even  tliough  the  respiration  is  so  much  disturbed. 

The  premonitory  symptoms  of  cardiac  paralysis  are  an  irregular  or 


838  DISEASES  OP  THE  NERVOUS  SYSTEM. 

intermittent  pulse,  often  slow,  but  becoming  very  rapid  from  even  the 
slightest  exertion.  It  is  always  weak  and  compressible.  The  first  sound 
of  the  heart  is  feeble  and  may  be  reduplicated.  As  the  symptoms  increase 
there  are  marked  pallor,  coldness  of  the  extremities,  great  restlessness, 
anxiety,  precordial  distress,  and  perhaps  orthopnoea.  Within  twenty-four 
hours  from  the  beginning  of  such  symptoms  death  usually  occurs.  In  other 
cases  it  may  come  suddenly  without  any  warning,  or  with  a  warning  so 
slight  as  to  be  overlooked.  At  such  times  it  often  follows  some  muscular 
exertion,  such  as  getting  out  of  bed,  walking  across  the  room,  or  so  slight 
an  effort  as  sitting  up  suddenly  in  bed.  Fits  of  temper  or  other  excite- 
ment have  at  times  produced  it.  It  is  by  no  means  certain  that  sudden 
heart  paralysis  is  always  due  to  a  lesion  of  its  nerves.  A  not  less  impor- 
tant cause  is  toxic  myocarditis.  In  the  cases  where  death  occurs  sud- 
denly without  premonition  after  some  muscular  effort,  it  is  in  all  prob- 
ability the  heart  muscle  which  is  most  at  fault.  However,  in  many  cases 
the  two  conditions  are  associated. 

Death  from  diphtheritic  paralysis  is  usually  due  either  to  cardiac  or 
respiratory  paralysis.  Of  one  hundred  and  seventy-one  cases  of  all  va- 
rieties collected  by  Eoss,  forty-five  were  fatal. 

Treatment. — Cases  of  paralysis  of  the  trunk  or  extremities  are  to  be 
managed  like  others  of  multiple  neuritis.  In  severe  forms  of  throat 
paralysis  feeding  by  a  stomach  tube  should  always  be  employed,  on  ac- 
count of  the  danger  of  the  entrance  of  food  into  the  air  passages.  It 
must  in  most  cases  be  continued  for  several  days.  The  tube  may  be 
passed  either  through  the  mouth  or  the  nose. 

The  great  mortality  attending  paralysis  of  the  heart  and  respiration 
shows  how  unsuccessful  is  treatment  in  most  of  the  cases ;  still,  no  doubt 
there  are  instances  where  life  may  be  saved  by  judicious  treatment.  In 
cases  of  threatened  heart  paralysis,  the  drug  most  to  be  depended  upon 
is  morphine,  hypodermically  ;  this  should  be  used  every  two  or  three  hours 
iu  sufficient  doses  to  keep  the  patient  under  its  influence  while  threat- 
ening symptoms  are  present.  In  some  cases  it  may  be  advantageously 
combined  with  strychnine.  The  patient  should  be  kept  absolutely  quiet, 
not  even  being  allowed  to  turn  in  bed.  In  respiratory  paralysis  the  gen- 
eral reliance  is  upon  strychnine  used  hypodermically  in  doses  sufficient 
to  produce  its  physiological  effects,  and  upon  faradization  of  the  respira- 
tory muscles,  particularly  the  diaphragm.  Faradism  is  to  be  used  in 
the  attacks  of  respiratory  failure  and  continued  while  they  last.  Some- 
times patients  may  by  these  means  be  tided  over  the  dangerous  stage  of 
the  disease. 

FACIAL   PARALYSIS. 

Peripheral  paralysis  of  the  face  occurring  as  a  result  of  injury  inflicted 
during  delivery  has  already  been  described  (page  108).    There  rouiain  to 


FACIAL   PARALYSIS. 


839 


be  considered  here  cases  which  arise  from  causes  that  operate  at  a  later 
period.  The  facial  uerve  may  be  affected  in  any  one  of  three  situations, — 
after  its  exit  from  the  cranium,  in  the  bony  canal,  and  within  the  cranium. 

In  the  first  situation,  the  principal  cause  of  neuritis  is  exposure  to  cold 
(the  "rheumatic"  cases),  but  it  occasionally  occurs  as  a  complication  of 
mumps  and  disease  of  the  lymph  glands  of  this  region.  The  nerve  is  af- 
fected just  after  it  has  escaped  from  the  stylo-mastoid  foramen,  and  all  the 
branches  given  off  beyond  its  exit  are  involved.  There  is  parah'sis  of  the 
muscles  of  the  forehead,  those  about  the  eye,  the  cheek,  nose,  and  mouth. 
The  alfected  side  of  the  face  is  smooth,  there  is  inability  to  wrinkle  the 
forehead,  contract  the  eyebrows,  close  the  eye  completely,  raise  the  nos- 
tril, whistle,  or  blow.  The  mouth  is 
drawn  to  the  healthy  side  (Fig.  156). 
If  the  paralysis  is  complete,  there  may 
be  difficulty  in  drinking  or  in  articula- 
tion. In  partial  paralysis  the  symp- 
toms may  not  be  noticeable  while  the 
face  is  at  rest.  There  are  no  sensory 
symptoms.  The  electrical  reactions 
resemble  those  of  other  forms  of  neu- 
ritis ;  there  is  diminution  in  the  re- 
sponse to  the  faradic  current,  which 
is  more  or  less  marked  according  to 
'the  severity  of  the  lesion,  and  there 
may  be  the  reaction  of  degeneration. 

In  the  bony  canal,  the  facial  nerve 
is  usually  inflamed  as  a  result  of  dis- 
ease of  the  ear.  In  children  this  is 
much  more  frequent  than  from  the 
causes  just  mentioned.  While  it  is 
possible  for  it  to  occur  in  acute  cases,  it  generally  accompanies  chronic 
otitis,  especially  where  there  is  caries  of  the  petrous  bone.  In  addition  to 
the  paralysis  there  is  present  or  there  is  a  history  of  a  discharge  from 
the  ear,  and  generally  there  is  some  deafness  upon  the  side  affected.  Tiie 
facial  symptoms  are  usually  the  same  as  in  the  cases  first  described. 
However,  when  the  nerve  is  affected  between  the  stapedius  and  the  genic- 
ulate ganglion,  there  is  a  disturbance  of  the  sense  of  taste,  and  of  tiie 
secretion  of  the  saliva. 

At  the  base  of  the  brain  the  trunk  of  the  nerve  may  be  involved  in 
cerebral  tumour,  basilar  meningitis,  and  in  fracture  of  the  skull.  In  any 
of  these  conditions  the  auditory  nerve  also  is  likely  to  be  affected. 

Prognosis. — The  result  is  greatly  modified  by  the  causes  in  tlie  dif- 
ferent cases.  In  those  which  are  due  to  cold,  spontaneous  recovery 
usually  occurs  in  the  course  of  a  few  weeks  or  months.     In  those  depend- 


\ 


Fig.  15G. — Facial  paralysis  of  right  side 
from  middle-Cin-  disease  in  a  child  two 
and  a  half  years  old. 


84:0  DISEASES  OP  THE  NERVOUS  SYSTEM. 

ing  upon  disease  of  the  ear,  the  outlook  is  not  so  favourable,  and  though 
there  may  be  improvement,  it  is  not  rare  for  some  paralysis  to  be  per- 
manent. In  the  third  group  of  cases,  facial  paralysis  is  only  one  of  the 
symptoms,  and  the  result  depends  entirely  upon  the  nature  of  the  cause. 

Diagnosis. — Facial  paralysis  is  easily  recognised.  It  is  important  to 
separate  the  peripheral  paralysis  from  that  due  to  a  lesion  above  the 
pons,  as  in  cases  of  ordinary  hemiplegia.  In  the  latter  group  only  the 
lower  half  of  the  face  is  affected,  the  muscles  of  the  forehead  and  those 
about  the  eye  escaping,  and  the  electrical  reactions  are  unchanged. 

Treatment. — This  is  essentially  the  same  as  in  other  cases  of  neuritis. 
In  cases  due  to  ear  disease  the  primary  lesion  should  receive  appropriate 
treatment. 


SECTioisr  yiii. 

DISEASES    OF    THE    BLOOD,    LYMPH    NODES,    SPLEEN,  BONES, 

AND  JOINTS. 

CHAPTER  I. 
DISEASES  OF  THE  BLOOD. 

In  general,  the  blood  in  infancy  and  childhood,  as  compared  with  that 
of  adult  life,  is  thinner  and  contains  a  larger  proportion  of  water ;  it  is 
also  poorer  in  solids  and  has  a  lower  specific  gravity. 

Specific  Gravity. — This  has  no  constant  relation  to  the  number  of 
white  or  red  corpuscles,  but  varies  with  the  amount  of  haemoglobin.  The 
highest  specific  gravity  is  seen  in  the  blood  of  the  newly  born.  During 
the  first  two  weeks  of  life  it  sinks  rapidly  to  its  lowest  point,  where  it 
remains  until  about  the  end  of  the  second  year;  after  this  time  it  rises 
gradually  until  about  puberty.  The  average  specific  gravity  during 
childhood  is  1  -050  to  1  -055. 

Haemoglobin. — The  percentage  of  haemoglobin  is  highest  in  the  blood 
of  the  newly  born,  and  falls  rapidly  during  the  first  few  days  after  birth. 
Throughout  childhood  it  is  considerably  lower  than  in  adult  life.  The 
hasmoglobin  is  lowest  between  the  third  month  and  the  second  year; 
after  the  second  year  it  gradually  increases  up  to  puberty.  The  usual 
range  in  young  children,  as  measured  by  the  adult  standard,  is  between 
65  and  85  per  cent,  65  per  cent  being  a  low  limit  in  healthy  children. 

Red  Corpuscles. — The  number  of  red  corpuscles  is  highest  in  the 
newly  born.  At  this  time  it  is  from  4,350,000  to  6,500,000  in  each  cubic 
millimetre.  In  infancy  it  is  from  4,000,000  to  5,500,000 ;  in  later  child- 
hood, from  4,000,000  to  4,500,000  (Hayem).  In  size  a  much  greater 
variation  is  seen  in  the  red  cells  of  the  newly  born  than  in  those  of  older 
children  and  adults.  In  the  blood  of  the  foetus  there  are  present  nucle- 
ated red  corpuscles  or  normoblasts  (Plate  XVIT,  A,  5).  These  diminish 
in  number  toward  the  cud  of  pregnancy.  They  are  always  found  in 
the  blood  of  premature  iiiranis,  bnt  in  infnnis  1)orn  at  term  they  are 
seen  only  in  small  numbers  and  disap])ear  after  a  few  days.  In  later 
infancy  their  presence  is  always  jiathological. 

8-41 


842  DISEASES   OF   THE   BLOOD. 

Normal  White  Cells. — According  to  Ehrlich,  the  following  varieties 
are  found  in  health : 

1.  Lymphocytes.  These  are  small  cells  about  the  size  of  a  red  blood- 
cell.  The  protoplasm  is  small  in  amount,  forming  merely  a  narrow  rim 
about  the  nucleus ;  it  stains  with  basic  d^'es  rather  more  deeply  than  does 
the  nucleus.  The  nucleus  is  relatively  large,  is  centrally  situated,  and 
shows  at  times  one  or  two  nucleoli.  The  protoplasm  may  have  a  reticu- 
lar structure.  These  cells  form  in  adults  from  22  to  25  per  cent  of  the 
white  corpuscles,  but  in  children  they  are  often  as  high  as  50  or  60  per 
cent. 

2.  Large  mononuclear  leucocytes  and  transitional  forms.  These 
cells  are  two  or  three  times  the  size  of  ordinar}'  red  cells  (Plate  XYII, 
A,  6).  The  oval  nucleus  is  not  so  centrally  situated  as  in  the  lympho- 
crtes,  and  stains  feebly  but  rather  darker  than  the  protoplasm,  which  is 
feebly  stained  by  basic  dyes.  The  protoplasm  is  homogeneous  and  rela- 
tively large  in  amount. 

The  transitional  forms  occasionally  contain  a  few  feebly  staining  neu- 
trophilic granules;  their  nuclei  are  bent  or  curved  and  stain  more  deeply. 

3.  Polynuclear  neutrophiles.  These  are  smaller  than  the  large  leu- 
cocytes (Plate  XYII,  A,  3).  The  nucleus  consists  of  three  to  four  parts, 
usually  connected  by  narrower  portions,  and  stains  darkly.  The  proto- 
plasm stains  with  acid  dyes  and  shows  a  great  number  of  granules  which 
stain  only  with  neutral  dyes.  In  adults  these  cells  form  about  70  per 
cent  of  the  white  cells;  but  in  children  they  are  less  numerous,  the  in- 
crease in  the  lymphocytes  being  at  the  expense  of  the  neutrophiles. 

4.  Eosinopliiles.  These  are  about  the  same  size  as  the  neutrophiles 
(Plate  XYII,  A,  1)  ;  they  have  deeply  staining  nuclei,  usually  divided 
into  two  parts.  The  protoplasm  has  many  large  granules  that  stain 
deeply  with  acid  dyes,  and  often  a  narrow  outer  layer  staining  more 
deeply  than  the  rest.  They  form  from  2  to  4  per  cent  of  the  white  cells. 
The  last  two  forms  alone  have  an  amceboid  movement. 

5.  Mast  cells.  They  are  onh'  occasionally  found,  their  proportion 
being  about  0  -o  per  cent  of  the  white  cells ;  they  are  mononuclear  or 
polynuclear  cells  whose  granules  stain  only  with  basic  dyes,  not  at  all 
with  tri-acid ;  often  they  are  metachromatic. 

Pathological  White  Cells. — Of  these  there  are  two  principal  forms : 

1.  Myelocytes.  They  have  neutrophilic  granules  and  a  single  rounded 
nucleus  (Plate  XYII,  A,  2).  Ehrlich's  myelocytes  differ  from  those  of 
Cornil  in  that  the  cells  as  a  whole  are  smaller,  the  nuclei  are  more  cen- 
trally situated  and  stain  more  intensely. 

2.  Mononuclear  eosinopliiles.  These  resemble  the  polynuclear  eosin- 
ophiles,  except  for  the  round  undivided  nucleus.  Pathologically,  the 
leucocytes  may  undergo  acute  or  chronic  degeneration,  with  swelling  and 
fragmentation,  nuclear  changes,  hydropic  degeneration,  etc. 


PLATE    XVII. 


Fig.  A. 


Fig.B. 

A.  '1'hi;  Mlood  in  IjRUc^^mia. 

1,  Eosinophile  cells;  2,  myelocytes:  3.  polyimclear  neiitrophilc  oells;  4,  red  cells; 
5,  nucleated  red  cells;  6,  lymjihocytes. 

R.  I'kkniciou.s  Anemia. 

1,  Megaloblasts :    2.  nucleated    Tnegaloblasts ;    :i    a  polynuclear  neutrophile  cell: 
4,  poikiloeytes.  (After  Monti  and  Berggriin.) 


LEUCOCYTOSIS.  §43 

The  numhcr  of  leucocytes  in  the  blood  of  the  newly  born,  according 
to  Eieder,  is  at  birth  from  14,200  to  27,400;  from  the  second  to  the 
fourth  day,  from  8,700  to  12,400;  after  the  fourth  day,  from  12,400  to 
14.800.  The  variations  in  infancy  are  from  9,000  to  14,000,  and  in  later 
childhood  from  6,000  to  12,000. 

LEUCOCYTOSIS. 

By  lencocytosis  is  meant  an  increase  in  the  white  corpuscles  of  the 
blood.  This  may  relate  to  all  or  any  of  the  varieties ;  although  it  is 
chiefly  of  the  polynuclear  neutrophiles,  there  is  seen  in  children  a  greater 
tendency  than  in  adults  to  an  increase  in  the  lymphocytes. 

It  is  customary  to  distinguish  between  physiological  lencocytosis, 
such  as  that  which  follows  a  full  meal,  exercise,  cold  baths,  or  that  which 
occurs  in  the  newly-born  infant,  and  pathological  lencocytosis  wdiich 
occurs  principally  in  inflammatory  and  toxic  conditions,  but  may  be  seen 
also  in  malignant  disease  and  after  serious  hgemorrhage. 

Digestive  lencocytosis,  that  which  occurs  after  feeding,  is  especially 
pronounced  in  children,  the  increase  frequently  amounting  to  33  per 
cent  of  the  total  number  of  leucocytes  present.  Lencocytosis  of  the 
newly  born  has  already  been  mentioned. 

Lencocytosis  is  present  in  a  great  variety  of  pathological  conditions. 
In  many  of  them  its  significance  is  not  yet  fully  understood;  further 
study  of  it  has  not  fulfilled  the  expectations  of  those  who  had  hoped 
to  obtain  from  it  exact  information  regarding  many  jDathological  pro- 
cesses. 

The  form  of  lencocytosis  which  is  chiefly  important  in  children  is  the 
inflammatory.  This  is  most  marked  in  acute  pneumonia,  diphtheria, 
and  in  inflammations  attended  by  the  formation  of  pus.  It  is  also  fre- 
c[uently  present  in  pertussis,  scarlet  fever,  erysipelas,  acute  rheumatism, 
septic  and  cerebro-spinal  meningitis,  and  in  severe  forms  of  rickets. 
Of  the  purulent  inflammations,  it  is  especially  important  in  appendicitis, 
peritonitis,  empyema,  pj^asmia,  septicaemia,  osteo-myelitis,  and  all  acute 
abscesses.  In  the  conditions  above  mentioned  the  increase  is  chiefly  or 
exclusively  in  the  polynuclear  neutrophiles. 

There  are  other  conditions,  especially  hereditary  syphilis,  scurvy,  and 
certain  diseases  of  the  spleen,  in  which  the  proportion  of  the  l5anpho- 
cytes  may  be  increased ;  but  under  these  circumstances  the  other  white 
cells  are  generally  diminislied. 

The  eosinophiles  are  principally  increased  in  leukaemia;  but  an  in- 
crease may  also  be  present  with  intestinal  parasites,  especially  tapeworm 
(Buckler),  and  in  some  forms  of  chronic  skin  disease.  As  a  rule,  lenco- 
cytosis is  absent  in  ty])hoid  fever,  measles,  malaria,  inlluenza,  and  in 
tuberculous  inflammations.  D'Orlaiidi  FouikI  it  wanling  in  twenty  cases 
of  gastro-enteritis  in  infants. 


8i4  DISEASES  OF   THE  BLOOD. 

Leucocytosis  may  be  regarded  as  the  reaction  of  the  organism  to  the 
toxins  in  the  blood  elaborated  by  the  bacteria  concerned  in  the  inflam- 
mation or  infection,  or  to  the  bacteria  themselves.  It  thns  depends 
upon  tTvo  factors:  the  severity  of  the  infection,  and  the  amount  of  re- 
sistance of  the  individual,  the  latter  being  the  more  important.  A 
severe  infection  with  a  high  degree  of  resistance  produces  the  most 
marked  leucocytosis,  while  with  very  feeble  resistance  and  the  same  in- 
fection the  leucocytosis  would  be  slight  or  possibly  absent. 

The  degree  of  leucocytosis  is  also  influenced  by  the  nature  of  the  in- 
flammatory process,  it  being  less  marked  in  serous  inflammations,  more 
pronounced  in  suppurative  processes.  In  inflammations  it  is  usually 
greatest  during  the  active  stage  of  exudation. 

The  Diagnostic  Value  of  Leucocytosis. — The  following  are  the  prin- 
cipal diseases  in  which  a  leucocyte  count  may  be  of  clinical  assistance: 

Appendicitis.  —  A  marked  leucocytosis  distinguishes  suppurative 
from  catarrhal  appendicitis,  and  also  points  to  the  existence  of  an  ab- 
scess.    (See  page  440.) 

Pneumonia. — A  marked  leucocytosis  is  a  characteristic  feature  of 
this  disease ;  the  exceptions  are  very  mild  cases  or  very  severe  infection 
with  little  or  no  reaction.  The  increase  begins  shortly  after  the  onset 
and  continues  during  the  stage  of  exudation,  generally  reaching  its 
maximum  shortly  before  the  crisis,  when  it  declines  rapidly.  The  usual 
number  of  white  cells  in  an  average  case  of  pneumonia  in  a  young  child 
is  from  12,000  to  30,000,  but  it  is  not  rare  for  the  count  to  run  up  to 
40,000  or  even  50,000.  The  absence  of  leucocytosis  in  a  strong  child 
who  is  acutely  ill  is  always  strong  presumptive  evidence  against 
pneumonia.  A  well-marked  leucocytosis  is  of  much  value  in  differenti- 
ating pneumonia  from  t5'phoid  fever,  tuberculosis,  influenza,  and  bron- 
chitis. 

Empyema. — A  rapid  increase  in  the  leucocytes  in  the  active  stage  of 
a  pneumonia  or  after  defervescence,  in  the  absence  of  physical  signs 
pointing  to  an  extension  of  the  pneumonic  process,  almost  invariably 
indicates  empyema. 

Typhoid  Fever. — Leucocj'tosis  is  regularly  absent  in  t^'phoid;  its 
presence  in  an  undoubted  case  indicates  complications. 

Pertussis. — Leucocytosis  is  of  considerable  value  in  the  diagnosis  of 
this  disease;  it  is  considered  on  page  992. 

Meningitis. — As  a  rule,  leucocytosis  is  jDresent  in  septic  and  cerebro- 
spinal meningitis  and  absent  in  tuberculous  meningitis,  although  some 
exceptions  have  been  observed. 

Tuberculosis. — Leucocytosis  is  regularly  absent  in  unmixed  tuber- 
culous infections. 

In  surgical  diseases  the  presence  of  leucocytosis  is  considered  a  reli- 
able guide  as  to  the  existence  of  acute  suppuration,  although  not  always 


SIMPLE  AX.'EMIA.  845 

as  to  its  degree.  An  increasing  leucocytosis  is  usuall}'  an  indication  for 
operative  interference  in  cases  where  operation  is  admissible.  This 
applies  particularly  to  appendicitis. 

The  Prognostic  Value  of  Leucocytosis. — As  the  leucocyte  count  de- 
pends largely  upon  the  resistance  of  the  individual,  it  is  generally  true 
that  in  the  diseases  usually  accompanied  by  leucocytosis  a  high  count  is 
a  favourable  sign.  This  is  generally  the  case  in  pneumonia,  unless  the 
attack  is  a  very  mild  one.  On  the  other  hand,  in  a  severe  attack  a  low 
count  is  very  unfavourable.  The  following  case  may  be  cited  in  illustra- 
tion :  A  delicate  child,  twelve  months  old,  on  the  eleventh  day  of  a  severe 
lobar  pneumonia  had  24,500  leucocytes.  Two  days  afterward  a  critical 
fall  in  the  temperature  occurred  and  resolution  followed.  The  same 
child  two  weeks  later  was  attacked  with  pneumonia  in  the  opposite  lung. 
On  the  second  day  the  leucocyte  count  was  18,000 ;  on  the  fourth  day, 
9,900 ;  on  the  sixth  day,  7,300.  Death  occurred  during  the  following 
night. 

The  value  of  the  leucocyte  count  in  diphtheria  and  its  bearing  upon 
prognosis  are  discussed  under  that  disease. 

SIMPLE  ANiEMIA. 

This  consists  in  an  impoverishment  of  the  blood,  especially  the  red 
<3ells,  and  a  corresponding  diminution  in  the  specific  gravity  and  in  the 
amount  of  hemoglobin.  It  is  essentially  a  secondary  anaemia,  and  occurs 
apart  from  disease  of  the  blood-making  organs.  The  important  factors 
in  its  etiology  are,  first,  an  insufficient  production  of  blood  in  conse- 
quence of  deficient  food  or  interference  with  the  absorption  of  food,  and, 
second,  an  increased  drain  or  destruction  of  blood,  as  in  exhausting  dis- 
eases. Infancy  and  childhood  are  themselves  strong  predisposing  causes 
of  antemia,  on  account  of  the  great  demands  made  upon  the  blood  in  the 
rapid  growth  of  the  body. 

Etiology. — In  certain  cases  angemia  may  be  congenital,  as  in  infants 
born  of  delicate  or  anaemic  parents,  or  where  the  mother  during  preg- 
nancy has  suffered  from  some  serious  disease,  such  as  syphilis  or  ne- 
phritis. Acquired  anaemia  may  come  on  at  any  period  in  infancy  or 
childhood.  The  cause  may  be  loss  of  blood,  as  in  hannorrhages  of  the 
newly  born,  epistaxis,  purpura,  scurvy,  or  hgemophilia.  Xone  of  these 
are  very  common  etiological  factors.  More  frequently  anaemia  depends 
upon  a  loss  of  albumin  of  the  blood,  as  in  prolonged  suppuration,  chronic 
nephritis,  large  serous  effusions  occurring  in  the  course  of  cardiac  dis- 
ease, certain  forms  of  diarrhoea,  and  in  malignant  disease.  Very  fre- 
quently also  it  depends  upon  improper  food,  or  disease  of  the  organs  of 
digestion  or  assimilation,  as  in  the  various  forms  of  chronic  diarrhoea, 
ileo-colitis,  or  chronic  indigestion.  These  cases  form  a  group  sometimes 
classed  as  anaemia  from  inanition.  In  infancy,  unhygienic  surroundings, 
55 


846  DISEASES  OP  T^E  BLOOD. 

bad  air^  and  close  confinement  to  unhealthy  apartments,  are  important 
factors  in  producing  anemia.  In  a  large  number  of  cases  the  ansemia  is 
of  toxic  origin.  In  this  group  may  be  classed  not  only  cases  in  which 
angemia  depends  upon  mineral  poisons  introduced  into  the  body,  such  as 
mercury  or  chlorate  of  potassium,  but  also  the  poisons  of  all  the  infec- 
tious diseases,  notably  diphtheria.  Febrile  angemia  is  not  entirely  due  to 
toxic  causes.  It  depends  in  part,  no  doubt,  upon  interference  with  diges- 
tion and  assimilation.  Anaemia  may  be  due  to  parasites  in  the  blood, 
the  most  striking  illustration  being  malarial  organisms,  and  it  may 
occasionally  arise  from  some  forms  of  intestinal  worms.  The  etiology 
of  the  anaemia  accompanying  certain  constitutional  diseases,  such  as 
rickets,  tuberculosis,  or  rheumatism,  is  of  a  complex  character. 

Symptoms. — One  of  the  most  striking  symptoms  is  the  pallor  of  the 
skin  and  mucous  membranes,  although  this  is  by  no  means  an  infallible 
guide  to  the  degree  of  anemia.  Such  children  usually  exhibit  also  symp- 
toms of  malnutrition:  their  muscles  are  soft  and  flabby;  they  are  fre- 
quently thin  and  poorly  nourished,  but  occasionally  have  an  unusual 
amount  of  fat.  They  almost  invariably  suffer  from  digestive  disturb- 
ances, such  as  coated  tongue,  poor  appetite,  and  constipated  bowels. 
The  extremities  are  often  cold,  the  pulse  is  rather  weak  and  often  slight- 
ly irregular.  The  heart-sounds  are  feeble,  and  anaemic  murmurs  may 
be  heard  either  over  the  heart  or  the  large  vessels  even  in  infancy,  and 
occasionally  a  venous  hum  may  be  heard  in  the  neck.  In  a  certain  num- 
ber of  cases  of  moderate  severity  there  is  found  enlargement  of  the 
spleen,  but  rarely  to  the  degree  seen  in  leukaemia,  or  in  the  pseudo-leu- 
kgemia  of  infants.  These  cases  were  formerly  classed  separately  as 
"  splenic  angemia." 

I^ervous  symptoms  are  frequent.  Angemic  children  are  fretful,  irrita- 
ble, and  often  exhibit  a  degree  of  nervousness  amounting  almost  to 
chorea.  Others  complain  of  headache  and  indefinite  pains.  Sleep  is 
restless  and  disturbed,  and  often  there  is  insomnia.  The  urine  is  scanty, 
frequently  pale,  and  in  many  cases  contains  an  excess  of  uric  acid ;  there 
may  be  enuresis.  Such  children  are  easily  fatigued,  they  frequently  suf- 
fer from  shortness  of  breath  upon  exercise,  and  occasionally  have  faint- 
ing attacks.  They  are  especially  prone  to  chronic  catarrhal  inflamma- 
tions of  the  nose,  pharynx,  and  bronchi.  Epistaxis  is  not  an  uncommon 
symptom.  Leucorrhoea  may  be  present  even  in  girls  of  three  or  four 
years.  CEdema  is  not  infrequent  in  infants,  and  is  occasionally  seen 
in  older  children.  In  infancy,  if  angemia  comes  on  rapidly,  as  in  the 
course  of  diarrhoeal  diseases,  cerebral  symptoms  may  be  present. 

The  hloocl. — The  red  cells  are  much  reduced  in  number,  and  a  slight 
or  moderate  leucocytosis  is  the  rule.  The  reduction  in  the  htemoglobin 
is  proportionately  greater  than  is  the  reduction  in  the  number  of  the 
red  cells.    Morphologically,  there  is  poikilocytosis ;  the  cells  are  of  nor- 


CHLOROSIS.  847 

mal  size  or  rather  smaller ;  there  are  no  megalocytes ;  a  few  normoblasts 
may  be  found. 

Prognosis. — The  course  and  termination  of  anaemia  depend  upon  its 
cause.  If  this  can  be  removed,  steady  improvement  and  recovery  may  be 
expected.  In  extreme  cases  death  may  take  place,  but  rarely  from  the 
ansemia,  usually  from  some  complicating  disease. 

In  making  a  prognosis  there  must  be  considered  not  only  the  general 
symptoms  and  the  cause  of  the  anaemia,  but  also  the  condition  of  the 
digestive  organs  and  the  state  of  the  blood.  If  there  is  only  a  moderate 
reduction  in  the  haemoglobin  and  in  the  number  of  the  red  cells,  with 
slight  changes  in  their  form  and  with  no  increase  in  the  leucocytes,  the 
prognosis  is  good.  If  the  haemoglobin  is  reduced  below  30  per  cent,  if 
the  number  of  red  cells  is  less  than  half  the  normal,  and  marked 
changes  in  form  are  present,  with  or  without  great  increase  in  the 
actual  number  of  leucocytes,  the  prognosis  is  unfavourable. 

The  treatment  of  all  the  forms  of  anaemia  will  be  considered  together 
at  the  close  of  the  chapter. 

CHLOROSIS. 

Chlorosis  is  a  primary  or  essential  anaemia  which  usually  occurs  in 
young  girls  about  the  time  of  puberty.  It  is  characterized  by  a  peculiar 
greenish-yellow  tint  of  the  skin,  and  is  not  accompanied  by  emaciation. 
The  changes  in  the  blood  consist  in  a  very  great  reduction  in  the  haemo- 
globin without  a  corresponding  diminution  in  the  red  corpuscles. 

Etiology. — The  exact  cause  of  chlorosis  is  not  yet  understood.  The 
disease  rarely  occurs  in  males;  it  is  usually  seen  in  girls  between  the 
fourteenth  and  seventeenth  years,  and  more  often  in  blondes  than 
in  brunettes.  Heredity  appears  to  be  a  factor  in  some  cases.  Other 
causes  are  occupations  deleterious  to  health,  such  as  employment 
in  factories  or  confinement  in  ill-ventilated  rooms;  insufficient  food  or 
clothing;  psychical  disturbances,  like  grief,  care,  or  fright;  excessive 
mental  or  physical  strain ;  and  disorders  of  menstruation — although  the 
latter  are  perhaps  more  frequently  a  result  than  a  cause  of  the  disease. 
Virchow  first  called  attention  to  the  fact  that  chlorosis  might  depend 
upon  a  congenital  narrowing  of  the  aorta,  sometimes  associated  with  a 
small  heart.  It  is  difficult  to  reconcile  this  etiology  with  the  rapid  recov- 
ery under  appropriate  treatment  which  is  seen  in  most  of  the  cases. 
Andrew  Clark  has  advanced  the  view  that  the  chief  cause  of  chlorosis 
is  constipation  and  the  resulting  absorption  of  toxic  materials  from  the 
intestine. 

Lesions. — Chlorosis  is  rarely  fatal.  In  the  few  fatal  cases  the  lesions 
noted  have  been  dilatation  of  the  right  heart  witli  hypertrophy  of  the  left 
ventricle,  a  small  aorta,  small  uterus  and  ovaries,  and  occasionally  round 
ulcer  of  the  stomach.     Under  the  microscope  there  may  be  found  a  very 


848  DISEASES  OP   THE  BLOOD. 

marked  degree  of  fatty  degeneration  of  the  heart  muscle,  and  sometimes 
of  the  inner  coat  of  the  blood-vessels. 

Symptoms. — The  general  symptoms  of  chlorosis  are  very  much  like 
those  of  simple  anaemia.  There  are  observed  shortness  of  breath  upon 
exercise,  palpitation,  syncope,  attacks  of  vertigo,  disturbances  of  diges- 
tion, amenorrhcea,  and  almost  invariably  constipation.  The  appetite  is 
capricious,  it  being  a  peculiarity  of  these  patients  to  crave  all  sorts  of 
indigestible  articles.  Instead  of  the  usual  pallor  of  anaemia,  the  skin 
has  a  yellowish-green  tint,  from  which  the  term  "  green-sickness  "  has 
arisen.  Occasionally  patches  of  pigmentation  are  seen.  Anaemic  car- 
diac murmurs  may  be  heard  in  various  situations,  most  frequently  a 
systolic  murmur  at  the  base  of  the  heart,  and  usually  loudest  over  the 
pulmonic  area.  There  may  be  a  venous  hum  in  the  neck.  In  some 
marked  cases  there  is  evidence  of  slight  cardiac  dilatation,  especially 
of  the  right  heart,  and  there  may  be  hypertrophy  of  the  left  ventricle. 
The  pulse  is  weak  and  soft,  oedema  of  the  feet  is  frequent,  and  some- 
times there  is  slight  albuminuria.  In  some  cases  there  is  fever.  Nerv- 
ous disturbances,  such  as  vague,  indefinite  pains,  attacks  of  migraine, 
supra-orbital  neuralgia,  various  hysterical  manifestations,  and  chorea, 
are  common.    Ulcer  of  the  stomach  is  sometimes  seen  as  a  complication, 

Tlie  hlood. — The  specific  gravity  is  reduced  in  proportion  to  the  loss 
of  haemoglobin.  The  characteristic  feature  of  chlorosis  is  a  loss  of  haemo- 
globin which  is  out  of  proportion  to  the  reduction  in  the  red  cells.  The 
haemoglobin  in  an  ordinary  case  is  frequently  as  low  as  35  or  40  per  cent, 
while  the  red  cells  may  be  3,500,000  to  4,000,000,  or  even  higher. 

Morphologically  the  cells  are  pale  with  a  wide  central  clear  area. 
Poikilocytosis  may  be  present,  but  is  not  marked;  rarely  normoblasts 
may  be  found.  The  presence  of  megalocytes  is  disputed.  The  leuco- 
cytes are  usually  unchanged  in  number  and  proportion,  but  the  lympho- 
cytes may  be  relatively  increased. 

Prognosis. — The  course  of  the  disease  is  essentially  a  chronic  one, 
often  lasting  for  a  year.  Relapses  are  quite  frequent.  Except  when  de- 
pendent upon  congenital  malformations  of  the  heart  and  blood-vessels, 
these  cases  regularly  recover  when  proper  treatment  can  be  carried  out. 
A  small  number  prove  fatal  by  the  development  of  tuberculosis  or  the 
occurrence  of  gastric  ulcer. 

Diagnosis. — The  diagnosis  is  in  most  cases  easily  made  from  the  eti- 
ology, the  functional  derangement  of  the  heart,  the  colour  of  the  skin, 
and  a  positive  diagnosis  always  by  an  examination  of  the  blood. 

PSEUDO-LEUK^EMIC   ANiEMIA  OF  INFANCY. 
This  form  of  anaemia  was  first  described  by  Von  Jaksch  in  1889,  and 
is  by  him  believed  to  be  peculiar  to  infants  and  young  children.     It  is 
characterized  by  marked  leucocytosis,  marked  reduction  in  the  number 


PSEUDO-LEUK.EMIC  ANAEMIA  OP  INFANCY.  849 

of  red  cells  and  m  the  haemoglobin,  a  great  enlargement  of  the  spleen, 
and  sometimes  a  moderate  enlargement  of  the  liver  and  the  lymphatic 
glands.  This  disease  is  not  to  be  confounded  with  the  pseudo-leukgemia 
of  adults,  or  Hodgkin's  disease,  which  is  purely  a  disease  of  the  lym- 
phatic glands  with  secondary  anaemia,  but  without  any  leucocytosis. 

The  existence  of  pseudo-leukaemic  anemia  as  a  distinct  disease  is 
denied  by  several  authorities  on  diseases  of  the  blood,  who  maintain  that 
all  such  cases  are  to  be  classed  as  secondary  ansemia,  pernicious  anemia, 
or  leukemia. 

Etiology. — Of  the  cases  thus  far  recorded  the  majority  have  been 
between  the  ages  of  seven  and  twelve  months.  Of  twenty  cases  col- 
lected by  Monti  and  Berggrtin,  sixteen  showed  evidences  of  rickets  and 
one  was  syphilitic.  The  exact  cause  of  the  disease  is  still  unknown,  and 
its  essential  nature  is  a  matter  of  some  doubt.  Monti  believes  that  it 
may  develop  from  the  more  severe  cases  of  anaemia  which  are  accompa- 
nied by  leucocytosis,  as  he  has  observed  this  condition  before  the  devel- 
opment of  pseudo-leukaemia  and  during  its  subsidence. 

Lesions. — The  most  characteristic  change  is  found  in  the  spleen, 
which  is  very  much  enlarged,  often  forming  an  abdominal  tumour  of  con- 
siderable size.  It  is  firm,  hard,  and  there  may  be  evidences  of  perisple- 
nitis. The  microscope  shows  a  simple  hyperplasia.  Enlargement  of 
the  liver  is  less  constant,  it  being  normal  in  more  than  half  the  cases. 
There  is  no  relation  between  the  size  of  the  spleen  and  that  of  the  liver. 
The  hepatic  cells  are  unchanged.  Enlargement  of  the  lymph  glands  has 
been  noted  in  about  half  the  reported  cases,  the  swelling  affecting  the 
cervical,  axillary,  or  inguinal  glands ;  but  it  is  rarely  great.  Changes  in 
the  bone-marrow  have  been  described  by  Luzet,  these  being  usually  most 
marked  about  the  epiphyses. 

Symptoms. — The  blood. — The  number  of  reported  cases  is  as  yet  too 
small  to  make  positive  statements  possible  upon  all  points.  The  main 
features  noted  thus  far  are  the  following: 

The  specific  gravity  is  lowered,  the  usual  range  being  between  1-035 
and  1  -044.  The  reduction  of  the  hsemoglobin  is  very  great ;  in  many  of 
the  cases  it  has  been  as  low  as  30  per  cent,  and  in  a  few  below  25  per 
cent. 

The  red  cells  are  always  diminished ;  in  6  of  20  cases  they  were  below 
1,600,000  (Monti  and  Berggriin).  There  is  also  great  inequality  in  their 
size  and  shape.  N"ucleated  red  cells  are  found  in  considerable  numbers ; 
as  a  rule,  these  are  chiefly  normoblasts,  but  when  the  anaemia  becomes 
more  severe,  it  is  usually  the  megaloblasts  that  predominate.  The  U'u- 
cocytes  vary  from  20,000  to  50,000.  They  may  sliow  an  increase  in  the 
mononuclear  or  in  the  polynuclear  forms.  The  eosinophiles  are  usually 
increased,  but  not  to  the  extent  to  suggest  leukasmia.  All  varieties  of 
cell  degeneration  are  found. 


850  DISEASES  OF  THE  BLOOD. 

The  general  symptoms  of  the  disease  develop  slowly  and  with  the 
usual  signs  of  anaemia.  In  some  cases  the  infants  continue  to  be  plump 
and  well  nourished.  Pallor  is  usually  very  marked.  Enlargement  of  the 
spleen  is  so  great  that  it  can  hardly  be  overlooked  if  the  abdomen  is  ex- 
amined. The  glandular  enlargements  are  not  marked,  and  in  many  cases 
are  wanting  altogether. 

The  course  of  the  disease  is  essentially  chronic.  Cases  have  been  seen 
in  which  pseudo-leuksemia  developed  from  an  ordinary  severe  simple 
anemia  in  the  course  of  a  few  weeks.  The  symptoms  and  blood  changes 
generally  come  on  slowly  in  the  course  of  weeks  or  months,  and  some- 
times remain  nearly  stationary  for  as  long  a  period  as  several  months,  and 
then  slowly  improve.  In  other  cases  they  grow  gradually  worse.  In 
the  cases  going  on  to  recovery,  there  is  noticed  improvement  in  the  gen- 
eral symptoms  coincident  with  a  diminution  in  the  size  of  the  spleen,  a 
reduction  in  the  number  of  leucocytes,  an  increase  in  the  red  cells,  the 
haemoglobin,  and  the  specific  gravity,  and  a  gradual  disappearance  of  the 
nucleated  red  cells. 

Prognosis. — In  Monti's  list  of  twenty  cases  four  proved  fatal;  one 
recovered,  in  which  the  proportion  of  leucocytes  to  the  red  cells  had 
been  1  to  13.  The  prognosis  should  be  guarded,  for,  although  improve- 
ment may  take  place,  many  patients  die  from  intercurrent  disease. 


PERNICIOUS  ANEMIA. 

This  is  the  most  severe  form  of  anemia  known.  Its  cause  and  essen- 
tial nature  are  as  yet  very  imperfectly  understood.  It  is  characterized  by 
quite  uniform  blood  changes  and  by  the  general  symptoms  of  a  very 
marked  ansemia,  and  it  tends  to  go  on  from  bad  to  worse,  terminating 
fatally  in  the  great  proportion  of  cases. 

Etiology. — Pernicious  ansemia  is  a  rare  disease  in  childhood,  and  es- 
pecially rare  in  infancy.  In  the  cases  which  have  been  observed  in  early 
life  the  following  etiological  factors  have  been  noted :  It  has  been  associ- 
ated with  hereditary  syphilis  and  with  severe  rickets,  especially  when  ac- 
companied by  a  marked  enlargement  of  the  spleen.  It  has  followed 
other  diseases,  especially  grave  disturbances  of  nutrition.  Sometimes 
simple  auEemia,  when  severe  and  of  long  standing,  has  gradually  de- 
veloped into  the  pernicious  type.  In  a  few  instances  parasites,  partic- 
ularly tapeworms,  have  been  the  cause.  Pernicious  anaemia  has  in 
some  instances  occurred  in  patients  where  no  cause  whatever  could  be 
assigned. 

Many  theories  have  been  advanced  in  explanation  of  pernicious  anae- 
mia. The  one  which  at  present  appears  to  have  most  in  its  favour  is  that 
the  disease  consists  in  a  great  destruction  of  the  red  blood-cells,  particu- 
larly in  the  liver,  and  that  this  is  brought  about  through  the  agency  of 


PERNICIOUS  ANAEMIA.  851 

some  poison  or  poisons  taken  up  from  the  intestine  by  the  portal  circula- 
tion. This  has  been  advanced  by  Hunter  and  others  in  explanation  of 
the  peculiar  deposit  of  iron  found  in  the  hepatic  cells. 

Lesions. — There  is  found  a  very  high  grade  of  anemia  in  all  the  in- 
ternal organs,  fatty  degeneration  of  the  heart  and  blood-vessels,  and 
sometimes  also  of  the  liver  and  kidneys,  with  numerous  capillary  haemor- 
rhages in  the  various  organs.  The  most  characteristic  post-mortem 
change,  however,  according  to  Hunter,  consists  in  the  deposit  of  iron  in 
the  hepatic  cells.  Its  distribution  is  peculiar  and  unlike  that  seen  in 
any  other  disease. 

Symptoms. — The  blood  (Plate  XVII,  B). — The  specific  gravity  is 
constantly  and  considerably  reduced,  and  the  coagulability  of  the  blood 
is  feeble.  The  haemoglobin  is  always  reduced,  usually  it  is  as  low  as  from 
20  to  40  per  cent.  The  red  cells  are  always  much  diminished  in  number 
and  generally  to  a  degree  greater  than  the  reduction  in  the  haemoglobin. 
Their  number  is  seldom  greater  than  2,000,000,  and  frequently  less  than 
1,000,000.  Megalocytes  are  present,  often  in  great  numbers,  and  a  pre- 
ponderance of  them  is  regarded  essential  to  the  diagnosis.  Microc3^tes 
are  rare.  It  is  characteristic  of  pernicious  anemia  that  owing  to  the 
relatively  high  hgemoglobin  the  red  cells  stain  well,  usually  deeper  than 
in  normal  blood.  A  striking  feature  of  these  cases  is  the  presence  of 
extreme  poikilocytosis.  Nucleated  red  cells  are  also  present,  megalo- 
blasts  in  greater  numbers  than  normoblasts.  The  red  cells  do  not  col- 
lect to  form  rouleaux. 

The  total  number  of  leucocytes  is  markedly  diminished,  but  the  lym- 
phocytes may  be  relatively  increased.  An  occasional  myelocyte  may  be 
found. 

The  general  symptoms  are  those  of  a  most  intense  anaemia.  There 
is  marked  pallor  of  the  skin  and  mucous  membranes,  with  great  weak- 
ness and  prostration.  Various  anaemic  heart  murmurs  are  heard.  There 
is  dyspnoea,  and  usually  the  urine  is  scanty  and  of  low  specific  gravity. 
There  may  or  may  not  be  emaciation.  The  late  symptoms  are  haemor- 
rhages from  the  nose  and  other  mucous  membranes,  subcutaneous  ecehy- 
moses  with  dropsy  of  the  feet  and  ankles,  and  sometimes  of  the  large 
serous  cavities  of  the  body,  but  without  albuminuria.  In  many  cases 
fever  is  present.  This  may  be  so  high  as  to  lead  to  the  suspicion  of  some 
acute  infectious  process. 

The  course  of  the  disease  is,  as  a  rule,  more  rapid  than  in  adults,  the 
duration  being  in  most  cases  several  months;  it  is  marked  by  periods  of 
exacerbation  and  remission.  During  the  exacerbations  all  the  symptoms 
are  intensified,  and  as  a  rule  some  fever  is  present.  During  the  remis- 
sions marked  improvement  may  take  place  in  all  the  symptoms  and  an 
increase  in  the  hauuoglol)in  and  red  colls  occur.  In  general,  the  progress 
of  the  disease  is  downward  and  sometimes  the  loss  is  very  rapid.     The 


852  DISEASES   OF   THE   BLOOD. 

only  exceptions  are  the  eases  in  which  the  disease  depends  upon  some 
intestinal  parasite,  where  improvement  and  even  recovery  may  occur. 

Treatment  of  the  Different  Forms  of  Anaemia. — In  secondary  ancemia 
the  thing  of  the  tirst  importance  is  to  discover  and  treat  the  primary 
condition  npon  which  the  angemia  depends.  In  infancy,  special  atten- 
tion should  be  given  to  diet  and  hygiene,  particularly  with  reference  to 
an  abundant  supply  of  fresh  air.  The  whole  manner  of  life  of  these  pa- 
tients must  be  carefully  studied  and  managed  according  to  the  direc- 
tions laid  down  in  the  chapter  upon  Malnutrition,  with  which  condition,, 
especially  in  infancy,  a  very  large  number  of  these  cases  are  associated. 
The  general  treatment  referred  to  is  often  more  important  than  the 
administration  of  the  preparations  of  iron,  which,  however,  should  never 
be  omitted. 

The  preparations  of  iron  available  .for  infants  are  the  Drees's  albu- 
minate, the  pepto-manganate  (Gude),  the  bitter  wine,  the  sweet  wine, 
the  saccharated  carbonate,  the  malate,  and  the  citrate.  The  dose  should 
be  regulated  according  to  the  age  of  the  child.  Older  children  may  take 
the  same  preparations  as  adults,  especially  reduced  iron  and  Bland's 
pills.  Much  benefit  is  seen  from  combining  arsenic  with  iron,  or  from 
alternating  the  two.  Arsenic  should  be  used  in  conjunction  with  iron 
when  there  is  enlargement  of  the  spleen  or  lymphatic  glands.  In  addi- 
tion to  these  remedies,  cod-liver  oil  should  be  given  if  the  condition  of 
the  digestive  organs  will  permit. 

In  chlorosis  more  decided  results  are  seen  from  the  use  of  iron  than 
in  any  other  form  of  anaemia.  Bland's  pills  are  here  the  favourite 
method  of  administration,  and  are  advantageously  combined  with  small 
doses  of  nux  vomica  and  aloin  to  overcome  the  tendency  to  constipation. 
Arsenic  is  useful  in  these  cases  also.  Great  benefit  in  chlorosis  results 
from  change  of  air  and  change  of  scene,  thus  removing  the  patient  from 
all  sources  of  nervous  excitement  or  disturbance.  The  general  condition, 
diet,  and  habits  of  life  should  also  receive  careful  attention,  particularly 
the  condition  of  the  bowels. 

Oxygen  is  a  valuable  adjuvant  in  the  treatment  of  all  angemias  not 
yielding  to  iron  alone.  It  is  important  that  the  administration  of  iron 
should  be  continued  for  several  months  after  the  disappearance  of  all 
symptoms,  on  account  of  the  tendency  to  relapse. 

In  the  pseudo-leukcemic  ancemia  of  infants,  arsenic  is  decidedly  the 
most  valuable  drug,  but  should  be  given  in  combination  with  iron. 
Fowler's  solution  is  the  best  preparation  for  infants ;  the  dose  should 
rarely  be  more  than  one  drop,  which  should  be  repeated  four  or  five  times 
daily  after  feeding,  and  continued  for  a  long  time.  The  general  treat- 
ment of  these  patients  is  the  same  as  in  cases  of  simple  anaemia.  When 
rickets  is  present  cod-liver  oil  and  phosphorus  should  be  added. 

In  pernicious  ancemia,  arsenic  offers  a  much  better  prospect  of  im- 


LEUKAEMIA.  853 

provement  than  iron.  Beginning  with  small  closes,  the  amount  should 
be  gradually  increased  up  to  the  point  of  tolerance,  very  much  as  in  cases 
of  chorea. 

In  every  case  of  anaemia  the  most  careful  attention  should  be  given  to 
the  general  condition,  particularly  guarding  against  exposure  to  cold  and 
dampness.  The  feeble  circulation  of  these  patients  renders  them  pecul- 
iarly susceptible.  Caution  should  also  be  given  against  much  muscular 
exercise.  With  a  severe  grade  of  anemia  very  active  exercise  should  be 
prohibited,  and  many  of  these  patients  do  best  when  complete  rest  in 
bed,  either  for  the  entire  time  or  for  a  considerable  part  of  each  day,  is 
insisted  upon.    This  applies  to  children  of  all  ages. 

LEUKEMIA. 

This  is  a  disease  in  which  the  essential  feature  is  a  great  increase  in 
the  number  of  leucocytes,  with  a  moderate  reduction  in  the  number  of 
red  corpuscles,  and  the  presence  in  the  blood  of  cellular  forms  not  found 
in  health. 

Etiology. — Leukffimia  is  a  rare  disease  in  childhood,  but  has  been  seen 
even  in  early  infancy.  Its  greater  frequency  in  males  holds  good  even  in 
childhood.  In  a  small  number  of  cases  heredity  seems  of  some  impor- 
tance as  an  etiological  factor.  Leukaemia  may  follow  syphilis,  rickets, 
malaria,  or  even  simple  anaemia,  or  it  may  occur  as  a  primary  disease  in 
children  previously  health3^  In  the  great  majority  of  cases  the  cause  is 
unknown. 

Lesions. — The  essential  lesions  of  leukaemia  are  found  in  the  spleen, 
the  lymphatic  glands,  and  the  bone-marrow.  In  rare  cases  the  most  im- 
portant changes  are  in  the  lymphatic  glands,  giving  rise  to  the  lym- 
phatic form  of  leukaemia.  In  such  cases  the  changes  in  the  spleen  or 
marrow  may  be  slight  or  absent.  Changes  in  the  spleen  and  marrow  are, 
however,  usually  associated,  giving  rise  to  what  is  known  as  the  spleno- 
myelogenous  form  of  the  disease,  which  is  the  most  frequent  variety. 
The  spleen  is  usually  enormously  enlarged,  sometimes  filling  half  the 
abdominal  cavity.  In  the  early  stage  it  is  soft,  vascular,  and  of  a  dark- 
red  colour;  in  the  late  stages  it  is  firm  and  hard,  and  usually  deeply 
fissured  at  its  margin.  There  may  be  perisplenitis.  On  section,  light- 
gray  patches  of  lymphoid  tissue  may  be  seen  scattered  throughout  the 
organ,  and  in  some  instances  there  may  be  wedge-shaped  infarctions. 
The  microscope  shows  thickening  of  the  trabeculns  and  deposits  of  lym- 
phoid tissue,  especially  about  the  arteries.  In  the  lymphatic  form  any 
of  the  external  glands  of  the  body  may  be  affected,  the  cervical,  axil- 
lary, and  the  inguinal,  or  the  mesenteric,  trachoo-bronchial,  the  tonsils, 
and  even  the  lymph  nodules  of  the  tongue,  pharynx,  and  intestines.  The 
changes  in  the  glands  are  generally  those  of  a  simple  hyperplasia.  The 
liver  is  enlarged  in  very  many  of  the  cases,  chiefly  from  an  infiltration 


854:  DISEASES  OF  THE  BLOOD. 

with  lymphoid  tissue,  which  may  be  diffuse  or  may  occur  in  patches. 
Less  frequently  similar  Ij-mphoid  masses  are  seen  in  other  organs. 

Symptoms. — The  blood  (Plate  XVII,  A). — The  colour  is  lighter 
than  normal  and  its  coagulability  usually  diminished.  Generally  the 
red  cells  are  much  reduced  in  number,  although  not  to  the  extent  seen 
in  pernicious  anaemia.  The  most  important  feature  is  the  great  increase 
in  the  leucocytes,  which  vary  in  form  according  as  the  type  is  spleno- 
myelogenous  or  lymphatic.  The  red  cells  are  usually  of  normal  size  and 
a  moderate  number  of  normoblasts  is  found;  the  hgemoglobin  is  dimin- 
ished. 

In  the  spleno-m^^elogenous  form  the  white  cells  may  be  from  100,000 
to  500,000,  but,  especially  under  the  influence  of  arsenic,  a  marked  tem- 
porary diminution  may  occur,  so  that  their  number  may  be  scarcely  above 
the  normal ;  both  Ehrlich's  and  Cornil's  myelocytes  are  present,  and  the 
presence  of  a  large  number  of  these  is  pathognomonic.  The  number  of 
polj^nuclear  neutrophiles  is  greatly  increased,  although  their  proportion 
is  diminished.  The  eosinophiles  are  very  much  increased  in  number, 
mononuclear  forms  being  present.  The  number  of  lymphocytes  is  in- 
creased, but  they  vary  according  to  the  type  and  stage  of  the  disease; 
this  is  true  also  of  the  large  mononuclear  leucocytes.  Mast  cells  are 
much  increased  in  number,  this  being  the  most  reliable  diagnostic  sign. 

In  the  lymphatic  form  the  lymphoc3'tes  alone  are  increased,  so  that 
the  other  white  cells  are  relatively  diminished.  The  increase  is  usually 
in  the  small  lymphocytes  which  form  from  80  to  90  per  cent  of  the  leuco- 
cytes present.  Myelocytes  and  mast  cells  are  either  present  in  small 
numbers  or  absent  altogether. 

The  other  symptoms  of  leukaemia  in  children  resemble  those  in 
adults,  with  the  difference  that,  as  a  rule,  the  progress  of  the  disease  is 
much  more  rapid  in  early  life.  In  most  of  the  cases  the  early  symptoms 
are  latent.  A  sudden  and  alarming  hemorrhage  is  sometimes  the  first 
thing  to  call  attention  to  the  serious  condition.  In  other  cases  there  are 
only  the  symptoms  of  general  weakness  and  auEemia.  Sometimes  the 
splenic  tumour  or  the  enlargement  of  the  lymphatic  glands  is  first  no- 
ticed. In  the  early  part  of  the  disease,  the  usual  symptoms  of  anemia 
are  present — digestive  disturbances,  shortness  of  breath,  weak  and  rapid 
pulse.  Haemorrhages  may  occur  as  an  early  or  late  symptom;  they  are 
most  frequently  from  the  nose,  but  severe  hemorrhages  inay  occur  from 
the  stomach,  the  mouth,  the  intestines,  or  there  may  be  ecchvmoses  upon 
the  skin.  The  enlargement  of  the  spleen  may  be  sufficiently  marked  to 
form  an  abdominal  tumour,  so  as  to  attract  the  attention  even  of  the 
parents.  The  swelling  of  the  liver  is  not  so  great.  The  lymphatic  glands 
are  enlarged  only  to  a  moderate  degree,  and  in  many  cases  this  symptom 
is  absent  altogether.  They  are  painless,  movable,  and  usually  several 
groups  are  affected. 


HEMOPHILIA.  855 

The  late  symptoms  are  dropsy  of  the  feet  or  general  anasarca,  haemor- 
rhages, diarrhoea,  headaches,  general  weakness,  and  attacks  of  fainting. 
Fever  is  quite  constant  in  the  late  stages  of  the  disease,  and  the  tem- 
perature may  be  from  101°  to  103°  F.  The  urine  may  contain  albumin 
and  casts.  Vision  is  sometimes  disturbed  by  the  formation  of  leukemic 
plaques  in  the  retina.  It  is  rare  that  there  are  any  symptoms  referable 
to  the  bones,  although  expansion  and  tenderness  of  the  flat  bones  have 
been  observed. 

Course  and  Prognosis. — The  course  of  leukaemia  is  chronic,  and  in 
most  cases  slowly  progressive,  but  not  always  so.  The  prognosis  is  very 
bad,  the  great  proportion  of  the  cases  in  children  proving  fatal  within  a 
year  from  the  first  symptoms,  in  infancy  sometimes  in  two  or  three 
months.  There  has  been  described  by  Epstein  and  others  an  acute  form 
of  the  disease,  proving  fatal  in  a  few  weeks.  The  usual  causes  of  death 
are  exhaustion,  hsemorrhages,  and  broncho-pneumonia. 

Diagnosis. — This,  in  children,  has  to  be  made  chiefly  from  simple 
anaemia  with  leucocytosis,  and  pseudo-leukaemic  anaemia.  Without  a 
blood  examination  this  is  impossible.  The^  chief  reliance  is  to  be  placed 
upon  the  enormous  increase  in  the  leucocytes,  and  especially  upon  the 
presence  of  numerous  mast  cells  and  myelocytes. 

Treatment. — The  general  treatment  of  leukaemia  should  be  the  same 
as  that  of  anaemia.  Of  the  drugs  now  in  use,  arsenic  has  altogether  the 
most  testimony  in  its  favour.  It  must  be  given  in  large  doses  and  for  a 
long  period.  Next  to  this  in  value  come  iron  and  cod-liver  oil.  Leu- 
kaemia, however,  is  in  most  instances  very  little  influenced  by  treatment. 
The  reported  cures  must  be  taken  with  some  allowance,  for  most  of  these 
were  published  before  the  time  when  leukaemia  was  sharply  differentiated 
from  simple  anaemia  with  leucocytosis  and  from  the  pseudo-leukiemic 
anaemia  of  infancy. 

HEMOPHILIA. 

Hasmophilia  is  an  hereditary  disease,  in  which  there  is  a  tendency  to 
profuse  or  even  uncontrollable  bleeding  from  slight  wounds,  or  some- 
times even  spontaneously.  In  many  cases  there  is  associated  an  inflam- 
mation of  the  joints.    Persons  so  affected  are  known  as  "  bleeders." 

Etiology. — The  hereditary  tendency  of  the  disease  is  very  strongly 
marked,  and  it  has  often  been  traced  through  seven  or  eight  generations. 
Males  are  much  more  frequently  affected  than  females,  the  proportion 
being  about  twelve  to  one.  In  the  matter  of  inheritance,  the  disease  is 
most  often  transmitted  through  the  mother,  who  may,  however,  herself 
■escape.  Patients  suffering  from  haemophilia  have  nothing  else  about 
them  that  is  abnormal.  The  exact  nature  of  the  disease  is  unknown. 
It  has  no  connection  with  either  purpura  or  scurvy.  Although  generally 
classed  among  the  diseases  of  the  blood,  it  has  not  been  established  that 
there  are  any  constant  changes  cither  in  the  blood  or  in  the  blood-vessels. 


856  DISEASES  OP  THE  BLOOD. 

Symptoms. — The  first  manifestations  of  haemophilia  are  not  often 
seen  before  the  second  year.  The  haemorrhages  of  the  newly  born  have 
no  relation  to  this  condition.  The  discovery  of  the  disease  is  generally 
quite  accidental.  The  first  hgemorrhage  may  be  traumatic  or  spontane- 
ous. In  traumatic  haemorrhages  there  may  be  very  severe  bleeding  after 
so  slight  a  wound  as  the  drawing  of  a  tooth;  sometimes  a  large  hgema- 
toma  forms  between  the  muscles  as  the  result  of  a  moderate  contusion. 

The  following  is  the  relative  frequency  of  spontaneous  hemorrhages 
in  334  cases  collected  by  Grandidier:  bleeding  from  the  nose  in  169,. 
mouth  in  43,  intestines  in  36,  stomach  in  15,  urethra  in  16,  lungs  in  17. 
There  may  be  haemorrhage  from  the  skin  or  from  any  mucous  membrane 
of  the  body.  The  attacks  of  spontaneous  hemorrhage  are  often  periodi- 
cal, and  may  be  accompanied  by  arthritic  symptoms  resembling  rheuma- 
tism. The  severity  of  the  hemorrhages  varies  much  in  the  different 
cases.  From  a  slight  wound  a  patient  may  bleed  until  he  is  exsangui- 
nated, and  even  until  death  occurs.  Such  a  result  from  the  first  hemor- 
rhage, however,  is  rare.  In  some  cases  the  disposition  to  bleed  is  out- 
grown in  later  life.  Grandidier  states  that,  of  152  boys,  over  one  half 
died  before  reaching  the  seventh  year.  It  is  striking  that  when  the  dis- 
ease affects  females  there  is  no  tendency  to  excessive  bleeding  at  men- 
struation or  j)arturition. 

Treatment. — The  indications  at  the  time  of  bleeding  are,  to  arrest 
the  hemorrhage  by  the  use  of  the  ordinary  surgical  means — compres- 
sion, styptics,  etc.  (For  epistaxis,  see  page  484.)  Little  benefit  is  to  be 
expected  from  drugs.  In  convalescence  after  attacks  of  hemorrhage, 
iron  and  general  tonics  should  be  given.  In  all  patients  who  are  bleed- 
ers everything  which  might  by  any  means  excite  hemorrhage  should  be 
avoided.  Marriage  should  be  discouraged  in  girls  who  inherit  the 
disease. 

PURPURA. 

The  term  purpura  is  used  to  designate  a  condition  in  which  there  is 
a  tendency  to  spontaneous  hemorrhages  beneath  the  skin,  from  the  vari- 
ous mucous  membranes,  and  in  some  cases  into  the  internal  organs. 
The  term  purpura  simplex  is  applied  to  those  cases  in  which  the  hemor- 
rhages are  limited  to  the  skin;  purpura  hcemorrhagica  to  those  in  which 
there  is  in  addition  bleeding  from  the  mucous  membranes  or  visceral 
hemorrhages.  It  is  impossible  to  draw  a  line  sharply  between  these  two 
classes  of  cases,  as  the  chief  difference  between  them  seems  to  be  one  of 
degree.  Purpura  is  sometimes  known  as  morlus  maculosus  or  as  Werl- 
liofs  disease. 

Symptomatic  Purpura. — This  occurs  in  quite  a  variety  of  conditions, 
the  hemorrhages  generally  being  limited  to  the  skin,  but  not  always  so. 
These  cases  may  be  grouped  in  the  following  classes: 


PURPURA.  857 

1.  Infectious. — This  form  of  purpura  is  very  constantly  seen  in  ma- 
lignant endocarditis,  in  the  hismorrhagic  forms  of  the  various  eruptive 
fevers — measles,  scarlet  fever,  variola,  vaccinia,  and  typhus — also  in 
epidemic  meningitis  and  occasionally  in  diphtheria,  pygemia,  and  septicse- 
mia.  The  occurrence  of  hajmorrhages  in  these  cases  appears  to  depend 
upon  an  altered  condition  of  the  blood,  which  is  a  direct  result  of  the  in- 
fection, and  it  is  a  bad  prognostic  sign. 

2.  Cachectic. — Purpura  occurs  late  in  the  course  of  many  protracted 
and  exhausting  diseases,  especially  in  infancy.  It  is  most  frequently  met 
with  in  broncho-pneumonia,  empyema,  tuberculosis,  ileo-colitis,  in  both 
the  tuberculous  and  the  simple  forms  of  meningitis,  and  in  malignant 
disease.  It  also  occurs  from  apparently  similar  causes  in  several  of  the 
diseases  of  the  blood,  particularly  in  leuksemia  and  pernicious  ana?mia. 
In  most  cases  of  cachectic  purpura  the  haemorrhagic  spots  are  small,  not 
very  abundant,  and  occur  either  upon  the  abdomen  or  the  lower  extrem- 
ities. This  form  is  quite  common  in  hospital  practice,  and  is  almost 
invariably  indicative  of  a  fatal  result.  In  cachectic  purpura  the  liEem- 
orrhages  are  usually  limited  to  the  skin.  The  condition  is  undoubtedly 
dependent  upon  a  deterioration  in  the  blood,  possibly  also  upon  the 
condition  of  the  minute  blood-vessels. 

3.  Toxic. — Certain  drugs,  such  as  phosphorus,  quinine,  potassium 
chlorate  and  sometimes  others,  may  in  rare  cases  produce  haemorrhages 
when  long  continued  or  in  large  doses.  The  liEemorrhage  of  jaundice 
may  also  be  considered  in  this  group. 

■i.  Mechanical  haemorrhages,  such  as  those  occurring  in  pertussis  or 
epilepsy,  are  sometimes  classed  with  purpura.  In  convalescence  from 
protracted  illness  there  are  sometimes  seen,  when  patients  first  stand  or 
walk,  purpuric  spots  on  the  lower  extremities.  They  may  occur  after 
confinement  of  a  limb  in  bandages  or  splints.  In  both  these  cases  the 
cause  is  partly  mechanical  and  partly  due  to  the  weakened  condition  of 
the  blood-vessels. 

5.  Neurotic. — These  cases  are  occasionally  seen  in  diseases  of  the 
spinal  cord  and  sometimes  in  hysteria  in  young  adults,  but  very  rarely 
in  children. 

Primary  Purpura. — This  occurs  in  children  of  all  ages,  being  not  un- 
common in  infancy.  Hasmorrhages  of  the  newly  born  have  not  gener- 
ally been  included  in  this  class,  although  there  are  some  reasons  why  they 
might  well  be.  The  age  at  which  primary  purpura  is  most  frequently 
seen  is  from  two  to  ten  years.  The  sexes  are  about  equally  affected; 
of  Steffen's  56  cases,  27  were  males  and  29  females.  The  disease  may 
occur  in  children  who  are  cachectic,  rachitic,  or  ansemic,  and  in  those 
whoso  surroundings  are  poor,  but  it  has  not,  like  scurvy,  any  close  rela- 
tion to  diet.  It  may  follow  any  acute  disease,  being  associated  most  fre- 
quently with  derangements  of  the  stomach  and  bowels.    Quite  frequently 


858  DISEASES  OF  THE   BLOOD. 

the  disease  develops  abruptly,  without  any  assignable  cause,  in  children 
previously  healthy. 

Lesions. — The  external  hemorrhages  may  occur  upon  any  part  of  the 
body.  There  are  smaller  or  larger  ecchymoses  or  an  infiltration  of  the 
tissues  with  blood,  which  undergoes  gradual  absorption  with  the  usual 
changes.  With  the  hemorrhages,  various  forms  of  inflammation  of  the 
skin  may  be  associated,  especially  erythema  and  urticaria,  with  some- 
times more  or  less  oedema.  HEcmorrhages  from  the  mucous  membranes 
are  more  frequent,  because  of  the  feebler  resistance  of  the  tissues. 
There  are  seen  ecchymoses  upon  the  visible  mucous  membranes  which 
resemble  those  upon  the  skin.  At  autopsy  they  are  occasionally  seen 
in  the  trachea  or  bronchi,  but  more  often  in  the  digestive  tract.  In 
the  colon,  and  occasionally  in  the  small  intestine,  ulcers  may  be  found; 
but  they  are  rarely  if  ever  seen  in  the  stomach.  They  may  be  super- 
ficial or  deep,  and  have  even  been  known  to  cause  perforation. 

Intracranial  hemorrhages  are  rare,  and  are  usually  meningeal. 
These  may  be  sufficient  to  cause  severe  symptoms.  In  1893  a  case 
occurred  in  the  New  York  Infant  Asylum  in  an  infant  six  months  old, 
with  an  extensive  meningeal  hemorrhage  covering  a  large  part  of  the 
brain.     In  Steffen's  paper  several  such  cases  are  mentioned. 

Pulmonary  hemorrhages  are  not  frequent.  Ecch3mioses  are  found 
beneath  the  pericardium;  but  endocarditis  and  pericarditis  are  extreme- 
ly rare,  probably  occurring  only  in  the  rheumatic  cases.  The  spleen  is 
occasionally  enlarged,  but  by  no  means  uniformly  so,  and  it  may  be  the 
seat  of  hemorrhages. 

While  hematuria  is  one  of  the  most  frequent  of  the  visceral  hemor- 
rhages, severe  nephritis  is  rare.  Acute  degeneration  of  the  renal  epithe- 
lium of  the  tubes  is  quite  common.  There  may  be  punctiform  hemor- 
rhages, and  occasionally  larger  ones  beneath  the  capsule  or  in  the  mu- 
cous membrane  of  the  pelvis  of  the  kidney.  The  suprarenal  capsules 
may  be  the  seat  of  extensive  and  even  fatal  hemorrhage.  There  may 
be  effusions  of  a  sero-sanguineous  fluid  into  any  of  the  large  serous 
cavities,  most  frequently  into  the  peritoneum.  The  articular  lesions 
of  purpura  may  be  of  a  rheumatic  character,  with  which  purpura  occurs 
as  a  complication;  or  there  may  be  hemorrhages  into  the  tissues  about 
the  joint,  or  even  into  the  joint  itself^ — usually  the  knee  or  elbow. 

Thus  far  no  constant  or  essential  changes  have  been  demonstrated  in 
the  blood,  other  than  those  which  are  due  to  hemorrhages — viz.,  a  mod- 
erate reduction  in  the  hemoglobin  and  the  red  corpuscles,  with  occa- 
sional irregularities  in  size  and  the  appearance  of  nucleated  red  cells.  In 
the  most  severe  cases  there  is  a  moderate  degree  of  leucocytosis. 

Pathology. — Why  it  is  that  under  certain  circumstances  the  blood- 
vessels will  not  hold  their  contents,  it  is  difficult  to  imderstand.  There 
have  been  described  by  Cassel,  Eiehl,  Wilson,  and  others,  changes  in  the 


PURPURA.  859 

small  blood-vessels,  usually  a  form  of  endarteritis,  but  it  is  not 
necessary  to  assume  a  lesion  in  the  blood-vessels,  since  we  know  that 
diseased  blood  may  pass  through  even  normal  vessels.  Henoch  has 
suggested  the  vaso-motor  origin  of  purpura,  in  which  there  is  first  a 
paralytic  distention  of  the  small  vessels,  followed  by  stasis,  haemorrhage, 
or  oedema.  In  certain  forms,  as  in  malignant  endocarditis,  it  is  well 
established  that  the  cause  is  an  infectious  thrombosis.  Although  the 
bacteriological  examinations  made  thus  far  in  purpura  are  not  numerous 
enough  to  settle  the  question  positively,  there  is  little  doubt  that  infec- 
tion is  the  essential  factor  in  some  forms  of  the  disease,  particularly  in 
the  cases  characterized  by  sudden  onset,  high  temperature,  and  cerebral 
symptoms,  and  which  run  a  rapidly  fatal  course.  At  the  present  time  the 
exact  pathology  of  purpura  is  unknown.  There  are,  no  doubt,  now  in- 
cluded under  this  term,  several  diseases  quite  distinct  from  one  another. 

The  clinical  types. — 1.  The  ordinary  form. — In  the  mild  cases  the 
hsemorrhage  is  confined  to  the  skin  (purpura  simplex),  or  it  is  accom- 
panied by  slight  bleeding  from  the  mucous  membranes.  There  is  usually 
some  general  indisposition  of  an  indefinite  character  for  a  day  or  two  be- 
fore the  purpuric  spots  are  noticed;  most  frequently  a  disturbance  of 
digestion  with  vomiting,  diarrhoea,  and  sometimes  slight  fever.  The 
haemorrhages  appear  as  small  petechige,  varying  in  size  from  a  pin's 
head  to  a  pea;  usually  first  upon  the  lower  extremities.  There  may  be 
only  a  few  widely  scattered  spots  or  the  body  may  be  covered.  The  col- 
our is  first  a  bright  red,  then  purple,  gradually  fading  in  the  course  of  a 
few  days.  N"ew  spots  come  as  the  old  ones  disappear,  so  that  the  amount 
of  eruption  may  not  diminish.    They  do  not  disappear  upon  pressure. 

The  course  of  these  cases  is  generally  favourable,  recovery  taking 
place  in  from  one  to  four  weeks  under  the  influence  of  general  tonic 
treatment.  Eelapses  are,  however,  very  frequent,  and  such  attacks  may 
come  at  intervals  of  a  few  weeks  or  months  for  a  considerable  period. 
One  must  be  guarded  in  giving  an  absolutely  favourable  prognosis  even 
in  cases  of  such  severity,  for  it  occasionally  happens  that  in  a  patient, 
who  for  several  days  has  had  symptoms  of  mild  purpura,  there  suddenly 
develop  those  of  the  most  severe  type  with  a  rapidly  fatal  termination. 

2.  The  severe  form. — Such  cases  are  characterized  by  hemorrhages 
from  the  mucous  membranes  (purpura  haemorrhagica)  from  the  outset. 
These  may  even  appear  before  the  spots  upon  the  skin.  In  severe  attacks 
the  petechial  spots  are  more  likely  to  appear  suddenly,  and  large  ecchy- 
moses,  varying  in  size  from  a  pea  to  the  palm  of  the  hand,  are  more  fre- 
quent. There  may  be  bleeding  from  the  nose,  gums,  mouth,  or  pharynx, 
and  ecchymoses  may  be  seen  upon  these  mucous  membranes,  also  upon 
the  conjunctivae.  Vomiting  of  blood  and  bloody  discharges  from  the 
bowels  are  quite  frequent  symptoms.  The  urine  may  contain  enough 
blood  to  give  it  a  bright-red  colour.    Less  frequently  there  are  seen  ha^m- 


860  DISEASES   OF   THE  BLOOD. 

orrliages  of  the  retina  or  choroid  and  from  the  female  genitals.  In  one 
of  my  own  cases  there  was  almost  continuous  bleeding  from  one  ear.  Cu- 
taneous ecchymoses  are  increased  by  slight  injuries,  such  as  the  pressure 
from  a  bandage  or  from  scratching.  Epistaxis  may  be  copious  enough  to 
necessitate  plugging  of  the  nares.  The  amount  of  blood  vomited  is  not 
often  large;  its  source  may  be  the  stomach,  the  mouth,  or  the  pharynx. 
The  blood  in  the  stools  is  usually  dark  coloured,  but  there  may  be  some 
bright-red  blood  even  when  there  are  no  ulcers  present.  In  one  of  my 
cases  so  much  blood  was  lost  by  the  bowels  as  to  produce  the  symptoms  of 
a  very  marked  cerebral  ansemia.  In  certain  cases  the  gastro-intestinal 
sym^Dtoms  are  very  prominent,  and  there  may  be  slight  icterus.  The  dis- 
charge of  blood  from  the  stomach  or  intestine  may  be  accompanied  by 
very  severe  attacks  cf  colic  and  tenesmus.  In  some  of  these  cases  there 
are  pains  and  slight  swelling  of  the  joints.  Eenal  symptoms  are  generally 
present.  These  attacks  of  pain  with  purpura  and  the  discharge  of  blood, 
may  come  on  paroxysmally  every  few  days  for  a  period  of  several  weeks. 
They  have  been  ascribed  to  thrombosis  of  the  intestinal  vessels.  This  is 
sometimes  known  as  "  Henoch's  purpura." 

Constitutional  symptoms  are  present  in  most  of  the  severe  cases. 
There  is  usually  fever,  from  101°  to  103°  F.,  and  sufficient  prostration  to 
keep  the  patient  in  bed.  If  the  amount  of  blood  lost  is  large,  there  are 
the  usual  symptoms  of  severe  anaemia.  The  loss  of  blood  may  be  suffi- 
cient to  cause  death,  particularly  in  infants.  Cerebral  sj^mptoms  may 
depend  upon  angemia  or  upon  meningeal  hemorrhage.  They  are  not 
frequent  in  this  form  of  the  disease.  CEdema,  especially  of  the  face 
and  feet,  may  exist  without  albuminuria,  and  albuminuria  may  be  pres- 
sent  in  cases  in  which  there  is  no  renal  hsemorrhage. 

In  some  of  the  cases  beginning  with  severe  general  symptoms,  and 
occasionally  when  the  onset  is  mild,  the  patients  after  a  few  days  pass 
into  a  typhoid  condition  with  low  delirium,  great  prostration,  weak  and 
irregular  pulse,  dry,  cracked  tongue,  and  high  temperature.  Such  cases 
are  almost  always  fatal.  They  are  not  to  be  confounded  with  ordinary 
typhoid  fever  complicated  by  purpura. 

The  course  varies  much  in  the  different  cases.  It  lasts  from  one  to 
six  weeks,  the  symptoms  slowly  subsiding,  but  often  showing  a  strong 
tendency  to  recurrence.  The  prognosis  depends  upon  the  age  of  the 
patient,  the  extent  of  the  haemorrhage,  and  the  presence  or  absence  of 
septic  symptoms. 

3.  The  hyper-acute  form  (purpura  fulminans). — This  is  a  rare  form, 
especially  in  young  children.  Its  development  is  usually  sudden  with  a 
chill,  vomiting,  marked  prostration,  and  high  temperature.  The  pur- 
puric spots  come  out  with  great  rapidity,  and  in  the  course  of  a  few 
hours  or  a  day  they  may  be  very  extensive.  In  addition  to  the  ordinary 
subcutaneous  haemorrhages,  bloody  vesicles  may  form  upon  the  skin.    In 


PURPURA.  861 

many  cases  the  hsemorrhages  are  limited  to  the  skin,  the  mucous  mem- 
branes and  the  viscera  escaping  altogether.  There  is  no  tendency  to 
gangrene.  Cerebral  symptoms  are  invariably  present  and  usually  promi- 
nent; there  may  be  delirium,  dulness,  stupor,  and  finally  coma.  The 
spleen  is  apt  to  be  enlarged.  The  urine  is  nearly  always  albuminous. 
This  form  of  purpura  has  all  the  characteristics  of  a  general  infectious 
disease,  and  it  is  almost  invariably  fatal. 

4.  The  gangrenous  form. — Sloughing  is  not  common  in  purpura,  but 
it  is  most  often  seen  in  the  mucous  membranes.  Osier  refers  to  two 
cases  affecting  the  uvula.  I  once  saw  a  slough  which  caused  perforation 
of  the  soft  palate.  Wickham  Legg  reports  a  case  with  gangrene  of  the 
prepuce.  Gangrene  of  the  skin  is  even  less  frec|uent,  although  cases 
have  been  reported  even  in  young  children.  Charron's  case  was  only  three 
years  old,  and  several  others  in  children  are  collected  in  Gimard's  mono- 
graph upon  this  subject.  The  gangrene  may  involve  the  skin  only,  or 
the  subcutaneous  tissues  and  even  the  muscles.  It  has  been  seen  upon 
the  upper  and  lower  extremities  and  even  upon  the  face,  and  may  extend 
over  quite  a  large  surface.  In  some  of  the  milder  forms  of  purpura,  gan- 
grene results  from  some  slight  injury,  such  as  a  blow,  the  pressure  from 
a  bandage,  or  in  the  nose,  from  the  pressure  of  a  tampon.  These  cases 
are  almost  invariably  fatal.  Those  in  which  the  sloughing  is  confined  to 
small  areas  of  the  mucous  membrane  of  the  mouth  often  recover. 

5.  The  rheumatic  form. — The  term  "  rheumatic  purpura  "  (peliosis 
rheumatica)  is  ajDplied  to  cases,  not  so  common  in  children  as  in  older 
patients,  in  which  subcutaneous  haemorrhages,  and  sometimes  bleeding 
from  the  mucous  membranes,  are  associated  with  painful  joint  swell- 
ings. These  are  to  be  regarded  as  cases  of  rheumatism  complicated  by 
purpura.  The  joints  most  frequently  affected  are  the  knee  and  the 
ankle.  The  arthritic  symptoms  are  usually  less  severe  than  in  attacks 
of  acute  rheumatism.  There  may  be  present  erythema  exudativum  or 
erythema  nodosum  or  urticaria.  Usually  there  are  throat  symptoms 
and  fever,  and  frequently  oedema  of  the  face  and  eyelids  with  albumi- 
nuria. The  spleen  may  be  enlarged.  The  usual  duration  is  from  one 
to  three  weeks,  and  although  relapses  may  occur,  the  cases  usually 
recover. 

Joint  symptoms,  particularly  articular  pains,  are  not  infrequent  in 
the  course  of  milder  attacks  of  purpura  without  the  febrile  symptoms 
mentioned.  In  severe  cases  extravasations  of  blood  have  been  reported 
as  occurring  in  the  tissues  about  the  joints,  and  even  in  the  joints  them- 
selves, these  being  cases  of  true  arthritic  purpura.  It  is  probable  that, 
in  the  past,  some  cases  of  scurvy  have  been  included  in  this  group. 

Diagnosis. — The  rapid  acute  cases  may  be  confounded  with  the  haem- 
orrhagic  forms  of  the  various  eruptive  fevers.  The  ordinary  subacute  or 
passive  forms  are  chiefly  to  be  differentiated  from  scurvy.  The  diagnosis 
56 


862  DISEASES  OF  THE  LYMPH  NODES. 

is  not  difficult  and  the  mistake  need  not  be  made  if  the  essential  features 
of  scurvy  are  borne  in  mind — its  dietetic  cause,  bleeding  gums,  hj'perges- 
thesia,  and  deep  rather  than  subcutaneous  hfemorrhages  which  are  usu- 
ally near  the  joints. 

Prognosis. — This  depends  very  much  upon  the  form  of  the  disease. 
Of  128  cases  of  all  varieties  occurring  in  children  in  Steffen's  collection, 
there  were  -iO  deaths.  In  12  cases  of  severe  primary  purpura  reported  by 
Gimard,  there  were  3  deaths  and  9  recoveries.  Purpura  simplex  is  rarely 
fatal;  cases  of  purpura  hemorrhagica  usuall}"  recover  unless  marked 
febrile  symptoms  are  present.  The  forms  classed  as  typhoid,  gangre- 
nous, and  purpura  fulminans  are  almost  invariably  fatal.  The  tendency 
to  relapses  exists  in  all  varieties. 

Treatment. — The  treatment  of  symptomatic  purpura  should  have  ref- 
erence to  the  cause  of  the  disease.  The  mild  cases  of  primary  purpura 
usuall}^  recover  promptly  under  a  tonic  plan  of  treatment.  The  more 
severe  cases  recjuire  confinement  in  bed,  absolute  quiet,  and  care  to  avoid 
exposure  and  even  the  slightest  injury  or  extra  pressure  upon  any  part. 
Drugs  do  not  seem  greatly  to  influence  the  course  of  the  disease.  Those 
most  frec[uently  employed  are  supra-renal  extract,  hydrastis,  hama- 
melis,  aromatic  sulphuric  acid,  the  vegetable  acids,  ergot,  and  gallic  acid. 
Whether  or  not  it  is  true,  as  claimed  by  some,  that  all  hgemorrhagic  dis- 
eases are  related  to  scurvj^,  the  striking  improvement  seen  in  this  disease 
from  the  use  of  fresh  fruit  and  vegetables,  suggests  their  employment  in 
purpura.  In  some  cases  very  decided  benefit  seems  to  follow  their  use  in 
the  acute  stage,  but  more  particularly  in  convalescence.  For  hyperacute 
and  gangrenous  cases,  little  can  be  done  except  to  treat  the  symptoms. 
Surgical  means  of  arresting  the  hsemorrhage  are  rarely  successful.  Iron 
and  arsenic  and  alcoholic  stimulants  should  be  used  in  all  cases  during 
convalescence. 


CHAPTER  II. 

DISEASES  OF  TEE  LYMPH  NODES  {LYMPHATIC  GLANDS). 

LYMPHATISM  (STATUS  LYMPHATICUS). 

It  is  characteristic  of  infancy  and  childhood  that  the  lymphatic 
glands,  or  the  lymph  nodes,  as  they  are  now  coming  to  be  generally 
called,  throughout  the  body  are  prone  to  swelling  and  hyperplasia. 
"While  this  tendency  belongs  to  all  children,  in  certain  individuals  it  is  so 
marked  as  to  deserve  a  place  as  a  distinct  diathesis.  It  was  formerly 
classed  as  one  of  the  manifestations  of  "scrofula"  or  "struma";  but 
the  proof  that  most  of  the  manifestations  formerly  classed  as  "  scrofu- 
lous ''■  are  really  forms  of  local  tuberculosis,  makes  it  undesirable  to  use 


LYMPHATISM.  •  863 

that  term  any  longer  as  descriptive  of  conditions  now  known  to  be  often 
due  to  other  causes  besides  tuberculosis.  By  French  writers  the  term 
lymphatisni,  and  by  German  writers  the  term  status  lymphaticus,  has 
been  used  to  designate  this  condition. 

In  stout,  robust  children,  infectious  processes  of  the  nose,  pharynx,  or 
bronchi,  cause  acute  swelliug  of  the  lymph  nodes  in  the  neighbourhood, 
but  these  rapidly  subside  when  the  cause  is  removed.  In  others,  in  whom 
a  certain  constitutional  condition  exists,  the  process  in  the  mucous  mem- 
brane is  likely  to  be  protracted,  and  the  enlargement  of  the  lymphatic 
glands  once  started  continues  even  after  the  primary  cause  has  subsided ; 
or,  diminishing  for  a  time,  it  increases  again  with  every  new  exciting 
cause  until  permanent  enlargement  may  be  produced. 

I  shall  use  the  term  lymphatism  in  the  sense  indicated, — viz.,  to  desig- 
nate an  exaggerated  susceptibility  of  the  lymphoid  tissue,  a  constitutional 
condition  in  which  any  inflammation  of  the  mucous  membranes  or  skin 
sets  up  hyperplasia  in  the  lymph  nodes  with  which  these  parts  are  con- 
nected, which  is  out  of  proportion  to  the  exciting  cause  and  which  con- 
tinues after  the  cause  has  ceased  to  operate.  Besides,  there  must  be  in- 
cluded in  this  category,  children  who  at  birth  have  an  excessive  develoji- 
ment  of  lymphoid  tissue,  seen  particularly  in  the  region  of  the  throat  in 
the  form  of  enlarged  tonsils,  adenoid  vegetations  of  the  pharynx,  etc. 

Lymphatism  may  be  inherited  or  acquired.  The  influence  of  heredity 
is  too  often  seen  to  be  passed  over  as  a  coincidence.  Frequently  the 
parents,  when  children,  suffered  from  the  same  condition,  and  very  often 
every  member  of  a  large  family  of  children  is  affected.  This  may  be  the 
case  in  those  who  are  in  other  respects  healthy,  who  have  been  reared  amid 
good  surroundings,  and  in  whom  no  evidence  of  any  other  constitutional 
disease  can  be  found.  Any  disease  in  the  parents  in  consequence  of  which 
children  are  born  with  tissues  having  less  than  normal  resistance,  may  be 
regarded  in  the  light  of  a  remote  cause.  As  such  may  be  mentioned  gout, 
rheumatism,  alcoholism,  syphilis,  or  tuberculosis,  the  child  under  these.- 
conditions  inheriting  not  the  disease,  but,  so  to  speak,  its  consequences. 

Among  the  causes  operating  after  birth  to  produce  lymphatism,  the 
surroundings  of  the  child  are  of  the  first  importance.  It  is  seen  to  per- 
fection in  children  reared  in  institutions ;  it  is  also  frequent  in  crowded 
tenements  and  in  cities  rather  than  in  the  country.  Anything  which 
produces  malnutrition  or  lowers  the  general  vitality  of  the  tissues  may  be 
ranked  as  a  cause.  Rickets  and  lymphatism  are  very  frequently  associated  ; 
sometimes  rickets  is  to  be  reckoned  as  a  cause,  and  sometimes  both  con- 
ditions depend  upon  the  same  causes. 

The  local  manifestations  of  lymphatism  are  modified  by  the  age  of  the 
child.  During  infancy,  the  glands  which  are  most  frequently  affected  are 
those  connected  with  the  gastro-enteric  and  tlic  bronchial  mucous  mem- 
branes ;  in  childhood  it  is  those  which  are  connected  with  the  pharynx 


864  DISEASES  OF  THE   LYMPH  NODES. 

and  tonsils.  This  localization,  of  course,  depends  largely  upon  the  fact 
that  the  susceptibility  of  the  different  mucous  membranes  is  greatly  in- 
fluenced by  age. 

The  degree  of  enlargement  of  the  lymph  nodes  which  is  sometimes 
found  in  the  different  situations  has  often  led  to  a  misinterpretation  of 
them,  particularly  by  those  who  only  seldom  see  autopsies  upon  infants 
or  young  children.  They  have  often  been  connected  with  pathological 
conditions  or  clinical  symptoms  with  which  they  have  really  nothing  to 
do.     One  or  two  examples  will  suffice : 

Enlargement  of  the  mesenteric  glands  and  of  the  solitary  follicles  of 
the  large  and  small  intestine,  are  very  frequently  seen  in  infants  who 
have  died  of  marasmus,  and  have  been  regarded  as  the  cause  of  the  wast- 
ing, while  in  reality  they  were  only  the  consequence  of  the  chronic  indi- 
gestion which  is  an  almost  constant  accompaniment  of  that  condition. 
The  finding  of  swollen  Peyer's  patches  in  cases  of  acute  diarrhoea,  with 
some  other  symptoms  during  life  suggestive  of  typhoid  fever,  have  often 
been  looked  upon  as  a  confirmation  of  that  diagnosis,  as  in  a  case  re- 
ported by  Korthrup,  in  which  cultures  showed  that  the  disease  was  not 
typhoid. 

The  condition  under  consideration  relates  not  only  to  the  larger 
Ij^mph  nodes,  but  to  the  smaller  ones  discernible  only  by  the  microscope. 
When  swelling  of  the  larger  ones  exists,  great  numbers  of  the  small  ones 
are  sure  to  be  affected  in  the  same  way. 

Lymphatism  is  essentially  a  condition  of  childhood.  As  time  passes 
we  see  a  regular  succession  of  retrograde  changes  in  the  different  series 
of  glands  unless  they  become  the  seat  of  tuberculous  infection.  Those 
connected  with  the  digestive  tract  begin  to  diminish  after  the  second 
year,  and  by  the  fifth  or  sixth  year  the  enlargement  has  almost  disap- 
peared; while  the  tonsils,  adenoid  growths  of  the  pharynx,  and  enlarged 
cervical  glands  are  usually  stationary  after  the  seventh  or  eighth  year 
and  undergo  quite  a  marked  atrophy  about  the  time  of  puberty.  The 
presence  of  these  enlarged  lymph  nodes,  the  catarrhal  condition  of  the 
mucous  membranes  with  which  thej^  are  associated,  and  the  constitu- 
tional condition  upon  which  both  depend,  are  important  in  relation  to  all 
acute  infectious  diseases  which  affect  these  mucous  membranes.  They 
bring  about  an  increased  susceptibility  to  scarlet  fever,  measles,  diph- 
theria, diarrhceal  diseases,  and  most  of  all  to  tuberculosis. 

A  point  of  much  practical  importance  with  reference  to  children  in 
whom  this  condition  is  marked  is  that  they  bear  ansesthetics,  particularly 
chloroform,  badly.  This  has  already  been  referred  to  in  the  chapter  upon 
Adenoids  in  operations  for  which  many  of  the  deaths  from  chloroform 
have  occurred,  but  the  danger  belongs  alike  to  all  operations. 


SIMPLE   ACUTE   ADENITIS. 


865 


Table  showing  the  Situation  and  the  Drainage-Areas  of  the  Various 
Groups  of  Lymph  Nodes  of  the  Head  and  Neck* 


9 
10 


Name  of  the 
group. 


Sub-occipital 
Mastoid. 

Parotid. 


Submaxil- 
lary. 

Supra-hyoid. 

Superficial 
cervical. 


Deep  cervi- 
cal, upper 
set. 


Deep  cervi- 
cal, lower 
set. 

Sub-hyoid. 


Retro-phar- 
yngeal. 


Number  and  situation. 


One  or  two  ;  at  nape  of  neck. 
Pour  or  five  small  ones ;  in 

mastoid  region. 
Five  to  ten ;  on  the  surface 

and  in  the  substance  of 

the  parotid  gland. 

Twelve  to  fifteen  ;  along  base 
of  jaw,  beneath  cervical 
fascia. 

One  or  two  ;  median  line  be- 
tween chin  and  hyoid  bone. 

Five  or  more  ;  along  external 
jugular  vein,  beneath  pla- 
tysma,  but  superficial  to 
the  sterno-mastoid. 

Ten  to  sixteen  ;  about  bifur- 
cation of  common  carotid 
and  along  internal  jugular 
vein.  They  are  just  above 
upper  border  of  thyroid 
cartilage  and  on  a  level 
with  hyoid  bone. 

A  chain  in  the  supra-clavicu- 
lar fossa. 


A  few  small  glands  below 
hyoid  bone  and  near  me- 
dian line. 

Two  small  glands  in  front  of 
spine  and  upon  preverte- 
bral muscles. 


Organs  or  areas  from  which  they  receive 
lymphatics. 


Scalp,  posterior  portion. 

Receive  efferent  vessels  from  group  1, 

and  through  them  from  part  of  scalp. 
Scalp,  frontal  and  parietal  portions ; 

orbit,  posterior  part  of  nasal  fossa, 

upper  jaw,  posterior  and  upper  part 

of  pharynx. 
Mouth,  lower  lip,  gums. 


Chin  and  middle  portion  of  lower  lip. 

Auricle,  part  of  scalp,  skin  of  face 
and  neck,  and  some  efferent  ves- 
sels from  groups  1  and  2. 

Lower  part  of  pharynx,  larynx,  palate, 
tonsils  and  part  of  tongue,  part  of 
nasal  fossa,  deep  muscles  of  head 
and  neck,  and  from  inside  the  crani- 
um. Receive  also  efferent  vessels 
from  groups  3  and  4. 

Connect  with  axillary  group  by  a  chain 
along  axillary  artery;  also  with 
glands  of  mediastinum  and  with 
groups  7  and  9. 

Communicate  with  group  8,  and  may 
connect  below  with  chain  of  bron- 
chial glands. 

Pharynx  and  part  of  nasal  fossa. 


SIMPLE  ACUTE   ADENITIS. 

This  is  an  acute  inflammation  of  the  lymph  nodes  which  in  infancy 
frequently  terminates  in  suppuration.  A  certain  amount  of  inflamma- 
tion of  the  lymph  nodes  occurs  in  children  in  all  acute  processes  affect- 
ing the  mucous  membranes,  especially  when  they  are  severe  or  prolonged. 
Those  in  connection  with  the  various  internal  organs  are  considered  with 
the  diseases  of  the  organs.  Acute  inflammation  of  the  external  nodes 
is  of  sufficient  frequency  to  require  separate  consideration.  While  this 
is  probably  always  secondary  to  some  pathological  process  in  the  skin 
or  mucous  membranes,  the  primary  condition  may  be  so  slight  as  to  be 
overlooked,  and  the  adenitis  may  be  the  more  important  condition  or  may 
even  assume  the  appearance  of  a  primary  disease.     It  is  particularly  in 


*  Modified  from  Treves  after  Curnow  in  the  Lancet,  1879,  vol.  i,  p.  397. 


866  DISEASES  OF  THE  LYMPH  NODES. 

infants  that  this  is  seen,  and  it  depends  upon  the  unusually  active  absorp- 
tion and  upon  the  susceptibility  of  the  lymphoid  tissues  at  this  age.  The 
cervical  glands  are  frequently  affected,  and  occasionally  those  of  the  axil- 
lary and  inguinal  regions. 

Etiology. — Acute  adenitis  occurs  in  children  of  all  ages  in  connection 
with  diphtheria,  scarlet  fever,  measles,  and  influenza.  In  such  cases  it  is 
often  severe,  and  after  scarlet  fever,  occasionally  terminates  in  suppu- 
ration. With  the  simple  acute  catarrhal  processes  of  the  pharynx  and 
rhino-pharynx  adenitis  also  occurs,  but  it  is  usually  mild  and  rarely 
ends  in  suppuration.  In  infancy,  on  the  other  hand,  acute  adenitis 
from  simple  catarrh  is  not  only  very  common  but  often  severe,  and  fre- 
quently terminates  in  suppuration.  Ulcerative  stomatitis,  carious 
teeth,  eczema  of  the  scalp  or  traumatism,  may  excite  adenitis  in  chil- 
dren of  all  ages.  Axillary  adenitis  may  result  from  vaccination;  ingui- 
nal adenitis,  from  vaginitis. 

Of  109  cases  of  acute  adenitis  from  my  records,  not  including  any 
associated  with  diphtheria,  measles,  or  scarlet  fever,  more  than  three 
fourths  occurred  in  the  first  two  years,  and  half  of  them  in  the  first  year 
of  life.  This  susceptibility  of  infants  is  very  striking.  The  disease  oc- 
curs frequently  in  those  who  are  in  other  respects  perfectly  healthy, 
and  often  when  the  evidences  of  disease  of  the  mucous  membrane  are 
slight.  This  is  true  not  only  of  the  cases  of  cervical  adenitis,  but  also 
of  others  in  which  the  inguinal  glands  are  involved.  The  inflammation 
is  excited  in  most  of  these  cases  by  the  absorption  of  pyogenic  germs, 
usually  staphylococci  or  streptococci,  from  the  mucous  membranes  or 
skin;  in  some  cases,  as  in  diphtheria,  probably  by  the  action  of  toxins. 

Lesions. — The  changes  taking  place  in  the  glands  are  acute  conges- 
tion, with  swelling,  oedema,  and  active  hyperplasia  of  the  lymphoid  ele- 
ments. The  process  may  terminate  in  resolution  or  in  suppuration  ac- 
cording to  the  intensity  of  the  infection  and  the  susceptibility  of  the  tis- 
sues. When  severe  enough  to  cause  suppuration,  the  adenitis  is  accom- 
panied by  considerable  inflammation  of  the  surrounding  cellular  tissue. 

In  the  series  of  109  acute  cases  to  which  I  have  referred,  not  includ- 
ing the  specific  infectious  diseases,  96  were  cervical,  9  were  inguinal, 
and  4  axillary;  62  per  cent  terminated  in  suppuration,  the  latter  being 
nearly  all  in  infancy.  Suppurative  otitis  was  present  in  16  per  cent  of 
the  cases.  Suppurative  retro-pharyngeal  adenitis  (retro-pharyngeal 
abscess)  was  seen  in  several  cases. 

In  infancy  the  disease  is  usually  unilateral,  or,  if  bilateral,  the 
glands  of  one  side  are  more  severely  affected  than  those  of  the  other. 
Suppuration  is  nearly  always  of  one  side,  and  usually  the  abscess  starts 
from  a  single  gland. 

Symptoms. — The  symptoms  and  course  of  the  adenitis  of  the  specific 
infectious  diseases  belong  to  their  clinical  history.  Suppuration  is  infre- 
quent, except  after  scarlet  fever.   It  is  very  rare  after  diphtheria,  and 


SIMPLE   ACUTE   ADENITIS. 


867 


when  present  nsnally  signifies  mixed  infection;  I  have  seen  it  occui'  but 
twice. 

The  typical  cases  of  acute  adenitis  are  those  which  occur  in  infancy. 
There  are  present  the  symptoms  of  the  original  disease, — usually  catarrh 
of  tlie  nose  or  rhino-pharynx,  mouth, 
or  ear,  which  may  not  be  very  severe, 

and  sometimes   is  ovei'looked.      The  ,-. . 

glands  most  frequently  affected  are 
tlie  deep  cervical  group.  The  tumour 
appears  just  below  the  angle  of  the 
jaw  at  the  anterior  border  of  the 
sterno-mastoid  muscle  (Fig.  157). 
The  swelling  during  the  acute  catarrh 
is  not  rapid  or  great,  but  continues 
after  the  original  process  has  sub- 
sided until  it  reaches  the  size  of  a 
w^alnut  or  even  larger.  In  the  most 
acute  cases  there  is  marked  inflamma- 
tion of  the  jDcriglandular  celhilar  tis- 
sue, with  pain,  tenderness,  and  extra 
heat.  If  suppuration  occurs,  it  is  gen- 
erally evident  in  the  latter  part  of  the 
second  week,  but  sometimes  it  may 
be  as  late   as  the  third  or  even  the 

fourth  week.  In  the  axillary  or  inguinal  region  (Fig.  158)  the  symptoms 
of  adenitis  are  essentially  the  same  as  in  the  neck.  In  the  inguinal  cases 
the  degree  of  catarrh  of  the  mucous  membrane  is  often  very  slight. 

Most  cases  run  their  course  wuth 
slight  fever  and  few  general  symp- 
toms ;  but  in  young  infants  the  con- 
stitutional symptoms  are  often  severe 
and  the  physician  may  be  in  doubt 
whether  the  local  process  is  suffi- 
cient to  explain  them.  The  temper- 
ature may  be  from  102°  to  104°  F.  for 
several  days,  with  considerable  pros- 
tration, which  is  much  increased  if 
there  is  complicating  otitis.  After 
suppuration,  if  freely  opened  at  the 
proper  time,  the  abscess  heals  rapidly 
and  permanently,  a  sinus  being  rare. 
Occasionally  infection  extends  from 
,,      ,        ,  .        ,      .  one  gland  to  another,  and  a  succession 

tio.   l.>^.— Aeulu   suj-iiurutive   adenitis   (in- 

guiiuii)  in  an  ini'aat  thruo  montlia  old.         of  these  glandular  abscesses  occurs. 


Fig.  157. — Acute  suppurative  adynitis  in  an 
infant  one  year  olcl,  showintr  tlie  most  fre- 
quent situation  of  the  tumour  in  the  cervi- 
cal retrion. 


868  DISEASES  OP  THE  LYMPH  NODES. 

In  the  non-suppurative  cases  the  sweUing  may  be  even  greater  than 
in  those  which  suppurate ;  but  it  is  less  diffuse  and  apparently  limited  to 
the  gland.  It  subsides  slowly  in  the  course  of  from  four  to  eight  weeks, 
often  leaving  a  small  tumour  which  may  be  apparent  for  several  months. 
In  susceptible  children  recurrent  attacks  of  acute  inflammation  may  lead 
to  chronic  enlargement  which  may  last  indefinitely.  These  glands  do 
not  become  cheesy,  except  from  subsequent  tuberculous  infection. 

The  acute  cases  in  infancy  in  which  suppuration  occurs,  appear  to 
recover  about  as  promptly  and  quite  as  completely  as  those  terminating 
in  resolution,  although  in  the  former  the  constitutional  symptoms  are 
more  severe. 

Diagnosis. — This  is  usually  easy  if  it  is  remembered  that,  with  the  ex- 
ception of  the  specific  infectious  diseases,  and  occasionally  local  causes 
like  eczema  of  the  scalp,  carious  teeth,  etc.,  acute  suppurative  adenitis  is 
essentially  a  disease  of  infancy.  I  have  often  seen  it  mistaken  for  mumps 
when  the  swelling  was  severe,  but  on  close  examination  there  is  but  little 
resemblance  between  the  conditions.  The  disease  is  essentially  acute,  and 
has  nothing  in  common  with  the  slow  suppuration  seen  in  later  childhood 
from  the  breaking  down  of  tuberculous  glands. 

Treatment. — Prophylaxis  requires  that  in  all  acute  catarrhs  the  mu- 
cous membrane  should  be  kept  as  clean  as  possible  by  the  use  of  nasal  or 
pharyngeal  sprays,  or  by  syringing  with  simple  solutions  like  Dobell's  or 
Seller's  (page  56),  or  one  of  common  salt. 

In  the  stage  of  acute  inflammation  very  hot  applications  or  an  ice- 
bag  may  be  used  for  the  relief  of  pain.  It  is  very  doubtful  whether 
either  of  these  means  has  much  influence  in  preventing  suppuration.  If 
abscess  forms,  incision  should  be  deferred  until  pointing  has  taken  place. 
If  this  plan  is  followed,  refilling  is  rare.  A  simple  free  incision  with 
proper  aseptic  treatment  is  all  that  is  required.  Curetting  may  be 
done  if  there  is  much  broken-down  tissue  present,  but  it  is  not  usually 
necessary.  In  most  of  the  cases  the  abscess  piomptly  heals  and  a  perfect 
cure  takes  place.  In  cases  which  do  not  suppurate,  absorption  may  be 
promoted  by  the  internal  use  of  the  iodide  of  potassium  in  full  doses — 
gr.  X  daily  to  an  infant  of  one  jeav.  1  confess  rarely  to  have  seen  any 
benefit  from  painting  with  iodine  or  from  inunctions  of  iodine  ointment 
or  the  oleate  of  mercury.  If  adenitis  is  secondary  to  carious  teeth, 
eczema,  or  ulcerative  stomatitis,  these  conditions  should  receive  appro- 
priate treatment.  Such  cases  do  not  usually  suppurate,  but  subside  rap- 
idly when  the  primary  cause  is  removed. 

SIMPLE  CHRONIC  ADENITIS. 
This  consists  in  a  simple  hyperplasia  of  the  lymph  nodes.    There  are 
considered  here  only  the  external  glands,  but  those  of  the  cavities  of  the 
body  are  affected  in  a  similar  way,  in  diseases  of  the  mucous  membranes 
with  which  they  are  connected. 


SYPHILITIC  ADENITIS.  869 

Simple  chronic  adenitis  is  not  nearly  so  frequent  as  the  acute  form 
even  in  infants  and  young  children,  and  it  is  rare  after  the  fifth  year.  It 
may  follow  one  or  more  attacks  of  acute  adenitis,  or  it  may  result  from 
subacute  or  chronic  inflammations  of  the  skin  or  of  the  various  mucous 
membranes,  infection  from  which  causes  the  acute  form.  The  most  fre- 
quent subjects  are  children  who  have  the  diathesis  described  as  "  lym- 
phatism.*' 

Symptoms.— The  glands  upon  both  sides  of  the  neck  are  usually 
involved,  and  more  often  a  group  than  a  single  gland.  The  degree  of 
swelling  is  not  generally  great,  being  much  less  than  in  acute  adenitis, 
and  usually  less  than  in  the  tuberculous  form.  There  are  no  constitu- 
tional symptoms.  Hypertrophy  of  the  tonsils  and  adenoid  growths  of 
the  pharynx  are  frequently  present.  There  is  no  tendency  to  suppura- 
tion or  caseation.  The  swelling  usually  increases  slowly  for  one  or  two 
months,  then  remains  stationary  for  about  the  same  length  of  time,  after 
which  it  slowly  subsides.  A  subacute  course  is  more  frequent  than  a 
very  chronic  one. 

Diagnosis. — These  cases  are  especially  to  be  distinguished  from  those 
of  tuberculous  adenitis.  The  most  important  points  for  differentiation 
are,  that  they  occur  most  frequently  in  children  under  three  years,  a 
period  when  tuberculous  adenitis  is  not  common;  some  definite  exciting 
cause  is  usually  present;  caseation  and  suppuration  do  not  occur;  the 
glands  do  not  become  adherent  to  the  skin  or  to  the  deeper  tissues; 
they  enlarge  much  more  rapidly  than  do  the  non-caseating  tuberculous 
glands;  and  they  are  influenced  to  a  much  greater  degree  by  constitu- 
tional treatment. 

Treatment." — Operative  measures  are  not  called  for  in  simple  ade- 
nitis; but  as  there  are  some  cases  in  which  a  positive  diagnosis  from 
tuberculous  adenitis  is  impossible,  operation  is  to  be  considered  in  all 
doubtful  cases  if  a  thorough  trial  of  other  measures  for  two  or  three 
months  has  been  without  benefit.  Local  causes  usually  found  in  the 
pharynx,  nose,  or  mouth  should  be  removed  if  possible.  Often  more  can 
be  accomplished  by  removal  to  a  climate  in  which  the  child's  catarrlial 
symptoms  are  relieved  than  by  all  else.  Little  benefit  is  seen  from  local 
applications.  The  most  useful  internal  remedies  are,  the  syrup  of  the 
iodide  of  iron  (twenty  drops  three  times  a  day  to  a  child  of  four  years), 
guiaquin  (one  grain  three  times  a  day),  and  arsenic  (two  or  throe  drops 
of  Fowler's  solution  three  times  a  day).  Cod-liver  oil  should  be  given 
except  during  warm  weather. 

SYPniLITIO  ADENITIS. 

It  is  quite  rare  that  a  marked  degree  of  glandular  enlargement  is 
seen  as  a  symptom  of  hereditary  syphilis :  iiidoed,  it  is  so  rare  that  it  is 
often  forgotten  that  chronic  iiuilliple  glnudul.-ii'  enlargements  are  ever 


870  DISEASES  OP  THE  LYMPH  NODES. 

due  to  this  disease.  In  the  few  examples  that  have  come  under  my  ob- 
servation, this  has  been  a  late  symptom  of  hereditary  syphilis.  The 
glandular  enlargements  were  cervical  and  multiple,  and  the  degree  of 
swelling  was  often  marked.  They  may  be  associated  with  disease  of  the 
bones  or  of  the  mucous  membrane  of  the  throat  or  of  the  nose,  or  with- 
out signs  of  such  disease.  The  diagnosis  of  syphilis  rests  upon  the  asso- 
ciation of  other  late  manifestations  of  the  disease — keratitis,  periostitis, 
deformities  of  the  teeth — and  the  prompt  improvement  under  anti- 
syphilitic  treatment.  In  their  local  appearance  they  resemble  tubercu- 
lous glands. 

TUBERCULOUS  ADENITIS. 
Synonym :  Scrofula. 

Tuberculous  disease  of  the  lymph  glands  of  the  cavities  of  the  body 
is  discussed  elsewhere;  only  that  of  the  external  glands  is  here  consid- 
ered. This  condition  presents  some  striking  peculiarities:  it  is  rela- 
tively rare  in  infancy,  although  a  frequent  form  of  tuberculosis  in 
older  children;  it  often  exists  as  the  only  tuberculous  lesion  in  the  body. 
In  the  great  majority  of  cases  it  is  the  cervical  glands  which  are  afEected. 

Etiology. — The  age  at  which  tuberculosis  of  the  cervical  lymph  glands 
is  usually  seen  is  from  three  to  ten  years.  In  my  experience  with  tuber- 
culosis in  infancy,  the  external  glands  are  rarely  involved,  while  the 
bronchial  glands  are  almost  invariably  the  seat  of  infection. 

Local  conditions  favouring  infection  are  adenoid  growths  of  the 
pharynx,  chronic  pharyngitis,  and  hypertrophied  tonsils ;  less  frequently 
chronic  otitis,  chronic  conjunctivitis,  and  pathological  processes  of  the 
skin  or  the  mouth,  such  as  eczema  of  the  face  or  scalp,  ulcerative  stoma- 
titis, carious  teeth,  etc.  That  the  pharynx  is  the  most  frequent  seat  of 
primary  infection,  is  shown  by  the  fact  that  the  deep  cervical  glands  are 
generally  first  affected.  The  question  often  arises  whether  the  process 
is  at  first  a  simple  one,  and  later  becomes  tuberculous,  or  whether  it  is 
tuberculous  from  the  outset.  My  own  belief  is  that  in  most  cases  the 
process  is  a  tuberculous  one  from  the  beginning. 

Children  who  are  by  inheritance  predisposed  to  tuberculosis  and  those 
also  who  are  prone  to  glandular  enlargements — two  conditions  which  are 
by  no  means  identical — are  the  ones  most  liable  to  be  affected.  Attacks 
of  acute  infectious  diseases,  particularly  measles,  scarlet  fever,  and  influ- 
enza, frequently  play  the  role  of  exciting  causes. 

The  age  of  those  affected  corresponds  very  closely  with  that  at  which 
children  are  most  often  seen  with  hypertrophied  tonsils  and  adenoid 
growths  of  the  pharynx.  The  subsidence  of  symptoms  about  the  time  of 
puberty,  is  also  characteristic  of  both  conditions. 

Lesions. — It  has  been  already  stated  that  in  the  great  majority  of 
cases  the  cervical  lymph  nodes  are  involved,  and  generally  they  are  the 


TUBERCULOUS  ADENITIS.  871 

only  ones  affected.  In  155  cases  of  tuberculous  glands  in  the  series  re- 
ported by  Treves,*  those  of  the  neck  were  the  seat  of  disease  in  1-15  and 
the  only  seat  in  131;  those  of  the  axilla  were  involved  in  17,  but  alone 
only  in  4;  the  groin  in  8,  and  alone  in  6.  This  indicates  the  close  asso- 
ciation of  the  disease  with  infection  through  the  upper  respiratory  tract. 
The  nodes  first  affected  are  most  frequently  the  upper  set  of  the  deep 
cervical  group;  sometimes,  however,  it  is  the  superficial  nodes  of  the 
submaxillary,  or  the  parotid  group,  and  occasionally  the  submental  or 
the  pre-auricular.f  The  chain  of  deep  cervical  nodes  which  is  involved, 
follows  the  carotid  artery,  and  often  extends  some  distance  below  the 
clavicle.  These  deep  nodes  are  sometimes  connected  with  the  bronchial 
group. 

The  process  in  all  tuberculous  glands  is  essentially  a  chronic  one,  but 
pathologically  the  cases  may  be  divided  into  two  groups,  corresponding 
somewhat  to  the  forms  of  disease  seen  in  the  lungs.  In  one  group  the 
process  is  more  rapid,  and  tends  to  early  caseation  and  softening;  the 
products  of  infiammation  are  mainly  cellular,  and  the  amount  of  fibrous 
tissue  is  small.  In  another  group  the  course  is  slower,  and  fibrous  tissue 
predominates,  caseation  and  softening  being  infrequent. 

In  the  first  group  the  glands  in  the  early  stage  are  swollen,  of  a  pale 
pink  colour,  and  homogeneous ;  later  they  become  more  firm,  and  show, 
as  the  first  gross  evidence  of  tuberculous  deposits,  small  grayish-white 
spots,  which  are  generally  numerous  and  scattered  through  the  affected 
gland;  these  spots  enlarge,  and  may  coalesce  to  form  one  large  gray 
mass,  involving  nearly  the  whole  gland.  Subsequently  there  is  caseation 
and  then  softening,  usually  beginning  in  the  centre  of  the  caseous  area. 
Inflammation  within  the  gland  is  followed  by  that  of  the  surrounding 
tissues,  which  may  result  in  adhesions  or  in  the  formation  of  a  periglan- 
dular abscess.  The  first  change  in  the  gland  is  the  production  of  epithe- 
lioid and  giant  cells,  about  which  there  is  a  zone  of  small  round  cells; 
cheesy  degeneration  then  begins  in  the  centre.  The  caseous  masses  may 
become  encapsulated  by  the  jiroduction  about  them  of  fibrous  tissue ;  or 
softening  may  occur  at  one  or  more  foci,  and  an  abscess  form.  Such  an 
abscess  contains  curdy  material  but  very  little  true  pus,  the  contents 
being  chiefly  detritus  from  the  broken-down  node.  Tubercle  bacilli  are 
usually  more  numerous  in  the  early  stages  of  the  process,  but  are  often 
difficult  of  detection  in  broken-down  tissues,  and  the  curdy  pus  is  some- 
times sterile.  As  the  glands  soften,  the  process  gradually  extends  from 
the  centre  to  the  surface,  and  they  become  adherent  to  the  surrounding 
structures — blood-vessels,  nerves,  or  the  fascia — they  fuse  together  and 
form  large  knotty  masses,  and  when  they  ultimately  break  down  they 
lead  to  the  formation  of  an  abscess  in  the  cellular  tissue,  finally  involv- 

*  Scrofula  and  its  Gland  Diseases.     Smith,  Elder  &  Co.,  London,  1882. 
f  Nicoll,  Glasgow  Medical  Journal,  Januai-y,  1896. 


872 


DISEASES   OP   THE   LYMPH  NODES. 


ing  the  skin.  In  the  form  of  supjDuration  which  occurs  in  and  about 
tuberculous  nodes,  an  important  part  is  often  played  by  other  bacteria, 
usually  the  staphylococcus  or  the  streptococcus. 

In  the  second  group  of  cases,  where  the  process  goes  forward  more 
slowly,  the  changes  are  not  quite  the  same,  the  essential  difference  being 
that  the  amount  of  fibrous  tissue  is  much  greater.    These  nodes  are  not 

so  vascular;  they  are  tough  and  hard,  ap- 
pearing like  small  fibrous  tumours.  The 
capsules  are  greatly  thickened,  and  under 
the  microscope  is  seen  fibrous  tissue  ar- 
ranged in  concentric  layers,  often  inclosing 
small  caseous  masses.  These  nodes  less  fre- 
quently form  adhesions  to  the  surrounding 
tissues,  and  consequently  are  freely  mov- 
able, while  suppuration  is  quite  exceptional. 
Although  the  separate  tumours  are  much 
smaller  than  in  the  first  group,  the  glandu- 
lar mass  is  often  a  large  one,  because  of  the 
number  of  glands  involved. 

It  is  seldom  in  either  group  of  cases  that 
the  process  is  limited  to  a  single  node  or 
even  to  two  or  three  nodes.  A^ery  often  an 
entire  chain  is  involved  (see  Fig.  159).  The 
pathological  process  under  such  circum- 
stances usually  varies  in  degree  according 
to  the  distance  from  the  main  focus  of  in- 
fection; the  nodes  nearest  show  the  most 
advanced  changes;  those  at  a  distance,  the 
early  stages  of  the  disease. 

Tuberculous  infection  of  the  lymph 
nodes  may  terminate  in  resolution,  encap- 
sulation, calcification,  or  suppuration.  The 
inflammation  may  subside  before  caseation 
has  taken  place  and  the  inflammatory  prod- 
ucts undergo  absorption.  After  caseation 
has  occurred  the  masses  may  become  encap- 
sulated and  contract  to  small  fibrous  nod- 
ules. Calcification  of  the  glands  in  this 
location  is  rare.  In  other  cases  caseation 
is  followed  by  breaking  down,  liquefaction, 
and  an  external  abscess.  The  course  which  the  local  disease  takes  will 
depend  upon  the  intensity  of  the  infection  and  the  general  vigour  and 
resistance  of  the  child.  There  is  seen  in  most  cases  a  tendency  of  the 
inflammation  to  subside  spontaneously  about  the  time  of  puberty.    Cure 


Fig.  159. — Posterior  cervical  chain 
of  tuberculous  lymph  nodes. 

The  upper  one  showed  giant  cells 
and  extensive  cheesy  degeneration; 
one  at  the  middle  showed  early 
tuberculous  changes— cell  infiltra- 
tion, giant  cells,  and  a  small  area 
of  cheesy  degeneration ;  the  lowest 
node  showed  one  small  tubercle 
with  a  cheesy  centre.  Child  two 
and  a  half  years  old.     (Dowd.) 


TUBERCULOUS  ADENITIS.  873 

has  sometimes  followed  an  acute  attack  of  intercurrent  disease,  such  as 
erysipelas  of  the  face,  and  even  scarlet  fever. 

Symptoms. — In  the  early  part  of  the  disease  there  are  no  symptoms 
hut  the  glandular  swelling,  and  this  begins  very  gradually.  In  most 
cases  both  sides  are  involved,  but  as  the  disease  progresses  the  advanced 
changes  are  usually  confined  to  one  side.  The  enlargement  is  seldom 
continuous;  it  often  increases  for  a  time  and  then  remains  stationary 
or  even  diminishes,  to  take  a  new  start  from  the  stimulus  of  some  fresh 
infection  of  the  mucous  membrane  with  which  the  glands  are  asso- 
ciated, such  as  an  attack  of  measles  or  influenza,  or  simply  from  a 
deterioration  in  the  patient's  general  health.  During  exacerbations,  the 
glands  may  be  painful  and  tender,  and  show  the  usual  signs  of  local  in- 
flammation. 

The  whole  course  of  the  disease  varies  from  several  months  to  as 
many  years.  Treves  gives  three  and  a  half  years  as  the  average  dura- 
tion where  suppuration  occurs.  The  glands  first  affected  are  usually 
those  situated  near  the  bifurcation  of  the  common  carotid  artery.  Such 
tumours  usually  make  their  appearance  just  in  front  of  the  sterno-mas- 
toid  muscle — sometimes  behind  it — and  at  the  level  of  the  upper  border 
of  the  larynx  or  the  hyoid  bone.  In  the  more  rapid  cases  the  tumours 
usually  attain  a  considerable  size  in  three  or  four  months,  sometimes  in 
half  that  time.  The  usual  size  reached  is  from  that  of  an  almond  to  an 
English  walnut.  At  first  the  tumours  are  movable  and  jDreserve  their 
distinct  outline ;  later  they  become  adherent,  first  to  the  deeper  tissues 
and  to  each  other,  finally  to  the  skin,  and  there  is  formed  an  irregular 
nodular  mass  in  which  it  is  sometimes  difficult  to  make  out  the  individ- 
ual glands.  As  the  process  approaches  the  surface  there  are  small  spots 
of  softening ;  then  there  is  distinct  fluctuation ;  the  skin  becomes  discol- 
oured and  finally  gives  wa}^,  and  there  is  a  discharge  of  thick,  curdy  pus, 
which  may  continue  for  an  indefinite  time,  until  the  whole  of  the  broken- 
down  gland  has  been  thrown  off.  This  course  is  repeated  with  each  suc- 
cessive gland  which  breaks  down.  In  cases  progressing  more  slowly  the 
glands  become  adherent  chiefly  to  one  another,  and  suppuration  is  loss 
frequent. 

In  what  proportion  of  tuberculous  lymph  nodes  suppuration  occurs, 
it  is  difficult  to  say.  Like  other  tuberculous  lesions  in  the  body,  this  one 
is  more  frequent  than  was  once  supposed ;  and  in  the  past  most  of  those 
which  did  not  break  down  were  not  classed  as  tul)erculous.  It  is  probable 
that  of  the  cases  allowed  to  run  their  course  about  one  half  terminate  in 
suppuration.  Two  forms  of  suppuration  occur  in  connection  with  liilicr- 
culous  glands — one  an  abscess  of  the  gland  proper,  the  other  outvidt'  of 
and  usually  over  it.  In  a  typical  case  of  the  first  variety,  the  gland  is 
distinctly  outlined  and  often  superficial,  there  is  very  little  iiillnDimation, 
the  spot  of  softening  and  fluctuation  is  small,  and  the  pus  discharged  is 


874 


DISEASES  OP  THE  LYMPH  NODES. 


always  curdy.  In  the  second  variety  the  abscess  is  preceded  by  a  more 
diffuse  swelling,  and  the  outline  of  the  gland  may  not  be  made  out;  the 
signs  of  inflammation  are  more  marked,  the  area  of  fluctuation  is  larger, 
and  the  pus  is  more  like  that  of  any  ordinary  abscess.  Often  the  two 
varieties  are  combined;  as  when  a  gland  beneath  the  deep  fascia  breaks 
down  and  there  is  formed  directly  over  it  an  abscess  in  the  cellular  tissue, 
which  communicates  through  a  narrow  opening  with  the  gland  beneath. 
In  such  cases  the  sinus  continues  open  for  a  very  long  time,  until  the 
whole  of  the  gland  has  been  discharged.  If  healing  occurs  before  this, 
the  cicatrix  soon  breaks  down. 

Where  abscesses  are  allowed  to  open  spontaneously,  large,  irregular, 
and  usually  very  intractable  ulcers  form.    The  skin  is  undermined  for  a 


^ 


Fig.  160. — Cicatrices  fbllowing  a  neglected  caae  of  tuberculous  adenitis,  in  a  girl  seven  years 
old.  There  is  also  a  tuberculous  patcli  upon  the  skin  of  the  cheek  in  a  very  frequent 
location. 


considerable  distance,  and  it  has  an  unhealthy  appearance.  Such  ulcers 
sometimes  continue  for  many  months  in  spite  of  all  treatment,  particu- 
larly if  the  patient's  general  health  is  poor.  The  scars  left  after  them 
are  large  and  unsightly,  and  sometimes  positively  deforming  (Fig.  160). 
Their  appearance  is  quite  characteristic.  They  often  have  many  tabs 
of  skin  attached  to  them;  they  may  form  prominent  ridges  which  un- 
dergo contraction  like  those  after  burns ;  they  are  of  a  purplish-red 


TUBERCULOUS  ADENITIS.  875 

colour,  and  adherent  to  the  deeper  tissues.  They  are  often  sensitive 
and  painful.  As  time  passes  thej'  atrophy  and  become  less  conspicuous, 
though  they  remain  through  life. 

The  general  health  of  children  with  tuberculous  gUmds  may  be  much 
or  little  affected,  and  not  a  few  remain  in  good  condition  throughout  the 
whole  course  of  the  disease,  particularly  when  suppuration  does  not 
occur,  but  sometimes  even  when  it  is  protracted. 

Prognosis. — Tuberculosis  of  the  external  lymph  nodes  is  seldom  if 
ever  the  direct  cause  of  death;  although  the  course  is  often  very  pro- 
tracted, ultimate  recovery  can  usually  be  predicted.  As  previously 
stated,  it  is  surprising  that  this  process  is  so  frequently  the  only  tuber- 
culous lesion  in  the  body.  Treves  states  that  the  percentage  of  those 
who  die  from  general  tuberculosis  is  so  small  that  this  danger  is  not  to 
be  considered  an  argument  for  operation.  Poore  *  reports  that  of  58 
cases  treated  by  operation,  only  2  were  known  to  have  died  from  tuber- 
culosis. Dowd  f  has  collected  reports  of  309  cases  treated  by  removal 
more  or  less  complete,  whose  histories  were  followed  for  several  years 
after  operation.  Of  these,  202,  or  65  -4:  per  cent,  were  apparently  cured; 
57,  or  18-4  per  cent,  were  living,  though  suffering  from  either  local  or 
general  tuberculosis;  50,  or  IG -2  per  cent,  died  of  tuberculosis.  These 
statistics  surely  do  not  support  the  hopeful  views  of  the  writers  first 
quoted,  but  they  are,  I  think,  more  in  accord  with  general  experience. 

Diagnosis. — The  diagnostic  features  of  tuberculous  glands  are  the 
age  of  the  patient — ^usually  from  three  to  ten  years — the  site  of  the  pri- 
mary swelling,  the  indolent  course,  the  trifling  original  cause,  and  most 
of  all  the  disposition  to  slow  caseation,  softening,  and  abscess.  The 
eases  of  simple  hj'perplasia  are  usually  in  children  under  three  5'ears, 
their  progress  is  much  more  rapid,  there  is  often  some  definite  cause,  and 
in  most  cases  they  nearly  or  quite  disappear  in  the  course  of  three  or 
four  months.  They  suppurate,  if  at  all,  during  the  first  month.  Syphi- 
litic disease  is  to  be  recognised  mainly  by  discovering  the  evidence  of 
syphilis  elsewhere,  and  by  the  effect  of  treatment.  In  Hodgkin's  dis- 
ease, glandular  groups  in  other  parts  of  the  body  are  involved  simulta- 
neously or  in  rapid  succession.  There  are  no  signs  of  inflammation  or 
caseation ;  and  the  swellings  are  accompanied  l)y  very  marked  and  defi- 
nite constitutional  symptoms — anemia,  emaciation,  and  general  prostra- 
tion. ^Malignant  growths  are  very  rare;  they  increase  rapidly,  often  at- 
taining a  great  size  in  a  few  months. 

Treatment. — The  general  treatment  of  tuberculous  glands  is  to  put 
the  child  under  the  very  best  surroundings  possible.  The  seaside  has  a 
great  reputation  for  such  cases,  and  no  doubt  tlie  majority  do  very  well 
there;  but  some  arc  bcncfiii'd  (■\cii  hku'c  l)y  a  di-y.  mountain  climate. 

*  New  York  Medical  Journal,  June  23,  1892.  f  Annals  of  Surgery,  May,  1899. 


876  DISEASES  OP  THE  LYMPH  NODES. 

At  all  events,  a  child  from  the  city  should  be  sent  into  the  country  when- 
ever this  is  possible.  Internally  the  only  remedies  which  have  any  spe- 
cial virtues  are  cod-liver  oil  and  the  syrup  of  the  iodide  of  iron.  The 
latter  should  be  given  in  full  doses — i.  e.,  twenty  or  thirty  drops,  three 
times  a  day,  to  a  child  of  six  years.  Arsenic  and  iron  are  useful  as  gen- 
eral tonics.  Local  applications  are  of  little  value  and  most  of  them  posi- 
tively harmful ;  painting  with  iodine  and  poulticing  should  be  discarded 
altogether.  The  parts  should  be  protected  against  cold,  and  should  be 
rubbed  or  handled  as  little  as  possible. 

It  is  important  in  every  ease  to  remove  from  the  nose  and  throat  all 
sources  of  local  irritation.  Hypertrophied  tonsils  should  be  excised,  and 
the  adenoid  tissue  of  the  pharynx  removed  even  when  not  very  exten- 
sive, since  these  are  the  two  regions  which  most  frequently  harbour  the 
tubercle  bacilli.  Any  pathological  conditions  in  the  nose,  such  as  hyper- 
trophy of  the  turbinated  bodies,  should  receive  attention ;  so  also  should 
chronic  otitis,  chronic  conjunctivitis,  carious  teeth  or  ulcers  in  the  mouth. 
All  these,  if  they  do  no  more,  keep  up  a  constant  glandular  irritation, 
and  produce  conditions  which  are  most  favourable  for  the  activity  of  the 
tubercle  bacillus. 

Operative  measures. — These  are  indicated  if,  after  two  or  three 
months  of  constitutional  treatment,  the  glands  affected  continue  to  in- 
crease in  size  and  number,  or  if  softening  occurs.  The  advantages  of 
operation  over  leaving  the  case  to  Nature  are,  that  it  leaves  a  clean  scar 
instead  of  a  large,  irregular  one;  that  it  shortens  the  disease  and  pre- 
vents the  long,  tedious  suppuration  of  cases  left  to  themselves;  that  it 
is  a  radical  measure;  and  that  it  avoids  the  danger  of  general  infection 
by  removing  the  tuberculous  focus. 

The  radical  operation  Avhich  aims  at  removal  of  all  the  diseased  nodes 
through  a  free  incision,  is  steadily  growing  in  favour  in  New  York.  The 
best  results  follow  this  operation  when  it  is  done  early  before  the  skin 
is  involved  or  the  glands  have  softened  or  have  formed  extensive  adhe- 
sions to  the  great  vessels  and  neighbouring  structures ;  also  where  a 
chain  of  glands  is  involved  and  where  the  inflammatory  process  is  slow 
or  indolent.  In  most  cases  operation  requires  a  free  incision  and  a  pro- 
longed and  careful  dissection,  for  the  purpose  is  the  removal  not  merely 
of  two  or  three  large  glands  which  were  evident  before  the  incision  was 
made,  but  the  entire  chain  of  fifteen  or  twenty  smaller  ones  (see  Fig. 
159),  some  of  which  may  not  be  larger  than  a  pea,  and  are  just  begin- 
ning to  be  affected.  If  performed  early  a  thorough  operation  by  a  good 
surgeon  in  the  majority  of  cases  will  result  in  a  permanent  cure.  How- 
ever, the  operation  is  not  contra-indicated  in  cases  which  have  gone  on  to 
a  later  stage,  although  the  results  may  not  be  quite  so  satisfactory. 

Other  less  radical  operations  are  curetting,  cautery  puncture,  and 
injections.     Curetting  is  adapted  to  single  large  glands  which  have 


HODGKIN'S  DISEASE.  877 

softened  and  are  adherent  to  the  skin.  It  may  he  done  at  any  time  except 
diu'ing-  a  period  of  acute  inlhunmation.  Cautery  puncture  is  an  opera- 
tion much  done  in  Europe,  though  but  little  in  this  country.  It  is  not 
applicable  to  glands  smaller  than  a  cherry.  This  operation  is  done  with 
a  small  cautery  point,  which  is  thrust  through  the  skin  into  the  gland, 
and  then  in  two  or  three  directions  through  it,  after  which  some  soothing 
dressing  is  applied.  The  substances  chiefly  used  for  injection  are  iodo- 
form emulsion,  chloride  of  zinc,  and  carbolic  acid.  Injections  and  cau- 
tery puncture  are  to  be  advised  only  when  the  general  or  the  local  condi- 
tion contra-indicates  the  radical  operation. 

Glandular  abscesses  should  in  all  cases  be  opened  as  soon  as  pus 
forms,  to  prevent  the  extensive  undermining  of  the  skin,  which  is  so 
likely  to  occur.  The  opening  should  be  a  small  one,  and  all  squeezing  of 
the  gland  or  surrounding  tissues  avoided. 

HODGKIN'S  DISEASE  (ADENIE). 

This  is  a  rare  disease  in  which  there  is  a  general  hyperplasia  of  the 
lymphatic  glands  throughout  the  body,  with  growths  of  lymphoid  tissue 
in  the  spleen,  liver,  and  other  internal  organs.  It  is  accompanied  by 
marked  ansemia,  is  progressive  in  its  course,  and  usually  terminates  fa- 
tally. The  cause  is  unknown.  It  is  much  more  common  in  males  than 
in  females.    Its  occurrence  in  childhood  is  exceedingly  rare. 

The  changes  in  the  glands  consist  in  a  simple  hyperplasia,  which  may 
be  extreme.  Suppuration  and  caseation  are  very  rare,  if  indeed  they  ever 
occur.  Any  of  the  external  or  internal  groups  of  lymph  glands  may  be 
affected,  and  in  severe  cases  the  disease  may  involve  almost  every  chain 
of  glands  in  the  body.  Of  the  external  groups,  the  cervical  and  the  axil- 
lary are  usually  most  affected ;  of  the  internal  groups,  those  of  the  medi- 
astinum and  the  retro-peritoneal  region.  The  spleen  and  the  liver  are 
moderately  enlarged,  and  lymphoid  growths,  varying  in  size  from  a  pin's 
head  to  a  grape,  are  usually  scattered  throughout  their  substance.  There 
may  be  changes  in  the  bone-marrow. 

Symptoms. — The  disease  develops  very  gradually,  often  insidiously. 
The  external  glandular  swellings  are  usually  the  first  noticed,  but  some- 
times it  is  the  anaemia  which  first  attracts  attention;  occasionally  it  is 
the  local  symptoms  resulting  from  the  pressure  of  internal  glands,  which 
may  give  rise  to  oedema,  pain,  cough,  or  dyspnea.  The  progress  is  gen- 
erally slow  but  steady,  and  the  glands  may  reach  an  immense  size.  The 
blood  changes  are  inconstant.  As  a  rule,  there  is  a  relative  increase  in 
the  lymphocytes,  while  the  total  number  of  white  cells  is  generally  less 
than  normal,  although  sometimes  increased. 

Treatment. — The  only  remedy  which  is  of  mueli  avnil  in  this  disease 
is  arsenic,  which  must  be  given  in  fnll  doses  and  for  a  long  time.     The 
general  treatment  should  be  tonic. 
57 


878  DISEASES  OF  THE  SPLEEN. 

CHAPTEE  III. 

DISEASES  OF  THE  SPLEEN. 

"Weight. — From  one  hundred  and  forty  observations  made  at  the  New 
York  Infant  Asylum  the  following  were  the  weights  recorded  at  the  dif- 
ferent ages : 

Weight  of  the  Spleen  in  Infancy  and  Early  Childhood. 


Age. 

Ounces. 

Grammes. 

Birth 

4- 
f 

7-7 

Three  months 

15-5 

Twelve     "       

23-2 

Two  years 

38-5 

Three  "    

46-4 

Position  and  Methods  of  Examination. — The  normal  position  of  the 
spleen  is  close  against  the  diaphragm,  its  external  surface  being  opposite 
the  ninth,  tenth,  and  eleventh  ribs.  Its  anterior  border  comes  as  far  for- 
ward as  the  middle  axillary  line,  its  posterior  border  being  usually  near 
the  vertebral  column.  In  infancy  it  is  practically  impossible  to  outline 
the  spleen  by  percussion,  unless  it  is  enlarged.  During  full  inspiration 
the  spleen  is  often  depressed  enough  to  be  felt  at  the  free  border  of  the 
ribs,  but  at  other  times  it  can  not  be  felt  unless  it  is  enlarged  or  pushed 
downward  by  some  pathological  condition  in  the  chest.  Normally,  the 
long  axis  of  the  spleen  is  nearly  parallel  with  the  ribs,  but  when  the 
organ  is  much  enlarged,  its  axis  corresponds  nearly  with  a  line  drawn 
from  the  axillary  line  at  the  border  of  the  ribs  to  the  middle  of  Pou- 
part's  ligament. 

The  thin  abdominal  walls  of  young  children  render  palpation  of  the 
spleen  much  easier  than  in  adults;  and  this  is  a  much  more  satisfactory 
method  of  examination  than  is  percussion.  In  fact,  the  results  from  per- 
cussion are  so  uncertain  and  misleading  that  in  most  cases  one  may  dis- 
pense with  it,  and  rely  on  palpation  to  determine  the  size  of  the  spleen. 
For  satisfactory  palpation  it  is  necessary  that  the  abdominal  walls 
should  not  be  tense.  It  is  therefore  important  that  the  child  should  be 
quiet,  and  that  the  examination  be  made  as  gently  as  possible,  and  no 
force  or  undue  pressure  used.  The  child  should  lie  upon  its  back  with 
the  thighs  flexed  and  the  skin,  of  course,  bared.  The  physician,  always 
having  taken  the  trouble  to  warm  his  hands,  should  stand  upon  the  left 
side  of  the  patient  and  make  pressure  with  the  tips  of  the  fingers,  which 
are  semiflexed.  The  pressure  should  be  at  first  light,  and  gradually  in- 
creased, the  fingers  being  then  held  stationary  during  two  or  three  re- 
spiratory movements.    It  is  sometim?s  better  to  use  the  fingers  of  one 


ENLARGEMENT   OF   THE   SPLEEN.  879 

hand  for  palpation,  and  make  pressure  with  the  other  directly  over  the 
first.  Palpation  should  be  made  in  the  axillary  line.  If  the  examination 
is  satisfactory,  and  in  the  great  majority  of  cases  it  is  so  if  the  child  is 
quiet,  the  spleen  can  easily  be  felt  when  it  is  sufficiently  enlarged  to  be  of 
any  diagnostic  importance.  With  a  little  practice  one  can  readily  detect 
even  slight  degrees  of  enlargement. 

When  moderately  enlarged,  the  lower  border  of  the  spleen  is  an  inch 
or  so  below  the  free  border  of  the  ribs ;  when  greatly  enlarged,  it  forms 
a  tumour  which  may  nearly  fill  the  left  half  of  the  abdomen.  A  tumour 
in  the  left  hypochondriac  region  is  recognised  to  be  the  spleen,  by  the  fact 
that  it  is  freely  movable  laterally  and  at  its  lower  border  or  extremity, 
while  it  is  attached  above ;  also  its  inner  border  can  usually  be  felt  to  be 
thin  and  sharp,  and  marked  about  its  middle  by  quite  a  deep  notch. 

ENLARGEMENT   OF  THE  SPLEEN. 

In  Acute  Disease. — The  spleen  is  most  frequently  and  most  constantly 
enlarged  in  malarial  and  typhoid  fevers,  but  it  is  occasionally  so  in  all 
the  acute  infectious  diseases. 

In  most  of  these  cases  the  enlargement  is  chiefly  from  congestion,  but 
there  may  be  acute  hyperplasia  and  an  increase  in  size  of  the  Malpighian 
bodies.  It  may  contain  small  haemorrhages,  and  in  extremely  rare  cases 
the  spleen  may  rupture.  In  appearance  it  is  generally  dark-coloured, 
soft,  and  somewhat  friable.  In  the  cases  which  recover,  the  splenic  swell- 
ing subsides  with  the  original  disease. 

In  Chronic  Disease. — Like  the  lymph  nodes,  the  spleen  is  much  more 
often  enlarged  in  children,  particularly  young  children,  than  in  adults. 
Enlargement  is  seen  at  times  in  almost  all  the  chronic  diseases  of  early 
life ;  but  it  occurs  most  frequently  in  rickets,  syphilis,  malaria,  tubercu- 
losis, the  blood  diseases,  and  in  amyloid  degeneration.  Besides,  it  may 
be  the  seat  of  a  primary  growth,  either  benign  or  malignant. 

Rickets. — The  splenic  enlargement  which  accompanies  rickets  is  gen- 
erally seen  during  the  first  year ;  at  this  period  it  is  very  frequent.  The 
swelling  is  usually  moderate,  but  occasionally  it  is  so  great  that  the  lower 
border  is  three  or  four  inches  below  the  ribs.  It  belongs  to  the  most 
severe  forms  of  the  disease. 

Sypliilis. — Enlargement  of  the  spleen  is  one  of  the  most  constant 
lesions  in  congenital  syphilis.  It  is  present  with  great  uniformity  in  chil- 
dren born  with  syphilitic  lesions,  and  very  frequently  during  the  active 
period  of  the  disease  in  early  infancy.  It  is  seen  at  a  later  period  during 
infancy  or  childhood,  associated  with  other  late  symptoms.  The  degree 
of  enlargement  is  often  great.  In  several  cases  I  have  seen  it  sufficient  to 
form  a  large  abdominal  tumour.  The  liver  also  is  increased  in  size,  but 
not  to  such  a  degree.  The  pathological  changes  in  the  spleen  in  syphilis 
are  considered  with  that  disease. 


880  DISEASES   OF  THE  SPLEEN. 

Malaria. — The  swelling  in  these  cases  may  be  very  great.  The  liver 
is  not  so  often  enlarged  as  in  syphilis.  There  is  usually  a  history  of  ex- 
posure in  a  malarial  district. 

Tuberculosis. — It  is  rare  to  find  anything  more  than  a  moderate 
swelling  of  the  spleen  in  tuberculosis.  In  the  most  acute  cases  this  may 
be  due  to  the  fever  and  general  infection  :  in  those  which  are  less  rapid,  it 
depends  either  upon  tuberculous  deposits  or  passive  congestion  from 
venous  obstruction,  the  result  of  the  pulmonary  disease. 

The  blood  diseases. — ^Marked  enlargement  of  the  spleen  is  found  in 
many  cases  of  simple  ansemia  accompanied  by  moderate  leucocytosis. 
This  is  quite  peculiar  to  infancy  and  early  childhood.  The  spleen  is  con- 
stantly swollen,  and  usually  greatly  so,  in  the  pseudo-leukeemic  anemia 
of  infants,  in  leukaemia,  and  in  Hodgkin's  disease.  In  the  last  two  dis- 
eases the  liver  is  also  enlarged,  but  to  a  much  less  degree  than  the  spleen ; 
in  the  others  it  is  but  slightly  changed. 

Amyloid  degeneration. — The  causes  of  this  condition  and  its  general 
symptoms  are  mentioned  in  connection  with  amyloid  disease  of  the  liver 
(page  459).  The  spleen  is  constantly  involved,  and  the  enlargement  of 
this  organ,  as  well  as  that  of  the  liver,  may  be  very  great.  The  changes 
resemble  those  found  in  the  liver. 

Cardiac  disease. — In  all  forms  of  cardiac  disease,  and  in  other  con- 
ditions in  which  there  is  obstruction  to  the  systemic  venous  circulation, 
the  spleen  is  enlarged.  It  is  seen  in  congenital  as  well  as  in  acquired 
eases.  The  liver  is  usually  enlarged  to  about  the  same  degree  as  the 
spleen,  and  there  may  also  be  dropsy  of  the  feet. 

New-grovjths,  tumours,  etc. — It  is  seldom  in  early  life  that  the  spleen 
is  the  seat  of  new-growths;  these  are  usually  varieties  of  sarcoma,  but 
carcinoma  has  also  been  reported. 

Primary  spleno-megaly. — The  rare  cases  of  immense  primary  en- 
largement of  the  spleen  have  been  variously  interpreted.  B}^  some  wri- 
ters the  condition  has  been  regarded  as  lymphoma.  Bovaird  *  has  re- 
ported two  cases  in  children,  sisters,  one  of  which  was  carefully  studied 
microscopically,  and  the  conclusions  reached  that  the  process  was  an 
endothelial  hyperplasia.  The  condition  was  first  described  by  Gaucher. 
Clinically  the  disease  is  characterized  by  a  slowly  progressing  enlarge- 
ment of  the  spleen  which  begins  in  early  childhood  and  may  continue  for 
from  five  to  twenty  years ;  the  size  attained  is  very  great,  it  often  nearly 
filling  the  abdomen.  In  one  of  Bovaird's  cases  the  weight  was  twelve 
and  a  half  pounds.  The  other  S3'mptoms  are  a  simple  ansemia,  inflam- 
mation of  the  gums  with  haemorrhages  from  the  nose,  gums,  and  some- 
times beneath  the  skin,  and  finally  secondary  symptoms  due  to  the  ab- 
dominal tumour.  The  course  is  very  chronic,  and  thus  far  no  known 
treatment  has  been  of  any  avail. 

*  American  Journal  of  the  Medical  Sciences,  October,  1900. 


ACUTE  ARTHRITIS  OF  INFANTS.  881 

CHAPTER    IV. 
DISEASUS  OF  THE  BONES  AND  JOINTS. 

ACUTE   ARTHRITIS   OF   INFANTS. 

The  term  acute  arthritis  of  infants  has  been  given  by  Thomas  Smith, 
Townsend,*  and  others,  to  a  form  of  joint  inflammation  which  is  peculiar 
to  infancy,,  biit  not  rare  at  this  time.  It  has  been  described  under  the 
names  of  acute  purulent  synovitis  of  infants,  acute  epipliysitis,  pyaemia 
of  hone,  acute  osteo-myelitis,  etc.  The  disease  is  essentially  a  form  of 
pyaemia,  and  is  a  suppurative  process  almost  from  the  outset.  It  may 
begin  at  the  epiphyseal  junction,  in  the  medullary  canal,  or  in  the  joint; 
usuall}^  however,  the  joint  is  invaded  secondarily,  the  disease  some- 
times spreading  to  it  with  great  rapidity  from  the  bone.  It  may  also 
result  in  a  diffuse  osteo-myelitis  or  in  a  subperiosteal  abscess.  Sec- 
ondary abscesses  may  form  in  the  viscera  or  in  distant  articulations.  As 
a  consequence  of  the  disease,  there  may  be  separation  of  the  epiphysis 
from  the  shaft,  sometimes  entire  destruction  of  the  articular  extremities 
of  the  bone  or  articular  cartilages.  As  late  results  there  may  be  a  patho- 
logical dislocation,  or  a  "  flail  joint " ;  less  frequently  there  may  be 
ankylosis.  The  extent  of  the  ravages  in  the  joint  structures  depends 
chiefly  upon  the  duration  of  the  process.  Where  the  pus  is  evacuated 
earty,  recover)^  may  take  place  with  very  little  permanent  damage ;  but 
in  neglected  cases  complete  destruction  of  the  joint  often  occurs. 

Etiology. — Of  73  cases  collected  by  Townsend,  all  but  four  occurred 
during  the  first  year  of  life,  and  over  half  of  them  during  the  first  three 
months.  These  early  cases  have  already  been  mentioned  among  the 
Pyogenic  Diseases  of  the  Newly  Born  (page  82) .  So  far  as  is  known,  the 
disease  has  no  relation  either  to  syphilis  or  tuberculosis.  There  is  in 
some  cases  a  history  of  traumatism,  but  this  can  only  play  the  role  of  an 
exciting  cause.  The  essential  cause  of  the  disease  is  the  entrance  of 
pyogenic  germs  into  the  circulation.  They  may  gain  admission  through 
the  umbilicus,  some  abrasion  of  the  skin,  or  through  the  conjunctiva 
(pages  79,  80).  Very  often  the  source  of  infection  cannot  be  discovered. 
Cases  occurring  later  than  the  first  few  months  of  life  have  sometimes 
followed  measles,  scarlet  fever,  or  empyema. 

Symptoms. — The  onset  is  often  sudden,  with  well-marked  local  and 
constitutional  symptoms.  The  disease  may  be  ushered  in  with  a  chill, 
followed  by  a  fever,  which  is  frequently  high,  fluctuates  widely,  and  is 
accompanied  by  general  prostration,  restlessness,  and  other  signs  of  pain. 
There  is  rapid  swelling  about  the  affected  joint,  which  is  usually  diffuse, 

*  W.  R.  Townsend.  M.  D..  American  Journal  of , the  Medical  Sciences,  January,  1890. 
Here  will  be  found  a  full  discussion  of  the  subject,  and  the  bibliography. 


882  DISEASES  OP  THE  BONES  AND  JOINTS. 

as  the  lesion  is  deep-seated.  There  is  also  acute  tenderness^  and  nsually 
deformity.  Later  there  is  redness,  oedema,  a  glazed  skin,  and  deep 
fluctuation.  In  some  cases  the  constitutional  s3'mptoms  are  slight  or 
wanting.  After  pus  forms,  it  may  lead  to  rupture  of  the  capsule  and  in- 
filtration of  all  the  tissues  about  the  joint,  often  burrowing  for  a  consid- 
erable distance  before  it  reaches  the  surface. 

When  the  progress  is  most  rapid,  death  may  occur  in  two  or  three 
days,  from  exhaustion  or  general  2D3^8emia.  The  lesions  in  such  cases  are 
usually  multiple.  The  usual  duration  is  from  one  to  two  weeks,  suppu- 
ration generally  being  evident  in  four  or  five  days.  In  Townsend's  collec- 
tion of  cases  the  joints  were  affected  in  the  f olloAving  order :  hip,  in  38 
cases;  knee,  in  27;  shoulder,  in  12;  wrist,  in  5;  elbow,  in  4;  ankle,  in 
4;  fingers,  in  2;  toes,  in  1;  sterno-clavicular,  in  1.  I  have  met  with  one 
case  in  which  suppuration  occurred  in  the  temporo-maxillary  and  the 
medio-sternal  joints;  in  another,  in  the  temporo-maxillary  and  shoul- 
der. In  75  per  cent  of  the  cases  collected  b}'  Townsend  only  one  joint 
was  involved,  and  of  these  two  thirds  recovered;  in  the  remaining  25  per 
cent,  with  multiple  joint  lesions,  only  one  fourth  of  the  cases  recovered. 
Of  those  who  survive  the  acute  period,  the  number  who  recover  with  per- 
fect joints  is  small. 

Diagnosis. — The  disease  is  not  usually  difficult  of  recognition,  from 
the  constitutional  sjmiptoms,  the  marked  swelling,  tenderness,  and  de- 
formity, and  the  rapidity  with  which  suppiiration  occurs.  It  has  been 
mistaken  for  rheumatism,  although  rheumatism  is  so  rare  in  infancy 
that  it  may  be  practically  ignored.  Syphilitic  epiphysis  resembles  it  in 
the  localized  pain,  tenderness,  and  general  immobility,  but  lacks  the 
rapid  swelling,  fever,  and  severe  constitutional  symptoms,  and  its  course 
is  more  prolonged.  Acute  cellulitis  in  the  neighbourhood  of  the  joints 
may  resemble  it,  but  this  is  rare  except  from  traumatism.  The  disease 
has  little  in  common  with  tuberculous  bone  disease  of  later  childhood. 

Treatment. — The  general  treatment  is  to  be  directed  toward  the 
patient's  condition,  and  the  purpose  of  it  should  be  to  relieve  pain  and 
promote  nutrition.  Suppuration  occurs  very  early,  and  no  time  should 
be  wasted  in  trying  to  allay  the  inflammation  by  local  applications.  The 
best  results  are  obtained  by  early  incision,  free  drainage,  and  thorough 
antiseptic  treatment.  Fixation  of  the  joint  should  follow  operation,  in 
order  to  prevent  deformity. 

THE  TUBERCULOUS  DISEASES  OF  THE  BONES  AND  JOINTS. 

The  chronic  forms  of  tuberculous  bone-disease,  on  account  of  their 
insidious  onset  and  the  frequency  with  which  they  simulate  other  dis- 
eases, more  frec|uently  fall,  in  the  early  stage  at  least,  into  the  hands  of 
the  physician  than  into  those  of  the  general  or  orthopfedic  surgeon.  All 
that  will  be  attempted  in  this  chapter  will  be  to  outline  in  a  general  way 


TUBERCULOUS  DISEASES.  883 

the  most  important  forms — viz.,  disease  of  the  vertebrte,  hip,  and  knee — 
dwelling  particularly  upon  the  early  symptoms  and  diagnosis.  For 
their  fuller  discussion,  particularly  as  to  the  details  of  treatment,  the 
reader  is  referred  to  text-books  on  general  or  orthopaedic  surgery.  The 
causes  are  the  same,  and  the  lesions  are  very  similar  in  all  forms,  and 
will  therefore  be  considered  together. 

Etiology. — The  age  at  which  tuberculosis  of  the  bones  most  frequent- 
ly begins,  is  from  the  third  to  the  eighth  year,  it  being  comparatively  rare 
before  the  end  of  the  second  year.  The  sexes  are  affected  with  about 
equal  frequency.  Tuberculous  bone  disease  may  occur  in  a  child  who  has 
previously  been  in  apparent  health,  but  more  often  in  one  who  has  been 
reduced  by  some  previous  illness,  especially  the  infectious  diseases;  of 
these,  it  most  frequently  follows  measles  and  whooping-cough. 

A  family  history  of  tuberculosis  is  present  in  a  large  number,  but 
by  no  means  in  a  majority  of  the  cases.  Like  tuberculosis  of  the  cervical 
glands,  it  is  rarely  preceded  by  other  tuberculous  processes,  although  it 
may  be  followed  by  them.  It  usually  appears  as  an  example  of  primary 
infection;  but  it  seems  very  improbable  that  such  should  actually  be  the 
case.  It  is  more  likely  that  there  has  previously  been  a  latent  focus  of 
tuberculosis  elsewhere  in  the  body.  In  many  cases,  antecedent  disease  of 
the  bronchial  glands  has  been  demonstrated  by  autopsy.  Infection  from 
these  or  from  other  tuberculous  lymph  glands  is  the  most  probable 
explanation  of  the  origin  of  infection  in  cases  of  bone  disease.  However, 
by  some  writers,  notably  Baumgarten,  tuberculous  disease  of  bone  is 
regarded  as  due  to  direct  inheritance,  and  is  to  be  compared  to  the  bone 
lesions  which  occur  as  late  manifestations  of  hereditary  syphilis. 

Traumatism  is  often  an  exciting  cause,  and  it  may  determine  the 
site  of  the  disease. 

Lesions. — The  tuberculous  joint  diseases  of  childhood  are,  as  a  rule, 
secondary  to  disease  of  the  bones.  Hip-joint  disease  usually  begins  in 
the  head  of  the  femur,  and  knee-joint  disease  in  one  of  the  condyles; 
ankle-joint  disease  in  the  lower  epiphysis  of  the  tibia,  etc. 

The  frequency  with  which  disease  is  seen  in  the  different  locations  is 
shown  by  the  following  table,  which  gives  the  number  of  cases  of  each 
form  applying  for  treatment  at  the  Hospital  for  Euptured  and  Crippled, 
New  York,  during  ten  years: 

Spine 2,145  cases,  or  37"5  per  cent. 

Hip 1,937  "  "  34-0  " 

Knee 1,222  "  "  21-5  " 

Ankle  or  tarsus 255  "  "     4-5  " 

Elljow 71  "  "     1-2  " 

Wrist 50  "  "    0-9  " 

Shoulder 24      "  "0-4  " 

Total 5,704  1000 


884  DISEASES  OF  THE  BONES  AND  JOINTS. 

The  character  of  the  bone  disease  upon  which  chronic  joint  disease  de^ 
pends  is  generally  a  primary  ostitis,  which  affects  the  articular  extremities 
of  the  long  bones  usually  beginning  near  the  epiphyseal  line  ;  in  the  short 
bones  it  is  a  central  ostitis.  The  stages  in  the  process  are  first  congestion, 
swelling,  and  cell  infiltration,  followed  by  caseation,  and  frequently  by 
softening  and  suppuration.  In  the  early  stage,  the  bone  is  slightly  en- 
larged, and  on  section  one  or  more  yellowish  foci  of  disease  are  seen.  The 
disease  may  be  arrested  in  this  stage,  encapsulation  of  the  inflammatory 
products  taking  place ;  or  it  may  continue  until  there  is  a  more  or  less 
extensive  breaking  down  or  disintegration  of  the  affected  bone.  As  the 
disease  extends  there  are  involved,  the  periosteum,  the  articular  cartilage, 
and  finally  the  joint  itself.  Abscess  may  form  in  the  joint  or  in  the  soft 
parts  surrounding  the  bone.  The  process  is  quite  analogous  to  tuberculous 
disease  of  the  lung.  As  the  disease  advances  ligamentous  attachments  are 
loosened,  and  displacement  of  the  parts  occurs  with  the  production  of 
deformity,  due  partly  to  muscular  contraction  and  partly  to  the  weight  of 
the  body.  The  inflammatory  process  with  its  resulting  disintegration 
generally  goes  on  to  a  certain  point,  where  it  is  arrested.  Gradually  the 
broken-down  bone  substance  is  separated  and  thrown  off  in  small  particles 
in  the  discharge,  and  a  reparative  process  begins,  with  the  formation  of 
healthy  bone.  Where  joint  structures  have  been  destroyed,  cure  takes 
place  by  bony  ankylosis.  Sometimes  the  disease  finds  its  way  to  the 
surface  without  involving  the  joint ;  at  other  times  the  disease  may  be 
arrested,  and  its  products  become  encapsulated  within  the  bone.  Inflam- 
mation of  the  joint  may  occur  by  a  gradual  extension  of  the  inflammatory 
process,  or  by  a  sudden  perforation  of  the  articular  lamella.  As  a  result 
of  extensive  disease,  all  the  joint  structures  may  be  affected, — the  synovial 
membrane,  ligaments,  articular  cartilages,  and  the  cellular  tissue  surround- 
ing the  joint.  The  process  of  disintegration  and  that  of  repair  are  both 
very  chronic  and  measured  by  months  or  years.  The  entire  course  of  the 
disease  is  from  one  to  ten  years,  three  years  being  about  the  average  dura- 
tion. In  the  great  proportion  of  cases  but  one  joint  is  involved,  although 
it  is  not  infrequent  in  hospitals  to  see  two,  three,  and  sometimes  four  of 
the  large  joints  affected  in  the  same  patient. 

Secondary  lesions. — Abscesses  form  in  a  considerable  proportion  of 
the  cases,  and  often  burrow  a  long  distance  before  they  reach  the  surface. 
Amyloid  degeneration  of  the  liver,  spleen,  and  kidney,  and  sometimes  of 
the  villi  of  the  intestines,  occurs  as  the  result  of  the  prolonged  suppura- 
tion, chiefly  in  connection  with  disease  of  the  hip  or  spine,  occasionally 
with  that  of  the  knee.  General  or  localized  tuberculosis,  particularly 
tuberculous  meningitis,  may  develop  at  any  time  and  prove  fatal. 

Caries  of  the  Spine — Pott's  Disease. — This  consists  in  a  chronic 
inflammation  of  the  bodies  of  the  vertebrae,  usually  beginning  in  the  cen- 
tral portion  and  extending  to  the  periosteum,  ligaments,  cartilages,  and^ 


CARIES  OP  THE  SPINE. 


885 


in  fact,  to  all  the  contiguous  structures.  Secondaril}"  it  involves  the  mem- 
branes of  the  cord,  the  roots  of  the  spinal  nerves,  and  even  the  cord  itself. 
The  number  of  vertebrae  usually  affected  is  from  two  to  five.  The  gross 
appearance  of  the  lesion  in  a  -well-marked  case  is  shown  in  the  accompany- 
ing cut  (Fig.  161).  After  the  bodies  of  the  vertebrte  have  become  soft- 
ened and  partially  broken  down  by  disease,  the  pressure  from  the  super- 
incumbent weight  of  the  body  causes  them  to  fall  together  and  produces 
a  backward  displacement  of  the  spinous  processes,  giving  rise  to  the  de- 
formity known  as  kyphosis,  which  in  its  ex- 
treme form  is  popularly  known  as  "  hunch- 
back." 

Any  part  of  the  vertebral  column  may  be 
affected ;  but  the  disease  is  most  frequent  in 
the  dorsal  region,  as  shown  by  the  following 
statistics  from  the  Hospital  for  Ruptured  and 
Crippled :  of  2,143  cases,  72-5  per  cent  affected 
the  dorsal  region,  15 '3  per  cent  the  lumbar 
region,  and  12*2  per  cent  the  cervical  region. 

Symptoms. — The  onset  is  gradual,  often  in- 
sidious, and  the  early  symptoms  are  frequently 
overlooked  or  misinterpreted.  The  case  may 
go  on  for  weeks  or  even  months  before  the 
true  nature  of  the  disease  is  recognised,  which 
is  often  not  until  deformity  has  occurred.  In 
nearly  all  cases,  however,  the  early  symptoms 
are  sufficiently  characteristic  to  enable  a  care- 
ful observer  to  make  a  diagnosis  before  the 
stage  of  deformity. 

The  most  constant  early  symptoms  are  :  (1) 
pains  caused  by  the  irritation  of  the  nerve 
roots  and  referred  to  various  parts  of  the  body, 
following  the  distribution  of  the  spinal  nerves ; 
(2)  rigidity  of  the  spine  from  muscular  spasm, 
this  being  an  attempt  to  prevent  motion  at 

the  seat  of  disease ;  and  (3)  the  assumption  of  various  postures  calculated 
to  relieve  pressure  upon  the  diseased  vertebral  bodies.  Sometimes  the  first 
symptoms  are  those  of  pressure-paralysis  (page  81-4) ;  at  others  they  are 
the  local  signs  of  abscess.  In  addition  to  the  local  symptoms  mentioned, 
there  is  usually  disturbed  sleep,  often  accompanied  by  moaning. 

Cervical  disease. — The  pains  are  often  felt  above  the  point  of  disease, 
frequently  in  the  form  of  occipital  neuralgia ;  sometimes  they  arc  referred 
to  the  front  or  the  side  of  the  neck.  They  may  be  so  frequent  and  so 
severe  that  the  face  assumes  a  constant  expression  of  anxiety  or  distress. 
In  other  cases  pain  is  excited  only  by  an  attempt  at  movement.     The 


Fig.  161. — Pott'.s  disease  of  the 
upper  dorsal  region  ;  a  ver- 
tical section  of  the  spine, 
showing  disintegration  of  the 
bodies  of  the  vertebrtp  and 
encroachment  upon  the  spinal 
canal.  ( From  a  patient  dying 
in  the  Hospital  for  Kuptured 
and  Crippled.) 


886  DISEASES   OF  THE  BONES  AND  JOINTS. 

muscular  spasm  most  frequently  takes  the  form  of  slight  torticollis,  some- 
times of  slight  opisthotonus ;  sometimes  there  is  simply  a  fixation  of  the 
head  by  a  tonic  spasm  of  all  the  muscles  of  the  neck ;  both  active  and 
passive  motion  is  resisted,  and  any  movement  may  be  so  painful  that  the 
child  involuntarily  steadies  its  head  with  its  hands.  These  symptoms 
come  on  gradually  and  are  persistent.  Sometimes  they  are  overlooked,  and 
the  first  thing  to  attract  attention  is  a  progressive  weakness  in  the  lower 
extremities,  which  proves  the  beginning  of  paraplegia.  Occasionally  the 
first  marked  symptoms  are  those  due  to  the  formation  of  a  retro-pharyn- 
geal  or  a  retro-oesophageal  abscess  (page  314). 

The  deformity  from  cervical  disease  develops  much  later  than  when 
the  disease  is  located  elsewhere.  Usually  the  neck  appears  broadened  or 
thickened  in  a  nearly  uniform  way,  and  often  the  head  seems  to  have 
settled  downward  upon  the  shoulders.  In  the  lower  cervical  region,  a 
kyphosis  is  not  infrequent ;  but  in  the  middle  and  upper  regions  there  is 
more  often  an  anterior  prominence,  which  may  be  felt  in  the  posterior 
"wall  of  the  pharynx. 

Dorsal  disease. — The  referred  pains  are  now  below  the  seat  of  disease, 
and  take  the  form  of  intercostal  neuralgia  or  pain  in  the  epigastrium  or  the 
abdomen.  They  are  often  ascribed  to  cold,  malaria,  indigestion,  or  worms. 
There  is  a  disposition  to  assume  the  prone  position  while  sleeping,  and 
also  to  lean  across  a  chair  or  the  lap  of  the  nurse.  The  child  walks  care- 
fully, holding  the  spine  erect  and  very  stiffly,  and  exhibits  great  caution 
in  getting  into  or  out  of  bed,  or  in  rising  from  a  recumbent  position.  In 
the  beginning  there  may  be  a  slight  lordosis,  or  forward  curve  at  the  seat 
of  disease,  instead  of  the  usual  kyphosis  or  backward  projection,  but  the 
latter  soon  takes  its  place,  and  with  it  is  seen  the  compensatory  lordosis  in 
the  lumbar  region. 

Lumbar  disease. — The  first  symptoms  here  are  often  pain  and  lame- 
ness, referred  to  one  of  the  lower  extremities.  This  frequently  leads  to 
the  suspicion  that  the  hip  is  the  seat  of  disease.  In  addition  to  the  lame- 
ness there  may  be  a  tilting  of  the  pelvis  to  one  side,  and  sometimes  quite 
a  distinct  lateral  curvature  of  the  spine.  Eeferred  pains  are  not  so  fre- 
quent nor  so  severe  as  when  the  upper  part  of  the  spine  is  affected ;  they 
may  be  felt  in  the  groin,  in  the  loin,  in  the  thigh,  in  the  buttock,  or  in 
the  hypogastrium.  The  gait  and  attitude  are  very  characteristic  :  throw- 
ing the  shoulders  well  back,  the  patient  walks  stiffly  with  short  steps, 
holding  the  spine  with  the  greatest  care.  He  rises  from  the  floor  awk- 
wardly and  with  difficulty.  Deformity  is  not  usually  so  early  or  so 
marked  as  when  the  disease  is  dorsal,  and  often  before  it  is  visible  there 
are  symptoms  due  to  the  formation  of  psoas  abscess, — lameness,  flexion  of 
one  thigh,  and  a  tumour  deep  in  the  iliac  fossa  or  at  the  upper  and 
inner  aspect  of  the  thigh;  in  both  locations  it  has  often  been  mistaken 
for  hernia. 


CARIES  OF  THE  SPINE.  88Y 

Physical  examination. — Whenever  any  of  the  above  symptoms  are 
present,  the  child  should  be  stripped  and  submitted  to  a  thorough  exami- 
nation, the  purpose  of  which  should  be  to  determine,  first,  the  existence  of 
any  deformity ;  secondly,  the  mobility  of  the  spine ;  thirdly,  the  presence 
of  any  secondary  lesions,  such  as  abscesses  or  paralysis.  The  mobility  of 
the  spine  is  best  determined  by  studying  the  attitude,  gait,  and  posture  of 
the  child,  and  the  manner  of  stooj)ing  or  rising  from  the  floor.  The  gait 
has  already  been  described  with  the  symptoms  of  lumbar  disease.  A.s  it 
has  been  aptly  put,  "  the  child  walks  with  its  legs  but  not  with  its  back." 
In  stooping,  the  same  disinclination  to  bend  or  move  the  spine  is  seen. 
It  is  often  impossible  to  induce  the  child  to  stoop  at  all,  and  when  it  does 
so,  to  pick  up  some  object,  there  is  acute  flexion  at  the  knee  and  hip,  but 
as  little  bending  of  the  spine  as  possible.  In  rising  from  the  recumbent 
position  the  same  thing  is  seen.  The  posture  and  attitude  of  the  child 
will  be  modified  by  the  position  of  the  disease,  and  somewhat  by  the  ac- 
tivity of  the  process  at  the  time ;  however,  by  comparing  the  movements 
referred  to  with  those  of  a  healthy  child,  the  great  difi'erence  will  at  once 
be  apparent.  If  the  symptoms  point  to  cervical  disease,  a  digital  explora- 
tion of  the  pharynx  for  deformity  or  abscess  should  be  made,  and  the 
extremities  should  be  examined  for  paralysis.  If  the  disease  is  in  the 
lumbar  region,  deep  palpation  of  the  iliac  fossa  should  be  made  to  discover 
a  psoas  abscess,  and  the  passive  movements  of  the  thigh  should  be  carefully 
tested  to  determine  whether  there  is  any  resistance  to  extreme  extension, 
this  often  being  present  before  the  psoas  tumour.  No  matter  how  clearly 
the  lameness  may  be  at  the  hip,  it  should  be  remembered  that  this  often 
results  from  disease  of  the  lumbar  spine.  If  the  thigh  is  flexed  and  freely 
movable  except  in  extension,  the  symptoms  are  probably  the  result  of 
psoas  irritation,  for  in  hip-joint  disease  the  other  movements  of  the  joint 
are  also  resisted. 

The  deformity  of  Pott's  disease  is  often  spoken  of  as  "  angular  "  curva- 
ture of  the  spine.  While  this  is  a  true  description  of  the  disease  at  an 
advanced  stage,  there  is  often  in  the  early  stage  only  a  general  curve. 
Later  a  slight  knuckle  is  seen  from  the  unnatural  projection  of  a  single 
spinous  process.  This  deformity  may  increase  and  finally  involve  five  or 
six  vertebrae.  It  is  usually  greatest  in  the  upper  dorsal  region.  A  slight 
prominence,  which  does  not  disappear  on  suspending  the  j^atient,  is  always 
suspicious. 

Tenderness  upon  pressure  over  the  spinous  processes  and  increased 
sensitiveness  to  heat  and  cold,  are  rarely  present.  Pain  may  sometimes 
be  produced  by  downward  pressure  upon  the  head  or  shoulders  in  the  axis 
of  the  spine.  This  symptom  is  not  necessary  for  diagnosis,  and  the  at- 
tempt to  elicit  it  is  strongly  condemned  by  Gibney,  who  lias  seen  serious 
harm  follow  such  a  test. 

Course  of  the  disease. — Caries  of  the  spine  is  a  very  chronic  disease,  its 


888  DISEASES  OP  THE  BONES  AND  JOINTS. 

course  being  measured  by  months  or  years,  but  marked,  as  in  all  chronic 
diseases,  by  periods  of  remission  and  exacerbation.  An  exacerbation  may 
follow  traumatism,  and  is  often  accompanied  by  the  formation  of  an  ab- 
scess. After  the  disease  has  lasted  from  one  to  three  years,  the  destruc- 
tive inflammation  usually  ceases  and  repair  begins,  a  cure  being  finally 
effected  by  a  process  of  consolidation  of  the  fragments  of  the  diseased 
vertebrae,  and  the  production  of  ankylosis.  Eelapses  are  easily  excited 
by  traumatism,  by  improper  treatment  or  by  discontinuing  the  use  of 
mechanical  supports  before  the  disease  is  arrested. 

Abscesses. — The  frequency  with  which  abscesses  occur  depends  some- 
what upon  the  treatment.  Townsend  states  that  of  380  cases,  abscess  was 
present  in  20  per  cent.  They  are  rarely  seen  earlier  than  three  or  four 
months  from  the  beginning  of  symptoms,  and  usually  belong  to  the  sec- 
ond year  of  the  disease.  They  sometimes  form  with  acute  symptoms,  but 
more  frequently  they  appear  as  typical  cold  abscesses.  Those  connected 
with  cervical  disease  are  retro-pharyngeal  or  retro-oesophageal,  or  they 
may  open  externally,  usually  just  above  the  clavicle,  in  front  of  the  sterno- 
mastoid  muscle.  Those  with  disease  of  the  lower  cervical  and  upper  dorsal 
vertebrae,  are  apt  to  burrow  along  the  spine,  appearing  in  the  lumbar  re- 
gion ;  rarely  they  may  rupture  into  the  oesophagus  or  the  pleural  cavity. 
Those  with  disease  of  the  lower  dorsal  or  lumbar  vertebrse,  may  open  just 
above  the  iliac  crest  posteriorly,  or  burrow  anteriorly  between  the  abdomi- 
nal muscles,  but  the  usual  course  is  for  them  to  follow  the  psoas  muscle, 
appearing  in  the  groin  just  above  Poupart's  ligament  or  at  the  upper  and 
inner  aspect  of  the  thigh. 

Paralysis  occurs  in  about  one  half  the  cases  in  which  the  disease  affects 
the  lower  cervical  and  upper  dorsal  vertebrae,  but  it  is  rare  when  the  dis- 
ease is  below  the  middle  dorsal  region  (see  Compression  Myelitis,  page  814). 
Prognosis. — The  actual  mortality  of  Pott's  disease  is  difficult  to  state, 
so  many  of  the  consequences  of  the  disease  being  remote  and  not  fully 
appreciated  until  adult  life  is  reached.  The  general  mortality  from  all 
causes  is  from  ten  to  twenty  per  cent.  The  causes  of  death  are  exhaus- 
tion from  prolonged  suppuration,  amyloid  degeneration,  myelitis,  general 
tuberculosis,  and  tuberculous  meningitis.  Sudden  death  occasionally  oc- 
curs from  pressure  upon  the  cord  in  the  upper  cervical  region,  or  from  the 
pressure  effects  of  abscesses  in  the  posterior  pharynx  or  in  the  posterior 
mediastinum. 

The  prognosis  as  to  the  amount  of  permanent  deformity,  will  depend 
upon  the  seat  of  the  disease,  the  time  at  which  treatment  is  begun,  and 
upon  the  thoroughness  with  which  it  is  carried  out.  The  best  results  as 
to  deformity  are  obtained  when  the  disease  is  below  the  middle  dorsal  re- 
gion. With  improved  methods  of  treatment  begun  early,  a  large  number 
of  these  patients  recover  with  an  insignificant  amount  of  deformity,  and 
some  with  none  whatever. 


HIP-.JOINT   DISEASE.  889 

Diagnosis. — The  spinal  deformity  resulting  from  Pott's  disease  may  be 
confounded  with  rachitic  kyphosis  or  with  rotary  lateral  curvature.  Eachitic 
curvatures  (page  259)  are  usually  seen  in  children  under  eighteen  months 
of  age,  a  time  when  Pott's  disease  is  rare  ;  there  are  other  signs  of  rickets 
present,  and  instead  of  rigidity  there  is  usually  undue  mobility  of  the  spine. 
What  is  true  of  rickets  may  be  said  of  all  curvatures  depending  upon  mal- 
nutrition. Rotary  lateral  curvature  is  seen  about  puberty,  rarely  in  young 
children  except  in  connection  with  rickets.  A  slight  lateral  deviation  of 
the  spine,  sometimes  seen  in  the  early  stage  of  caries,  may  resemble  a  case 
of  incipient  rotary  curvature.  The  latter  is  not  attended  by  pain  or  rigidity, 
and  is  most  frequent  in  young  girls  from  eleven  to  fourteen  years  of  age. 

Other  abscesses  may  be  mistaken  for  those  dependent  upon  vertebral 
caries.  This  difficulty  is  likely  to  exist  in  the  cases  attended  by  very 
little  spinal  deformity.  These  abscesses  are  most  frequently  in  the  iliac 
fossa  or  in  the  lumbar  region,  and  may  be  due  to  perinephritis  or  ap- 
pendicitis. The  latter  are  more  acute  than  those  depending  upon  bone 
disease  and  usually  accompanied  by  fever.  Tumours  of  the  vertebrae  or 
of  the  spinal  cord  may  give  rise  to  symptoms  almost  identical  with  those 
resulting  from  compression  myelitis  due  to  Pott's  disease,  but  both  of 
these  are  extremely  rare. 

Treatment. — The  treatment  of  Pott's  disease  is  both  general  and  local, 
and  neither  should  be  neglected.  The  constitutional  treatment  should  be 
similar  to  that  employed  in  other  forms  of  tuberculosis. 

The  indications  for  local  treatment  are  to  put  the  diseased  parts  at 
rest,  by  immobilizing  the  spine  and  removing  the  superincumbent  weight 
of  the  body.  With  the  great  advances  made  in  orthopedic  surgery  it  is 
no  longer  necessary  to  confine  these  patients  in  bed,  as  was  formerly  prac- 
tised, to  secure  this  result.  It  may  be  accomplished  either  by  plaster-of- 
Paris,  or  some  other  form  of  jacket,  or  a  properly  fitting  steel  brace.  A 
head-support  should  be  attached  to  all  forms  of  apjjaratus,  if  the  disease 
is  above  the  middle  dorsal  region.  The  closest  attention  to  details  and 
much  experience  in  the  use  of  apparatus  are  required  to  secure  the  best 
results.  In  perhaps  no  class  of  cases  has  the  beneficial  results  of  mod- 
ern scientific  treatment  been  more  apparent  than  in  those  of  Pott's  dis- 
ease. For  the  details  in  regard  to  the  mechanical  treatment  and  the 
different  forms  of  apparatus,  the  reader  is  referred  to  works  on  general 
or  orthopaedic  surgery. 

Articular  Ostitis  of  the  Hip — Hip-Joint  Disease — Morbus 
CoxARius. — In  early  childhood  this  generally  begins  as  a  chronic  ostitis 
in  the  head  of  the  femur,  starting  near  the  epiphyseal  line.  Excejition- 
ally,  and  according  to  Gibney,  oftener  in  older  children,  it  begins  in  the 
acetabulum.  The  pathological  process,  as  well  as  the  clinical  history,  is 
generally  described  as  consisting  of  three  stages.  'In  the  first  stage — that 
of  ostitis — the  lesions  are  limited  to  tlie  bone ;  in  the  second  stage — that 


890  DISEASES  OF   THE  BONES  AND  JOINTS. 

of  arthritis — all  the  joint  structures  are  involved,  and  in  this  stage  sup- 
puration usually  occurs ;  in  the  third  stage  there  is  breaking  do-wn  and 
absorption  of  the  head  and  sometimes  of  the  neck  of  the  femur,  which, 
with  destruction  of  the  ligaments,  leads  to  marked  displacement  of  the 
parts  from  muscular  contraction.  The  disease  may  be  arrested  in  the 
first  or  in  the  second  stage,  or  it  may  continue  through  all  three  stages. 

Symptoms. — Clinically,  the  usual  duration  of  the  first  stage  is  three  or 
four  months ;  it  may  last  only  for  a  few  weeks,  it  may  extend  over  two 
or  three  years,  and  the  disease  may  be  arrested  in  this  stage.  The  onset 
is  usually  very  gradual,  and  the  symptoms  are  often  considered  of  trivial 
importance  until  they  have  continued  for  some  weeks.  Generally  the  first 
thing  noticed  is  slight  lameness,  due  to  stiifness  of  the  Joint.  In  the 
beginning  this  may  be  seen  only  in  the  morning,  wearing  off  during  the 
day.  It  may  be  accompanied  by  some  tenderness  about  the  hip  and  a  dis- 
inclination to  walk.  A  little  later  the  child  complains  of  pain,  which  is 
most  frequently  referred  to  the  front  of  the  knee  or  the  inner  aspect  of 
the  thigh,  but  only  in  rare  cases  to  the  hip  itself.  This  is  slight  at  first, 
but  gradually  increases  in  frequency  and  severity,  and  soon  there  are 
added  the  "  starting  pains  "  at  night,  which  are  one  of  the  most  character- 
istic features  of  early  hip-disease.  These  pains  are  produced  by  a  sudden 
spasm  of  the  muscles  during  sleep.  The  child  often  cries  out  sharply 
without  waking,  sometimes  wakes  with  a  cry ;  this  is  often  repeated  sev- 
eral times  during  the  night.  Soon  restlessness  and  fretfulness  during  the 
day  are  present.  The  lameness,  which  at  first  was  slight  and  occasional, 
or  noticed  only  in  the  morning,  comes  to  be  a  constant  symptom,  and 
week  by  week  increases  in  severity.  The  evolution  of  these  symptoms 
may  take  only  a  few  weeks,  but  sometimes  they  come  and  go  in  the  most 
inexplicable  manner  during  a  period  of  several  months,  or  even  one  to 
two  years,  before  they  are  fully  developed. 

Physical  examination. — Every  child  with  a  suspicious  lameness,  or 
with  pains  like  those  mentioned,  should  be  stripped  and  submitted  to  a 
thorough  examination.  The  first  points  to  be  observed  on  inspection  re- 
late to  the  general  contour  of  the  hip ;  every  prominence  and  depression 
should  be  carefully  noted.  Then  the  attitude  and  gait  should  be  studied ; 
and  finally  all  the  functions  of  the  joint  should  be  carefully  tested,  and 
the  limbs  measured,  to  determine  the  existence  of  shortening  or  atrophy. 
At  every  step  a  comparison  should  be  made  with  the  sound  limb.  The 
contour  of  the  hip  is  changed  quite  uniformly  :  there  is  broadening  and 
flattening  of  the  whole  gluteal  region ;  the  trochanter  is  unnaturally 
prominent;  the  gluteal  fold  is  shortened,  and  often  single  instead  of 
double.  There  is  no  characteristic  position  of  the  limb  in  this  stage. 
There  is  atrophy  of  the  thigh  and  often  of  the  calf.  In  Fig.  162  is  shown 
the  appearance  of  a  typical  case  in  the  full  development  of  the  first  stage. 
In  walking,  the  child  favours   the  diseased  side,  throwing  the  weight  as 


HIP-JOINT  DISEASE. 


891 


much  as  possible  upon  the  sound,  limb ;  but  all  these  symptoms  are  of 
much  less  importance  for  diagnosis  than  is  an  examination  of  the  func- 
tions of  the  joint. 

For  this  purpose  the  child  should  be  placed  upon  a  table  upon  its 
back,  and  the  various  movements  of  the  hip — abduction,  adduction,  flexion, 
extension,  and  rotation — should  be  executed,  first  with  the  sound  limb 
and  then  with  the  suspected  one,  the  two  being 
carefully  compared  at  every  point  to  determine 
the  degree  of  motion  allowed.  It  is  not  neces- 
sary that  force  should,  be  employed  or  pain  in- 
flicted. If  the  symptoms  have  existed  for  some 
weeks,  there  is  generally  a  limitation  of  motion 
at  the  hip  in  all  directions,  but  first  usually  in 
abduction,  rotation,  or  extension.  In  more  ad- 
vanced cases,  no  motion  whatever  may  be  per- 
mitted at  the  joint,  the  pelvis  tilting  with  the 
slightest  movement  of  the  femur.  This  fixation 
of  the  hip  is  due  to  tonic  muscular  spasm. 
Crowding  the  articular  surfaces  together,  by 
pressure  upon  the  heel  or  trochanter,  produces 
pain,  which  is  usually  referred  to  the  joint. 
This  test  should  be  carefully  made,  lest  injury 
be  inflicted.  Gibney  cautions  against  examina- 
tions under  ether,  since  in  this  way  serious  in- 
jury may  be  done  unconsciously. 

Second  stage. — This  has  been  called  the  stage 
of  arthritis.  Its  existence  may  be  assumed  when 
the  limb  takes  the  position  of  marked  perma- 
nent deformity,  which  is  due  at  this  period  to 
muscular  action,  not  to  destructive  bone  changes. 
The  transition  from  the  first  to  the  second  stage 
is  in  most  cases  a  gradual  one,  and  the  line  be- 
tween the  two  can  not  be  sharply  drawn ;  some- 
times, however,  it  is  rapid,  and  marked  by  a 
sharp  exacerbation  of  all  the  symptoms.  This 
may  indicate  a  sudden  j^erf oration  of  the  joint, 

and  the  rapid  development  of  suppurative  arthritis.  Such  is  the  usual 
result  when  an  abscess  which  has  been  slowly  forming  in  the  bone,  opens 
into  the  joint;  or  acute  joint  inflammation  may  be  lighted  up  without 
so  evident  a  cause.  Sometimes  the  pus  reaches  the  surface  below  the 
capsular  ligament,  and  the  joint  remains  intact.  An  acute  exacerba- 
tion is  indicated  by  increased  pain,  excessive  tenderness  about  the  hip, 
often  by  inability  to  walk,  or  even  to  bear  any  weight  upon  the  limb,  and 
frequently  by  fever.      The  position  assumed  by  the  limb  is  now  fairly 


Fig.  Itjii. — Hiir-jiiiul  <ii.-(.-a^^i.-.  at 
tlie  end  of  tlie  tirst  ^tiiijo, 
showinjj  muscular  utrcnliy, 
prominence  of  the  trocliiin- 
ter,  flattening  of  the  gluteal 
region,  and  a  single  gluteal 
fold. 


892  DISEASES  OF  THE  BONES  AND  JOINTS. 

characteristic.  The  foot  is  generally  everted,  the  thigh  slightly  flexed  and 
rotated  outward,  and  the  limb  apparently  lengthened.  There  may  be 
infiltration  anywhere  about  the  hip,  due  to  the  formation  of  an  abscess. 
The  muscular  spasm  is  so  great  that  the  joint  is  locked, — no  motion 
whatever  being  allowed.  Abscesses  may  form  at  any  point  about  the 
hip ;  they  are  especially  frequent  at  the  upper  and  outer  aspect  of  the 
thigh,  and  may  burrow  long  distances  before  reaching  the  surface.  The 
duration  of  the  second  stage  also  is  indefinite,  but  it  usually  lasts  from  a 
few  months  to  a  year,  or  the  disease  may  be  arrested  in  this  stage. 

Third  stage. — There  is  now  marked  deformity,  which  is  the  result  of 
muscular  contraction  after  absorption  of  the  head  and  sometimes  the 
neck  of  the  femur,  and  destruction  of  the  ligaments.  The  position  of 
the  limb  is  a  very  constant  one,  and  resembles  that  present  in  dislocation 
upon  the  dorsum  of  the  ilium.  There  is  shortening  of  from  one  to  four 
inches ;  the  thigh  is  strongly  flexed,  adducted,  and  rotated  inward,  and 
the  foot  is  inverted ;  the  trochanter  lies  against  the  outer  surface  of  the 
ilium,  and  is  above  Nelaton's  line.  In  this  position  the  joint  may  be- 
come ankylosed.  The  displacement  usually  comes  on  gradually,  but  it  is 
sometimes  so  sudden  as  to  be  mistaken  for  a  true  dislocation,  although 
the  latter  is  exceedingly  rare  in  the  course  of  hip-disease. 

There  is  now  marked  atrophy  of  all  the  muscles  of  the  limb,  and  the 
thigh  may  be  two  or  three  inches  smaller  than  its  fellow.  No  motion  at 
all  is  usually  allowed  at  the  hip,  but  this  is  compensated  for  to  some  degree, 
by  the  exaggerated  mobility  of  the  lumbar  spine.  The  spinal  curvature— 
lordosis — is  very  marked  both  upon  standing  and  walking.  The  duration 
of  this  stage  may  be  several  years.  From  time  to  time  exacerbations  oc- 
cur, often  excited  by  falls,  and  accompanied  by  the  formation  of  new  ab- 
scesses. In  protracted  cases,  all  the  soft  parts  about  the  hip  may  be  seamed 
with  cicatrices  from  old  sinuses.  After  the  disease  has  gone  on  to  the 
third  stage,  cure  can  take  place  only  by  ankylosis. 

Diagnosis. — The  important  point  in  the  early  diagnosis  of  ostitis  of 
the  hip,  is  the  gradual  evolution  of  the  symptoms,  the  most  characteristic 
of  which  are  lameness,  "  starting  pains  "  at  night,  and  impairment  of  all 
the  functions  of  the  joint.  Mistakes  in  diagnosis  most  frequently  arise 
from  a  failure  to  obtain  a  careful  history,  and  from  relying  too  much 
upon  the  symptoms  of  lameness  and  deformity.  The  essentially  chronic 
character  of  the  disease  should  constantly  be  borne  in  mind.  In  the  vast 
majority  of  cases,  with  a  careful  history,  and  a  thorough  examination, 
there  can  be  but  little  doubt  as  to  the  diagnosis  except  at  the  very  outset. 
The  proportion  of  obscure  and  irregular  cases  to  those  following  the 
regular  course,  is  small. 

In  the  early  stage,  hip- joint  disease  maybe  confounded  with  a  strain  of 
the  joint,  with  muscular  rheumatism,  poliomyelitis,  periostitis  of  the  shaft 
of  the  femur,  phlegmonous  inflammation  in  the  neighbourhood  of  the 


KNEE-JOINT   DISEASE.  893 

joint,  or  with  caries  of  the  lumbar  spine.  In  the  second  stage  there  is 
even  less  difficulty  in  diagnosis,  although  abscesses  resulting  from  perine- 
phritis or  appendicitis  have  been  mistaken  for  those  arising  from  hip-dis- 
ease.    In  the  third  stage,  a  mistake  is  almost  impossible. 

Prognosis. — This  is  to  be  considered  both  with  reference  to  life  and 
limb.  The  records  of  the  Hospital  for  Ruptured  and  Crippled  show  the 
mortality  of  hospital  joatients  with  hip-disease  to  be  nearly  25  per  cent. 
This  includes  deaths  directly  or  indirectly  traceable  to  the  disease.  The 
causes  are  nearly  the  same  as  in  caries  of  the  spine, — exhaustion  from  pro- 
longed suppuration,  amyloid  degeneration,  and  general  tuberculosis  or 
tuberculous  meningitis. 

Under  the  most  favourable  conditions,  the  disease  may  be  arrested  in 
the  first  stage,  and  recovery  occur  without  lameness  or  any  noticeable  im- 
pairment of  the  joint  functions.  This  result,  however,  is  not  often  ob- 
tained, because  the  disease  is  usually  well  advanced  before  it  is  recognised, 
or  because  of  the  difficulty  in  the  way  of  carrying  out  all  the  details  of 
treatment  in  the  best  230ssible  manner.  If  the  disease  has  advanced  to  the 
second  stage,  and  suppuration  has  occurred,  there  always  results  some  im- 
pairment of  the  joint  functions ;  usually  there  are  decided  lameness  and 
marked  muscular  atrophy,  but  very  little  shortening  or  deformity,  provided 
the  limb  has  been  kept  in  the  proper  position.  If  the  disease  has  ad- 
vanced to  the  third  stage,  there  are  always  marked  shortening,  deformity, 
and  lameness. 

Treatment. — The  indications  for  constitutional  treatment  are  the  same 
as  in  caries  of  the  spine.  The  purpose  of  local  treatment  is  to  secure  con- 
stant and  complete  rest  for  the  diseased  parts,  and  to  prevent  deformity. 
Rest  is  secured  by  overcoming  the  muscular  spasm  by  means  of  extension, 
'by  immobilizing  the  joint,  and  by  transferring  the  weight  of  the  body,  in 
w^alking,  from  the  hip  to  the  perinaeum.  All  these  indications  are  now 
met,  while  the  patient  is  up  and  about,  by  the  use  of  the  most  approved 
apparatus.  Formerly,  rest  and  immobilization  could  be  secured  only  by 
keeping  the  patient  in  bed,  with  the  use  of  the  weight  and  pulley.  The 
general  opinion  of  orthopaedic  surgeons  at  the  present  day  is  against 
excision,  except  in  cases  where,  in  spite  of  treatment  by  apparatus,  the 
disease  has  advanced  to  the  third  stage,  and  in  cases  where  life  is  threat- 
ened from  prolonged  suppuration  and  exhaustion.  Under  these  con- 
ditions, excision  should  be  performed  ;  but  early  excision  gives  results 
very  much  inferior  to  those  obtained  by  mechanical  and  constitutional 
treatment. 

Articular  Ostitis  of  the  Knee — Knee- Joint  Disease — White 
Swelling. — Ostitis  of  the  knee  usually  begins  in  one  of  the  condyles  of 
the  femur,  the  inner  much  oftencr  than  the  outer  one;  less  frequently  it 
begins  in  the  head  of  the  tibia.  The  pathological  process  is  very  much 
like  that  at  tlio  hip.  There  is  in  the  first  stage  a  central  ostitis  accom- 
58 


894  DISEASES   OF   THE   BOXES  AND   JOINTS. 

panied  by  infiltration  and  expansion  of  the  part  of  the  bone  affected. 
The  disease  may  remain  limited  to  the  bone,  the  inflammatory  products 
becoming  encapsulated,  or  softening  and  breaking  down  may  occur,  with 
the  formation  of  an  abscess.  Gradually  the  process  extends  outward,  and 
the  periosteum  and  the  soft  parts  are  involved.  The  disease  may  invade 
the  joint  itself  in  a  destructive  inflammation,  or  pus  may  escape  externally 
without  seriously  involving  the  joint  structures.  The  degree  to  which  the 
joint  is  involved,  varies  much  in  difl:erent  cases ;  there  may  be  only  a  sim- 
ple synovitis,  a  suppurative  arthritis,  or  a  destruction  of  the  cartilages 
and  articular  ends  of  the  bones,  synovial  membrane,  and  ligaments,  so 
that  in  the  advanced  stage  all  traces  of  a  joint  structure  are  lost. 

If  the  process  remains  limited  to  the  bone,  recovery  may  take  place 
with  very  little  impairment  of  the  joint  functions.  If  suppuration  in  the 
joint  has  taken  place,  there  will  be  more  or  less  stiffness  and  fibrous  or 
bony  ank3dosis.  When  there  is  destruction  of  the  ligaments  and  articu- 
lar ends  of  the  bones,  the  limb  assumes  a  characteristic  position — the 
joint  is  flexed,  the  tibia  is  displaced  backward  and  rotated  outward,  and 
there  is  marked  over-riding  of  the  femur.  Bony  ankylosis  in  this  posi- 
tion is  often  seen. 

Symptoms. — The  earliest  symptoms  of  disease  at  the  knee  are  usually 
a  slight  stiffness  of  the  joint,  with  a  disposition  to  flexion  and  slight 
lameness.  At  first  these  symptoms  are  noticed  only  occasionally ;  finally 
they  become  constant  and  there  is  pain,  which  is  usually  referred  to  the 
knee.  In  some  cases  there  are  "  starting  pains  "  at  night,  although  these 
are  less  constant  and  less  severe  than  in  hip-disease.  Swelling  is  noticed 
early,  as  the  diseased  parts  are  so  superficial.  At  first  this  is  chiefly  of 
the  bone  itself ;  the  condyle,  usually  the  inner  one,  is  enlarged  and  elon- 
gated, often  to  a  marked  degree,  before  there  is  any  infiltration  of  the  soft 
parts.  Later  there  is  a  general  fusiform  swelling,  involving  the  entire 
joint  and  effacing  all  the  normal  outlines.  Some  tenderness  u|)on  pres- 
sure over  the  bone  affected  is  present  quite  early,  and  there  may  be  atrophy 
of  the  muscles  of  the  thigh  and  calf.  The  knee  is  flexed  and  slightly 
rotated  outward,  the  position  which  secures  the  most  complete  relaxation 
of  the  joint  structures.  In  some  cases  there  is  seen  the  characteristic 
swelling  due  to  distention  of  the  synovial  membrane.  Abscesses  may 
form  anywhere  about  the  joint ;  very  frequently  they  burrow  beneath  the 
tendon  of  the  quadriceps  extensor  as  far  as  the  middle  of  the  thigh. 
Grradually  the  deformity  increases  until  the  leg  may  be  flexed  at  a  right 
angle,  and  rotated  outward  over  an  arc  of  twenty  or  thirty  degrees. 

The  course  of  the  disease  resembles  that  of  ostitis  of  the  hip  and  the 
spine.  During  periods  of  remission,  pain  and  tenderness  often  subside  for 
several  months  so  completely  as  to  lead  to  the  supposition  that  the  disease 
has  been  arrested.  An  exacerbation  is  often  excited  by  a  fall  or  a  strain 
of  the  joint,  or  it  may  follow  an  attack  of  acute  illness.     The  disease  may 


TUBERCULOUS   OSTEO-MYELITIS.  895 

then  progress  rapidly  and  abscess  after  abscess  form,  with  extensive  de- 
struction of  all  the  joint  structures  and  the  production  of  permanent 
deformity. 

Prognosis. — The  danger  to  life  is  considerably  less  than  in  disease  of 
the  hip  or  spine.  Death,  however,  results  from  the  same  causes — exhaus- 
tion, amyloid  degeneration,  and  general  tuberculosis  or  tuberculous  men- 
ingitis. 

With  an  early  diagnosis  and  proper  treatment  the  disease  may,  in  a 
considerable  proportion  of  cases,  remain  limited  to  the  bone,  and  the 
resulting  lameness  and  deformity  be  very  slight ;  but  otherwise  a  certain 
amount  of  lameness  results  from  the  stiffness  of  the  joint.  This  may  be 
due  either  to  fibrous  thickening  or  to  bony  ankylosis.  Nearly  all  patients 
are  able  to  walk  without  crutches,  and  if  proper  treatment  has  been  carried 
out  there  is  neither  marked  shortening  nor  deformity,  although  there  is 
always  great  muscular  atrophy. 

Diagnosis. — The  important  synii:)toms  for  diagnosis,  are  the  gradual 
onset,  the  early  swelling  which  is  due  to  enlargement  of  the  bone,  and  the 
constant  lameness  and  deformity.  The  disease  may  be  confounded  with 
rheumatism,  with  synovitis,  and  even  with  scurvy.  In  all  these  cases  the 
resemblance  exists  only  during  the  period  of  exacerbation.  A  careful  his- 
tory, however,  will  usually  clear  up  the  diagnosis. 

Treatment. — The  general  treatment  is  the  same  as  in  other  forms  of 
joint  disease.  The  indications  for  local  treatment  are  the  same  as  in  hip- 
disease, — viz.,  to  immobilize  the  affected  limb  and  prevent  deformity. 
This  is  accomplished  by  a  form  of  apparatus  which  transfers  the  weight 
of  the  body  from  the  joint  to  the  perinaeum,  and  which  overcomes  the 
muscular  spasm  which  produces  flexion  and  inward  rotation  of  the  joint. 
As  in  hip-disease,  the  results  with  mechanical  and  constitutional  treat- 
ment are  decidedly  better  than  from  early  operative  measures ;  but  late 
operations  are  indicated  under  the  same  conditions. 

Tuberculous  Osteo-Myelitis. — This  disease  is  rarely  seen  except  in 
the  short  tubular  bones,  most  frequently  those  of  the  hand  and  fingers. 
From  this  fact  it  is  often  called  scrofulous  or  tuhercuJous  dactylitis.  It 
is  described  by  many  writers  under  the  name  of  spina  ventosa.  linger* 
gives  the  following  figures  showing  the  frequency  with  which  the  different 
bones  were  affected :  fingers  in  43,  toes  in  3,  metacarpus  in  41,  metatarsus 
in  14,  radius  in  2,  ulna  in  2,  tibia  in  3,  jaw  in  3.  The  first  phalanx  of  the 
index  finger  is  the  bone  which  is  most  frequently  the  seat  of  disease.  In 
the  majority  of  cases  the  process  is  confined  to  a  single  bone,  although  it 
is  not  rare  to  see  five  or  six  affected.  In  such  cases  the  disease  is  seldom 
symmetrical.  The  process  is  a  chronic  inflammation,  beginning  in  the 
centre  of  the  bone  with  the  deposit  of  tuberculous  material.    The  swelling 

*  Archiv  fiir  Kinderheilkunde,  Bd.  ii,  233. 


896 


DISEASES   OF   THE   BOXES   AXD   JOIXTS. 


■^hich  follo^vs  causes  an  expansion  of  the  bone  and  thinning  of  the  shaft, 
until  a  mere  shell  may  remain.  The  later  changes  are,  inflammation  of 
the  periosteum  and  the  soft  parts,  the  formation  of  abscesses  and  sinuses, 
necrosis,  the  exfoliation  of  sec^uestra,  etc.  The  entire  disease  lasts  from 
one  to  three  years,  and  causes  in  most  cases  marked  deformity. 

Tuberculous  dactylitis  is  essentially  a  disease  of  early  childhood,  being 
seen  most  frequently  during  the  second  and  third  years.  In  a  consider- 
able proportion  of  the  cases  there  is  a  family  history  of  tuberculosis.  The 
disease  frecjuently  appears  to  be  the  only  tuberculous  lesion  in  the  body, 
but  tuberculosis  of  the  hip,  knee,  ankle,  or  spine  may  be  associated. 

Symptoms. — Tuberculous  dactylitis  usually  begins  as  a  painless  en- 
largement of  one  of  the  phalanges,  most  frec[uently  the  first  one  of  the  in- 
dex fina'er.    It  mav  be  two  or  three  months  before  it  is  of  sufficient  size  to 


Fig.  163. — Tuberculous  dactylitis  of  the  first  plialaux  of  the  iudex  riiii.'er. 


attract  much  attention.  Exceptionally  the  inflammation  is  a  more  active 
one,  and  is  accompanied  by  both  pain  and  tenderness.  The  swelling  is 
quite  characteristic ;  it  is  smooth,  hard,  uniform,  and  generally  spindle- 
shaped,  involving  the  entire  phalanx  of  the  affected  finger.  The  appear- 
ance of  a  severe  typical  case  is  shown  in  Fig.  163.  Later  there  is  discol- 
ouration of  the  skin,  and  usually  there  is  suppuration.  Tlie  abscess 
generally  opens  at  the  side  of  the  finger,  and  a  curdy  pus  is  evacuated.  If 
the  opening  is  enlarged  by  an  incision  there  is  found  a  cavity  partly  filled 
with  caseous  matter,  and  dead  bone  is  felt,  and  perhaps  a  loose  sequestrum. 
The  cavity  is  surrounded  by  a  thin  shell  of  new  bone,  which  is  formed 
from  the  periosteum.  If  no  operation  is  done  the  discharge  continues  for 
weeks  or  months,  other  abscesses  often  form,  and  finally  several  small 


SYPHILITIC    DISEASES  OF   BONE.  897 

sequestra  are  exfoliated, — sometimes  a  single  large  one,  which  is  the  shell 
of  the  diseased  ijhalanx  almost  entire. 

In  some  cases  the  disease  is  arrested  before  necrosis  occurs,  but  in  the 
majority  this  is  not  so.  After  the  wounds  have  all  healed  the  finger 
remains  shortened,  deformed,  and  often  useless.  In  some  cases  the  disor- 
ganization is  so  extensive  that  amputation  is  necessary. 

Diagnosis. — The  recognition  of  dactylitis  is  usually  easy,  but  as  symp- 
toms identical  in  almost  every  particular  may  be  seen  in  a  svjihilitic  in- 
flammation, it  is  often  difficult  to  tell  with  which  of  the  two  forms  one 
has  to  deal.  The  tuberculous  form  is  very  much  more  frequent ;  it  may 
occur  in  a  patient  with  tuberculous  antecedents,  or  it  may  be  associated 
with  other  tuberculous  lesions.  Syphilitic  cases  are  distinguished  by  the 
fact  that  the  lesion  is  more  frequently  multiple,  that  it  is  often  symmetri- 
cal, and  that  other  manifestations  of  syphilis  are  generally  present.  It  is 
affected  by  anti-syphilitic  remedies,  which  is  not  the  case  in  the  tubercu- 
lous variety. 

Treatment. — Painting  with  iodine  and  like  measures  are  useless.  The 
diseased  part  should  be  kept  at  rest, — if  a  finger,  by  the  application  of  a 
splint.  Every  means  should  be  taken  to  build  up  the  patient's  general 
health,  as  this  is  the  most  effective  way  to  influence  the  local  process.  The 
general  verdict  of  surgeons  is  against  early  excision  as  a  means  of  arresting 
the  disease.  Abscesses  should  be  opened  early  and  freely,  all  diseased 
bone  removed,  the  finger  kept  in  proper  position,  and  the  wound  treated 
according  to  general  surgical  principles.  Under  almost  any  treatment  the 
disease  is  a  protracted  one,  and  rarely  lasts  less  than  a  year. 

THE   SYPHILITIC  DISEASES  OF  BONE. 

The  bone  lesions  of  hereditary  syphilis  are  not  infrequent,  but  were 
long  unrecognised,  and  have  only  within  comparatively  recent  times  been 
fully  understood.*  They  may  be  divided  into  two  groups, — those  occur- 
ring with  the  early  symptoms,  and  those  which  belong  to  the  late  manifes- 
tations of  the  disease. 

Acute  Epiphysitis. — This  is  the  most  frequent  variety  of  bone  dis- 
ease in  early  hereditary  syphilis.  It  may  begin  even  in  intra-uterine  life, 
and  it  forms  one  of  the  most  characteristic  lesions  of  the  disease.  To  some 
degree  it  is  almost  invariably  present  in  syphilitic  foetuses  and  in  syphilitic 
infants  who  are  still-born. 

In  the  early  stage,  there  is  an  increase  in  the  cartilage  cells  and  delayed 
ossification.  Later,  a  line  of  softening  forms  at  the  epiphyseal  junction, 
which  may  cause  loosening  of  the  cartilages  and  ultimately  complete 
separation  of  the  epiphysis  from  the  shaft,  by  the  formation  of  granula- 

*  See  Taylor,  Bone  Syphilis  in  Children,  New  York,  1875;  also  G.  Wegner,  Vir- 
chow's  Archives,  Bd.  ],  Ileft  3. 


898 


DISEASES  OF  THE   BONES  AND  JOINTS. 


tion  tissue  between  them.  In  cases  receiving  jDroper  treatment,  recovery 
may  take  place  with  good  union,  perfect  function,  and  without  any  de- 
formity. In  other  cases  degenerative  changes  continue,  and  infection 
with  pyogenic  germs  may  be  added.  The  periosteum  and  the  soft 
parts  in  the  neighbourhood  are  now  involved,  with  the  formation  of 
external  abscesses ;  or  the  disease  extends  to  the  medullary  cavity,  giving 
rise  to  acute  osteo-myelitis,  which  may  lead  to  necrosis ;  or  the  contiguous 
joint  may  be  invaded,  causing  an  acute  supjDurative  arthritis  (page  881). 
This  last  result  is  more  likely  to  occur  where  the  epiphysis  joins  the  shaft 
within  the  joint  cavity.     The  large  joints  are  usually  affected,  and  the 


Fig.  164. — Syphilitic  bone  disease  in  a  boy  four  years  old.  The  lower  eud  of  the  radius  of  both 
arms  is  enlarged  as  a  result  of  former  epiphysitis  ;  there  are  sinuses  leading  to  dead  bone 
over  the  metacarpal  bone  of  the  right  thumb,  and  over  the  upper  extremity  of  the  left  ulna. 
The  last  two  are  recent  lesions. 


lesions  are  frequently  symmetrical.  Acute  suppurative  arthritis  may  oc- 
cur independently  of  changes  at  the  epiphysis ;  but  even  when  these  are 
seen  in  syphilitic  infants  they  are  to  be  regarded  as  of  pyaemic  rather 
than  of  syphilitic  origin.  Secondary  to  the  changes  at  the  epiphysis,  there 
is  periostitis  and  inflammation  of  the  soft  parts.  Periostitis  of  the  shaft 
is  rare  in  early  infancy, 

The  bones  most  frequently  the  seat  of  acute  epiphysitis  are  the 
humerus,  radius  and  ulna,  although  any  of  the  long  bones  may  be 
affected. 

Symptoms. — The  early  symptoms  are  usually  quite  acute,  and  appear 
during  the  first  six  weeks  of  life ;  they  may  precede  any  other  mani- 
festations of  syphilis.     In  some  cases  there  is  first  noticed  an  inability  on 


SYPHILITIC   DISEASES   OF   BONE.  899 

the  part  of  the  child  to  move  the  limb,  which  may  easily  be  mistaken  for 
paraksis.  It  is,  iu  fact,  often  described  as  "  s^-pliilitic  pseudo-paral^'sis." 
The  limb  lies  perfectly  motionless,  and  any  attempt  at  passive  movement 
causes  evident  pain.  There  is  tenderness  on  pressure  and  soon  swelling  is 
seen,  both  being  most  marked  at  the  epiphyseal  line.  If  the  bone  affected 
is  superficially  situated,  as  the  lower  epiphysis  of  the  humerus,  radius,  or 
tibia,  swelling  is  very  apparent,  while  it  may  be  scarcely  perceptible  at  the 
upper  epiphysis  of  the  humerus.  The  swelling  is  usually  cylindrical  and 
moderate  in  degree,  being  limited  to  the  extremity  of  the  bone.  In  the 
more  severe  cases  it  may  involve  a  great  part  of  the  limb.  Abscess  may 
form  and  separation  of  the  epiphysis  take  place,  so  thnt  crepitation  may 
be  obtained  by  moving  the  limb.  Separation  of  the  epiphysis  not  infre- 
quently occurs  even  when  there  has  been  no  suppuration. 

In  the  milder  cases,  or  those  which  have  been  subjected  to  active 
treatment,  both  the  swelling  and  the  tenderness  subside  rapidly  without 
suppuration  ;  and  even  though  the  epiphysis  has  separated  from  the  shaft, 
it  speedily  unites.  Where  pseudo-paralysis  has  been  the  chief  symptom, 
very  rapid  imjjrovement  occurs  under  treatment,  and  usually  complete 
recovery  of  function  in  two  or  three  weeks.  If  the  disease  extends  to  the 
joint,  or  if  osteo-myelitis  develoj)s,  the  case  is  almost  certainly  fatal. 

Diagnosis. — This  is  usually  easy,  from  the  age  of  the  patient — gener- 
ally under  three  months — the  early  prominence  of  pain  and  apparent  loss 
of  power,  with  the  later  appearance  of  swelling  and  signs  of  inflamma- 
tion at  the  epiphyseal  junction.  In  all  these  respects  the  disease  closely 
resembles  scurvy ;  but  the  latter  is  rare  before  the  eighth  or  tenth  month, 
there  is  usually  a  history  of  the  long-continued  use  of  some  proprietary 
infant  food,  and  it  is  cured  by  dietetic  treatment  alone. 

The  apj)arent  loss  of  ^oower  may  lead  to  the  diagnosis  of  birth  palsy, 
especially  of  the  upper-arm  type  (page  110).  The  presence  of  acute  pain 
and  tenderness,  the  absence  of  the  characteristic  deformity,  and  the  prompt 
recovery  under  constitutional  treatment,  usually  make  the  distinction  be- 
tween the  two  conditions  an  easy  one. 

Treatment. — This  is  the  same  as  in  all  early  syphilitic  manifestations, 
for  which  see  the  article  on  Syphilis.  Locally,  the  part  requires  in  the 
early  stage  only  protection  and  rest.  Should  suppuration  occur  in  the 
neighbouring  joint,  or  should  osteo-myelitis  develop,  these  conditions 
should  be  treated  surgically  as  they  are  when  due  to  other  causes. 

Chroxic  Osteo-Periostitis. — This  is  the  usual  form  of  bone  disease 
which  is  seen  in  late  hereditary  syphilis,  and  it  is  one  of  the  most  frequent 
and  most  characteristic  lesions  of  that  stage  of  the  disease.  Occurring 
in  adults,  tliis  would  be  classed  as  a  tertiary  symptom.  Chronic  syphilitic 
osteo-periostitis  is  rarely  seen  before  the  third  year,  and  most  of  the  cases 
occur  between  the  fifth  and  fourteenth  years.  The  most  frequent  seat  of 
disease  is  the  tibia,  and  next  to  this  the  bones  of  the  forearm  and  the 


900 


DISEASES  OP  THE  BONES  AND  JOINTS. 


cranium.  The  following  is  the  frequency  with  which  the  different  bones 
were  affected  in  the  series  of  cases  reported  by  Fournier  :  *  tibia  in  91 
cases,  ulna  in  23,  radius  in  15,  cranium  in  16,  humerus  in  12,  all  others  in 
37.  The  process  may  result  either  in  a  diffuse  or  a  localized  hyperplasia 
of  bone  or  in  necrosis. 

The  typical  changes  are  seen  in  the  tibia.     The  shaft  of  the  bone  is 


Fig.  165. — Syphilitic  di.sca.sc  ul'  Uic  tilji;i,  ^huwinu-  Uio  subrc-likc  Jcl'oriuity,  in  a  boy 

nine  years  old. 

principally  or  solely  affected.  There  is  often  produced  a  very  characteristic 
deformity,  consisting  of  a  forward  curve  of  the  anterior  border  of  the 
tibia,  which  has  been  compared  to  a  sabre  blade  (Fig.  165).  In  some 
cases  the  bone  is  bent  inward  at  its  lower  third,  resembling  somewhat  a 
rachitic  curvature  (Fig.  166).  Sometimes  the  entire  shaft  of  the  bone  is 
affected,  and  it  may  be  enlarged  to  nearly  twice  its  normal  dimensions. 


*  Syphilis  Hereditaire  Tardive,  Paris,  1886. 


SYPHILITIC   DISEASES  OF   BONE. 


9(11 


At  other  times  the  swelling  is  chiefly  near  the  epiphysis,  where  large 
bosses  may  form  of  sufficient  size  to  interfere  with  the  functions  of  the 
joint.  Instead  of  affecting  the  bone  uniformly,  the  disease  often  affects 
only  certain  parts,  leading  to  the  formation  of  large  nodes  which  are  more 
likely  to  be  followed  by  necrosis  than  are  the  other  lesions.  In  most  of 
the  cases  the  process  is  purely  a  hyperplastic  one,  leaving  the  bone  per- 
manently enlarged.     Less  frequently,  there   occur   gummatous   deposits 


Fio.  166. — Syphilitic  disease  of  both  tibise.  The  left  shows  a  general  t;iilai-i:ement  of  the  bone, 
the  characteristic  curve  of  its  anterior  border,  with  ulcers  due  to  necrosis.  The  enlarge- 
ment of  the  right  tibia  is  less  marked,  and  there  is  a  pseiulo-rachitic  curve  at  its  lower 
third.     Cicatrices  near  the  knee  mark  the  site  of  former  ulccj-s.    (After  Fournier. ) 


in  or  beneath  the  periosteum,  which  may  soften,  suppurate,  and  lead  to 
superficial  necrosis,  with  the  formation  of  sinuses  that  remain  open  until 
the  sequestrum  is  exfoliated  (Fig.  167).  Syphilitic  deposits  sometimes 
take  place  in  the  interior  of  the  bones,  generally  near  the  articular  ends ; 
these  may  soften  and  break  down  with  abscesses,  sinuses,  etc.,  very  much 
after  the  manner  of  a  tuberculous  inflammation  (Fig.  I(i4). 

The  lesions  of  the  other  long  bones  are  essentially  the  same  as  of  the 
tibia.  They  are  nearly  always  symmetrical  and  often  multiple.  In  a  case 
recently  under  observation  in  a  boy  of  four  years,  the  disease  involved 
both  tibi?e,  both  radii,  the  right  ulna,  the  left  metatarsus,  and  the  meta- 
carpal bone  of  the  left  thumb.     The  course  of  syphilitic  osteo-periostitis 


902  DISEASES  OF   THE  BONES  AND  JOINTS. 

is  very  chronic,  and  some  permanent  deformity  is  the  rule,  unless  cases 
come  very  early  under  treatment. 

When  affecting  the  bones  of  the  cranium  the  disease  usually  takes  the 
form  of  a  gummatous  periostitis,  which  leads  to  the  formation  of  large 
nodes.  These  may  remain  as  permanent  deformities,  or  they  may  break 
down  and  suppurate,  with  necrosis  of   one   or  both  tables  of  the  skull. 

This  may  be  followed  by  inflammation 
^ '  .  ^  of  the  dura,  the  pia,  and  even  of  the 

brain  itself. 

J  Symptoms. — When  the  long  bones 

#  are   alfected,  the   symptoms  are  pain, 

tenderness  and  deformity.    These  come 

^;  on  very  gradually,  and  often  the  de- 

f,;  formity  is  noticed  before  either  pain  or 

I  tenderness  is  sufficiently  marked  to  at- 

I  .  i  tract  attention.     The  pain  is  regularly 

?  .     I  worse  at  night,  and  often  felt  only  at 

f  that  time  ;   it  may  be  mild  and  occa- 

^  _  sional,  or  so  severe  as  virtually  to  pre- 

^,  vent    sleep.      There   is   tenderness  on 

*''  pressure  over  the  bones  affected,  the 

/  acuteness  of  which  will  depend   upon 

;  ,1  the  activity  of  the  process.    When  sup- 

puration occurs,  it  comes  very  slowly, 
and  never  with  symptoms  of  acute  in- 
flammation.    Sinuses  usually  continue 
.       to  discharge  until  a  sequestrum  is  ex- 
%  .1  foliated.     The  course  of  the  disease  is 

_     ; '  7^7  7  "'     T        very  tedious,  and  the  whole  duration  is 

iiG.    lo.. —fevpliilitic  ucero^ls  ot  the  tibia, 

showing  moderate  enlargement  of  the       USUally  several  years. 

boue  and  a  sinus.     (From  the  same  pa-  Ttru^^  +!,„  •  •       ^     x   j    i.i 

tient  as  Fig.  164.)  When  the  cranmm  is  aflected,  there 

are  seen  the  irregular  nodes,  especially 
upon  the  frontal  and  parietal  bones.  They  are  from  one  to  two  inches 
in  diameter,  and  project  from  one  eighth  to  one  fourth  of  an  inch  above 
the  general  outline  of  the  skull.  There  may  be  pain,  tenderness,  soften- 
ing, suppuration,  and  necrosis,  as  in  the  long  bones. 

Diagnosis. — It  is  so  very  rare  that  disease  of  the  bones  of  the  cranium 
is  due  in  childhood  to  any  other  cause  than  syphilis,  that  this  disease  may 
always  be  assumed  to  exist  if  traumatism  can  be  excluded.  The  bosses 
upon  the  cranium  in  rickets  (page  260)  are  always  large,  smooth,  and 
regular  in  position,  and  belong  to  infancy. 

Syphilitic  disease  of  the  long  bones  is  recognised  by  the  nocturnal 
pain,  the  tenderness  and  peculiar  deformity,  and  by  the  association  of 
Ather  late  manifestations  of  syphilis, — i.  e.,  the  peculiar  notched  teeth, 


SYPHILITIC   DISEASES   OF   BONE.  903 

the  interstitial  keratitis,  the  enlarged  epitrochlear  glands,  etc.  Tuber- 
culous disease  generall}'  affects  the  articular  ends  of  the  bones;  syphilis 
nearl}^  always  the  shaft.  The  diffuse  hyperplasia  of  the  tibia  and  the 
sabre-like  deformity  of  its  anterior  border  are  rarely  if  ever  due  to  any 
other  cause  than  syphilis. 

The  deformities  of  the  long  bones  have  in  some  cases  a  certain  resem- 
blance to  those  due  to  rickets,  but  on  close  examination  there  are  seen 
striking  differences.  The  epiphyseal  enlargement  at  the  wrist  in  rickets 
affects  both  bones  (Plate  V,  page  256)  ;  in  syphilis  it  is  usually  of  one 
bone  only  (Fig.  164).  The  differences  between  rachitic  curvatures  of  the 
tibia  and  the  deformities  from  syphilis  may  be  readily  seen  by  comparing 
Figs.  48,  -19,  and  50  (pages  261-263)  with  Fig.  166. 


Fig.  168. — Multiple  syphilitic  dactylitis,  In  a  child  two  years  <il  i.      rin    disease  afleets  the  first 
phalanges  of  both  thumbs,  both  little  fingers,  and  the  index  tiui,a-r  of  the  left  hand. 

Treatment. — The  constitutional  treatment  of  these  lesions  is  the  same 
as  that  of  the  other  late  manifestations  of  syphilis, — mercury  and  the 
iodide  of  potassium ;  for  details,  see  the  chapter  on  Syphilis.  Surgical 
treatment  is  required  in  cases  which  terminate  in  necrosis,  whether  of  the 
cranium  or  the  extremities.  They  are  to  be  managed  like  the  same  con- 
ditions in  adults. 

Syphilitic  Dactylitis. — This  belongs  to  a  somewhat  earlier  period 
of  syphilis  than  the  disease  just  described,  and  is  usually  seen  in  children 
under  five  years  old.  It  is  not  a  frequent  manifestation  of  syphilis,  and 
as  compared  with  tuberculous  dactylitis  it  is  rare.  It  was  first  fully  de- 
scribed by  Taylor  (New  York).  The  symptoms  closely  resemble  the  tuber- 
culous form.  It  may  begin  as  a  periostitis  but  more  frequently  as  an 
osteo-myelitis.  Like  the  tuberculous  form  it  usually  goes  on  to  suppura- 
tion and  necrosis.  According  to  Taylor,  dactylitis  is  more  often  single 
than  multiple,  but  in  my  own  cases  several  phalanges  have  generally  been 


904  DISEASES  OP   THE  SKIK 

iavolved,  and  the  lesions  have  often  been  symmetrical  (Fig.  168).  In  one 
case,  the  first  phalanx  of  every  finger  of  both  hands  was  affected.  This  oc- 
curred in  a  child  nine  months  old  who  was  under  observation  for  over  two 
years,  and  who  presented  during  this  period  almost  every  lesion  of  he- 
reditary syphilis. 

The  symptoms  and  course  of  syphilitic  dactylitis  are  essentially  the 
same  as  in  the  tuberculous  form.  The  differential  diagnosis  is  considered 
with  the  latter  disease  (page  89T).  The  prognosis  is  much  the  same  in 
the  two  varieties,  with  the  exception  that  in  the  early  stage  the  syphilitic 
cases  may  often  be  arrested  by  constitutional  treatment.  This  is  the  same 
as  in  other  late  lesions  of  syphilis.  The  same  local  treatment  should  be 
employed  as  in  the  tuberculous  cases. 


CHAPTER  V. 

DISEASES  OF  THE  SKIN. 

The  skin  at  birth  is  covered  with  a  whitish  sebaceous  secretion,  the 
vernix  caseosa.  The  skin  itself  is  of  a  deep  purplish  colour,  which  changes 
to  a  bright  red  over  the  face  and  trunk  in  a  few  minutes,  with  the  estab- 
lishment of  normal  respiration,  and  in  a  few  hours  the  whole  body  has 
the  same  tint.  This  excessive  redness  slowly  fades  during  the  first  month, 
at  the  end  of  which  time  the  skin  has  assumed  the  pale  pink  of  infancy. 
On  the  third  or  fourth  day  there  are  usually  seen  the  first  signs  of  icterus ; 
this  generally  fades  by  the  end  of  the  second  week. 

The  epidermis  which  is  present  at  birth  soon  loosens  and  is  thrown 
o2.  This  normal  desquamation  usually  begins  upon  the  fourth  or  fifth 
day,  and  is  completed  in  ten  days  or  two  weeks.  If  the  skin  is  frequently 
oiled  and  properly  bathed,  desquamation  is  scarcely  noticeable  unless  a 
close  examination  is  made.  In  some  infants,  especially  those  who  are  deli- 
cate and  cachectic,  it  is  very  much  more  marked,  and  closely  resembles 
that  seen  in  scarlet  fever.  Eitter  has  described  an  exfoliative  dermatitis 
of  the  newly  born,  appearing  generally  during  the  second  and  third  weeks, 
a  condition  which  is  regarded  by  Kaposi  as  simply  an  exaggeration  of 
normal  physiological  desquamation.  This  process  may  be  mistaken  for 
that  due  to  hereditary  syphilis ;  the  latter,  however,  is  rarely  general,  ap- 
pears later,  and  is  much  more  prolonged. 

Perspiration  is  rarely  present  before  the  end  of  the  fourth  month,  and 
is  then  seen  only  upon  the  forehead.  In  healthy  infants  it  is  scarcely 
noticeable  during  the  first  year.  Copious  perspiration  is  most  frequently 
a  symptom  of  rickets ;  less  marked  perspiration  may  occur  with  any  gen- 
eral weakness  or  during  acute  illness. 


CONGENITAL   ICHTHYOSIS. 


905 


CONGENITAL  ICHTHYOSIS. 

Congenital,  or  more  properly  foetal,  ichthyosis,  sometimes  known  also 
as  diffuse  keratoma,  is  a  rare  disease,  characterized  by  the  formation,  usu- 
ally all  over  the  body,  of  a  thick,  horny  eijidermis  resembling  parchment. 
This  is  divided  by  fissures  or  shallow  furrows  into  irregular  j)atches; 
sometimes  these  are  two  or  three  inches  wide,  at  others  as  small  as  a  pin's 
head.  The  disease  begins  in  the  early  months  of  foetal  life,  and  is  an 
abnormality  in  the  development  of  the  skin,  there  being  an  excessive  pro- 
liferation of  the  layers  of  the  epidermis. 

Symptoms. — In  the  gravest  form  of  the  disease  the  child  often  lives  but 


109. — Concrenital  ichthyosis  in  a  child  ten  months  old.  The  larsfe  scaly  patches  are  well 
shown  on  the  lower  part  of  the  riorht  chest  and  abdomen,  and  the  constricting  bands  upon 
the  legs.    (From  a  photograpli  by  Dr.  Cabot.) 

a  few  hours,  and  rarely  more  than  a  week.  The  openings  of  the  nostrils 
and  the  ears  maybe  occluded  by  the  excessive  production  of  epithelial  cells. 
The  eyes  are  in  a  condition  of  ectropion,  and  there  are  often  deformities 
of  the  mouth  and  other  orifices  due  to  the  contractions  of  the  skin.  The 
nails  and  hair  are  usually  imperfectly  developed.  The  body  seems  in- 
cased in  a  hard,  horny  covering,  and  looks  as  if  it  had  been  varnished  or 
covered  with  collodion.  The  skin  cracks  or  splits  and  the  edges  curl  up, 
an  appearance  which  has  been  aptly  compared  to  the  skin  of  a  boiled 
potato. 

In  the  milder  form,  the  duration  of  life  is  indefinite,  depending  upon 


906  DISEASES  OF  THE  SKIX. 

the  degree  of  development  of  the  disease ;  but  even  in  such  cases  there 
are  frequently  seen  the  deformities  at  the  orifices  of  the  body,  and  there 
may  also  be  a  continued  exfoliation  of  the  epidermis  in  large  irregular 
patches.  After  this  has  separated,  the  skin  beneath  appears  red  and  moist, 
but  gradually  becomes  dry,  hard,  and  shining,  slowly  contracting  until  it 
splits  in  various  directions.  In  a  case  recently  under  observation  in  the 
Babies'  Hospital,*  a  picture  of  which  is  shown  in  the  accompanying  illus- 
tration (Fig.  169),  it  -was  stated  by  the  mother  that  during  the  first  ten 
months  of  life  complete  exfoliation  of  the  skin  had  occurred  in  the  course 
of  every  two  or  three  months. 

The  outlook  is  bad  in  all  cases ;  in  most  of  the  severe  forms  death 
occurs  in  infancy,  but  in  some  of  the  milder  ones,  life  may  be  prolonged 
throughout  childhood.  The  "  alligator  boy  "  of  the  Dime  Museum  is  an 
example  of  this  class. 

Treatment. — The  indications  are  to  keep  the  skin  moist  and  soft  by 
the  use  of  oils,  continuous  baths,  etc.,  and  to  prevent  infection  by  perfect 
cleanliness.  Although  a  certain  amount  of  improvement  usually  follows 
these  measures,  a  cure  is  not  to  be  expected. 

MILIARIA. 

The  term  miliaria  is  applied  to  an  obstruction  of  the  sweat  glands, 
which  may  occur  either  with  or  without  inflammation.  The  non-inflam- 
matory form  is  known  as  sudamina,  the  inflammatory  forms  as  miliaria 
ruhra,  miliaria  vesiculosa,  and  miliaria  papulosa. 

Sudamina. — In  this  form  there  is  no  inflammation.  The  sweat  ducts, 
according  to  Crocker,  are  blocked  by  an  accumulation  of  epithelial  cells 
while  no  perspiration  is  going  on ;  and  when  the  process  is  restored  the 
fluid,  being  unable  to  escape,  accumulates  in  the  form  of  tiny  vesicles. 
These  appear  like  small  pearly  bodies  very  closely  set,  and  disappear  in 
the  course  of  a  few  days  by  absorption.  Fresh  crops  may  appear  from  time 
to  time.  Sudamina  may  be  seen  in  any  of  the  continued  fevers  or  ex- 
hausting diseases.     It  requires  no  treatment. 

Miliaria  Rubra. — This  condition,  also  known  as  red  gum,  strophulus^ 
etc.,  is  a  sweat  rash,  usually  seen  in  young  infants  as  the  result  of  excess- 
ive clothing.  It  is  most  frequently  observed  upon  the  cheeks  and  neck, 
often  upon  the  side  of  the  face  upon  which  the  infant  sleeps,  or  the  side 
held  against  the  mother's  body  while  nursing,  if  this  is  done  upon  only 
one  breast.  The  eruption  consists  of  scattered  red  papules,  sometimes 
with  tiny  vesicles.      Miliaria  rubra  is  an  inflammation  about  the  sweat 


*  This  case  has  been  fully  reported  by  Cabot,  Xew  York  Medical  Record,  July  6, 
1895.  For  fuller  description  of  the  disease,  see  Ballantyne,  Diseases  of  the  Foetus,  voL 
ii,  1895 ;  also  Archives  of  Paediatrics,  April  and  June,  1894. 


MILIARIA.  907 

glands,  the  result  of  which  is  a  retention  of  their  secretion.  There  is 
generally  little  or  no  itching.  The  treatment  consists  in  the  removal  of 
the  cause,  and  the  application  of  some  absorbent  powder,  such  as  boric 
acid  and  starch. 

Miliaria  PapiQosa  (Lichen  Tropicus,  Prickly  Heat,  etc.). — This  is  the 
most  common  and  most  important  variety  of  miliaria.  There  is  in  this 
disease  an  obstruction  of  the  sweat  glands  by  inflammatory  products.  The 
lesion  consists  in  the  formation  of  bright-red  papules,  which  are  very 
closely  set,  the  summits  of  some  of  them  being  surmounted  by  tiny  vesi- 
cles, and  here  and  there  in  severe  cases  even  small  pustules  may  be  seen. 
If  not  interfered  with  by  scratching,  the  vesicles  dry  up  without  rupture, 
and  are  followed  by  a  slight  desquamation.  Where  there  is  much  scratch- 
ing, an  eczematous  condition  may  result.  Miliaria  papulosa  comes  out 
with  great  rapidity,  especially  upon  the  neck,  forehead,  back,  and  chest. 
It  is  accompanied  by  an  almost  intolerable  itching  and  stinging  sensa- 
tion. Over  other  parts  of  the  body  profuse  perspiration  occurs.  The 
disease  is  produced  by  very  hot  weather  and  excessive  clothing.  Although 
the  duration  of  a  single  attack  is  but  two  or  three  days,  in  susceptible 
patients  it  may  keep  recurring  for  weeks,  being  exceedingly  intractable. 
Where  there  is  much  scratching  the  resulting  eczema  is  very  troublesome. 
It  is  not  infrequently  followed  by  furunculosis. 

The  diagnosis  of  miliaria  rubra  and  miliaria  papulosa  is  usually  easy. 
They  are  distinguished  from  eczema  by  the  suddenness  with  which  they 
appear,  by  the  associated  sweating  of  other  parts  of  the  body,  by  the  tran- 
sitory character  of  the  eruption,  and  by  the  fact  that  the  rash  never  occurs 
in  circumscribed  patches.  Prickly  heat  sometimes  resembles  the  rash  of 
scarlet  fever,  but  the  fact  that  the  tiny  papules  are  in  some  places  crowned 
by  vesicles  and  that  constitutional  symptoms  are  absent,  usually  make  the 
distinction  an  easy  one. 

Treatment. — Prickly  heat  is  to  be  prevented  by  light  clothing,  fre- 
quent bathing,  and  the  plentiful  use  of  a  good  toilet  powder,  such  as  boric 
acid  and  starch.  During  an  attack,  the  bowels  should  be  freely  opened  by 
calomel  or  a  saline,  and  secretion  of  the  kidneys  stimulated  by  the  use  of 
citrate  of  potassium  or  the  sweet  spirits  of  nitre.  The  skin  should  be 
protected  against  the  irritation  of  flannel  undergarments  by  the  interposi- 
tion of  silk  or  linen.  When  the  inflammation  is  at  its  height,  relief  is 
obtained  by  the  application  of  a  calamine  and  zinc  lotion  (page  915),  or  by 
a  dilute  solution  of  the  acetate  of  lead  ;  carbolic  acid  may  be  added  to 
either,  where  the  itching  is  intense.  In  some  cases  powders  are  preferable 
to  lotions.  One  of  the  best  is  the  stearate  or  the  oxide  of  zinc,  twelve 
parts ;  bismuth,  three  parts  ;  powdered  camphor,  one  part ;  or  equal  parts 
of  starch  and  boric  acid  may  be  used,  or  simply  rice  flour.  All  of  these 
must  be  very  freely  applied.  The  diet  should  be  light  and  fluid,  and  if 
milk  is  the  food  it  should  be  considerably  diluted. 


908  DISEASES  OF   THE  SKIN. 


SEBORRHCEA. 


Seborrhoea  is  considered  by  dermatologists  generally,  as  a  functional 
disease  of  the  sebaceous  glands  ;  although  Unna  regards  all  such  cases  as 
inflammatory,  and  classes  them  as  seborrhoeic  eczema,  which  is  of  para- 
sitic origin  (page  911).  The  disease  may  affect  almost  any  part  of  the 
body,  and  children  of  any  age,  but  the  most  frequent  form  is  that  which 
is  seen  upon  the  scalp  in  young  infants.  This  is  the  most  important 
variety,  and  the  only  one  which  will  be  here  considered. 

Seborrhoea  of  the  scalp  is  characterized  by  the  formation  upon  the 
vertex,  of  dirty-yellow  crusts,  which  are  soft,  greasy,  and  friable.  They 
are  composed  of  epithelial  cells,  fat-globules,  and  granular  masses,  to  which 
is  always  added  dirt.  In  neglected  cases  the  hairy  scalp  is  nearly  covered 
by  a  dense  crust,  which  may  be  as  thick  as  heavy  pasteboard.  If  the 
crusts  are  removed  the  underlying  scalp  may  be  found  perfectly  healthy, 
but  more  frequently,  in  cases  of  long  standing,  it  is  eczematous.  The 
eczema  is  set  up  by  the  decomposition  of  the  exudation,  or  by  the  efforts 
to  remove  the  crusts  by  such  means  as  the  fine-toothed  comb,  commonly 
employed  in  domestic  practice.  There  is  little  tendency  to  spontaneous 
improvement  or  recovery,  and  the  condition  often  lasts  for  months.  Every 
seborrhcea  should  be  treated,  for  when  neglected  it  furnishes  a  favourable 
soil  for  the  development  of  eczema. 

Treatment. — Only  local  measures  are  required.  The  crusts  are  first  to 
be  softened  with  oil,  and  then  removed  by  washing  thoroughly  with  warm 
water  and  soap,  after  which  an  ointment  of  resorcin  (resorcin,  gr.  x ;  ungt. 
aquge  rosse,  |  j)  or  sulphur  (precipitated  sulphur,  3  j ;  lanoline,  3  j) 
should  be  applied.  The  oil  and  soap  and  water  are  repeated  every  few  days, 
or  as  often  as  the  crusts  form.  In  the  meantime  the  scalp  is  kept  cov- 
ered with  the  ointment. 

ECZEMA. 

Eczema  may  be  defined  as  a  catarrhal  inflammation  of  the  skin.  It 
is  the  most  frequent  and  altogether  the  most  important  disease  of  the  skin 
in  early  life.  The  scope  of  the  present  work  permits  only  a  discussion  of 
such  features  and  varieties  as  are  peculiar  to  infants  and  young  children. 
The  eczema  of  older  children  does  not  differ  in  any  essential  points  from 
that  of  adults. 

Etiology. — The  conditions  in  infancy  which  predispose  to  eczema  are, 
first,  that  the  skin  is  extremely  delicate,  and  hence  more  easily  affected  by 
external  irritants  and  micro-organisms ;  secondly,  its  more  intense  glandu- 
lar activity.  While  all  children  are  susceptible,  there  are  certain  ones 
in  whom  the  susceptibility  is  very  marked,  and  in  them  the  slightest 
amount  of  external  irritation,  or  the  most  trivial  disturbance  of  diges- 
tion may  produce  a  severe  eruption.     It  was  formerly  the  fashion  to  class 


ECZEMA.  909 

eczema  of  the  face  and  scalp  among  the  manifestations  of  infantile 
"  scrofula."  We  can  not  connect  eczema  with  any  single  diathetic  con- 
dition; but  it  is  much  more  often  seen  in  children  with  gouty  antece- 
dents than  in  others ;  or  to  state  it  differently,  the  most  frequent  mani- 
festation of  gout  during  infancy  is  the  tendency  to  eczema.  Children  of 
rheumatic  families  are  also  prone  to  the  disease.  Eczema  of  the  face  is 
common  in  fat,  healthy-looking  infants,  both  in  those  who  are  nursing 
and  in  those  who  are  artificially  fed.  It  also  occurs  in  poorly  nourished 
children,  but  rarely  in  those  suffering  from  marasmus. 

The  exciting  causes  of  eczema  may  be  external  or  internal.  Of  the 
former  the  most  important  are  heat,  cold  dry  air,  and  winds — as  in  the 
familiar  chapping  of  the  face — the  use  of  hard  water  or  of  strong  soaps 
in  bathing.  The  disease  may  be  due  to  the  irritation  of  clothing,  to  want 
of  cleanliness,  or  to  irritating  discharges  from  mucous  surfaces,  as  in 
the  eczema  of  the  upper  lip,  thighs,  or  buttocks.  It  accompanies  most 
of  the  parasitic  skin  diseases,  particularly  pediculosis,  scabies,  and  ring- 
worm. 

What  part  is  plaj^ed  by  micro-organisms  in  the  etiology  of  eczema  has 
not  yet  been  fully  determined.  The  observations  of  Gilchrist  and  others 
seem  to  indicate  that  as  a  primary  factor  they  are  not  of  the  first  impor- 
tance. Secondary  infection,  however,  occurs  in  most  of  the  cases,  and  is 
a  factor  of  the  greatest  importance  in  keeping  up  the  disease. 

The  internal  causes  of  eczema  are  chiefly  associated  with  deficient 
elimination  from  the  kidneys  and  bowels,  and  digestive  disturbances.  It 
often  accompanies  chronic  constipation  where  there  is  intestinal  torpor 
and  the  white  stools  of  deficient  biliary  secretion  ;  and  it  is  seen  where  the 
urine  is  scanty  and  concentrated  because  children  partake  too  largely  of 
solid  food.     The  latter  is  true  both  in  the  first  and  second  years. 

Eczema  may  be  produced  by  any  form  of  digestive  disturbance,  but  it 
is  especially  frequent  in  the  intestinal  indigestion  which  results  from 
overfeeding,  or  the  too  early  or  excessive  use  of  farinaceous  food,  or  from 
breast  milk  in  which  the  percentage  of  fat  is  very  high.  From  personal 
experience  in  the  post-mortem  room,  I  can  confirm  the  observation  of 
Bohn  regarding  the  frequency  with  which  fatty  liver  occurs  in  very  fat 
infants.  Enlargement  of  the  liver  may  sometimes  be  made  out  during  life. 
It  is  highly  probable  that  the  interference  with  the  hepatic  functions  which 
accompanies  these  fatty  changes  has  much  to  do  with  the  production  of 
eczema  in  such  subjects.  In  children  fed  upon  cow's  milk  the  excessive 
fat  may  be  the  cause,  or  it  may  be  due  to  excessive  proteids.  Of  farina- 
ceous articles,  the  two  which  are  most  often  to  be  blamed  are  potato  and 
oatmeal.  Although  eczematous  patients  usually  appear  to  be  well  nour- 
ished, it  is  rare  that  some  symptoms  of  indigestion  are  not  present. 

Eczema  is  often  due  to  some  form  of  reflex  irritation.  Such  are  the 
cases  which  accompany  dentition,  and  the  rare  ones  due  to  genital  irrita- 
59 


910  DISEASES  OP  THE  SKIN. 

tion.  By  many  writers  the  eczema  caused  by  disorders  of  the  stomach  or 
intestines  is  regarded  as  reflex.  The  stronger  the  predisposition,  the  more 
trivial  is  the  reflex  irritation  which  will  induce  an  eruption. 

Simple  Chronic  Eczema — Eczema  Rubrum. — This  is  the  most  frequent 
form  of  eczema  occurring  in  infants  and  young  children,  and  is  usually 
seen  upon  the  face.  It  affects  by  preference  the  cheeks,  forehead,  and 
scalp,  not  infrequently  the  ears  and  neck,  and  may  occur  upon  any  part 
of  the  body.  Upon  the  trunk  and  extremities  the  eruption  is  usually  in 
patches,  but  in  rare  cases  may  cover  nearly  the  entire  body.  The  disease 
generally  begins  upon  the  cheeks  with  the  formation  of  small  red  papules ; 
later  these  coalesce,  and  there  is  a  moist,  red  surface  exuding  serum  or 
sero-pus.  The  secretion  dries  and  forms  thick,  gummy  crusts,  which  may 
be  so  hard  as  to  form  a  mask  for  the  face.  From  the  scratching  caused 
by  the  almost  intolerable  itching,  the  surface  bleeds  freely,  and  the  dried 
blood  gives  to  the  crusts  a  dirty-brown  colour  and  adds  to  the  distressing 
appearance.  The  skin  is  often  much  swollen.  After  the  removal  of  the 
crusts  there  is  seen,  in  acute  cases,  a  red,  inflamed,  granular  surface,  dis- 
charging pus  or  serum  and  bleeding  readily.  When  the  process  is  less 
active,  there  is  redness,  thickening,  induration,  and  scaliness  of  the  skin, 
and  marked  itching.  In  the  same  case  these  stages  may  alternate,  exacer- 
bations occurring  whenever  the  exciting  cause  is  particularly  active. 
From  the  cheeks  the  disease  spreads  to  the  forehead,  ears,  and  scalp,  and 
here  similar  lesions  are  seen.  Upon  the  trunk  and  extremities  thick  crusts 
rarely  form,  but  the  skin  is  red,  thick,  and  scaly.  The  parts  most  often 
affected  are  the  forearms,  chest,  elbows,  knees,  abdomen,  and  back ;  occa- 
sionally the  eruption  is  general. 

Swelling  of  the  lymph  nodes  in  the  neighbourhood  of  the  eruption  is  a 
constant  feature  of  eczema  of  the  face  and  scalp ;  these  may  reach  the 
size  of  a  chestnut  or  walnut,  and  occasionally  they  suppurate.  Intense 
itching  is  a  characteristic  feature  of  all  cases  of  eczema  of  the  face  or 
scalp.  It  causes  restlessness  and  loss  of  sleep,  and  usually  it  is  only  in 
this  way  that  the  disease  affects  the  general  health  of  the  patient ;  but  in 
most  cases  the  health  remains  good.  With  eczema  of  the  occipital  region 
of  the  scalp,  pediculosis  is  usually  associated. 

Eczema  of  the  face  is  very  chronic,  easily  improved,  but  cured  only 
with  great  difficulty.  There  is  a  strong  tendency  to  relapses,  brought  on 
by  neglect  of  local  treatment  or  by  any  digestive  disturbance. 

The  predisposition  to  eczema  often  ceases  with  the  second  year ;  those 
who  have  suffered  from  it  almost  constantly  during  infancy  may  be  free 
from  it  during  the  remainder  of  childhood.  This  is  in  part  to  be  ex- 
plained by  the  loss  of  fat  in  consequence  of  more  active  exercise  and  a 
diet  which  is  more  largely  nitrogenous.  Where  the  disease  continues 
through  the  third  and  fourth  years,  the  associated  infantile  condition — ' 
obesity — is  not  infrequently  present. 


ECZEMA.  911 

Seborrhoeic  Eczema. — This  form  of  eczema  has  been  brought  into 
promiueuce  by  the  writings  of  Unnu,  according  to  whom  not  only  are  all 
the  cases  usually  classed  as  seborrhoea  to  be  regarded  as  eczematous,  but 
also  many  others  classed  as  ordinary  eczema.  Instead  of  seborrhauc 
eczema  being  a  form  of  disease  in  which  the  fat-producing  glands  are 
involved  in  the  inflammatory  process,  Unna  believes  it  to  be  parasitic  and 
due  to  a  certain  "  mulberry  coccus  "  which  he  has  described.  Although  his 
investigations  have  not  yet  been  corroborated,  there  are  many  arguments 
in  favour  of  the  pathology  which  he  has  advanced  for  this  disease.  Elliot, 
who  accepts  XJuua's  views,  defines  seborrhoeic  eczema  as  follows:  "An 
inflammatory  disease  of  the  skin,  catarrhal  in  nature,  due  to  micro-organ- 
isms— a  parasitic  dermatitis — characterized  by  its  primary  seat  being  upon 
the  scalp,  whence  it  tends  to  spread  downward,  involving  by  preference 
the  middle  portion  of  the  face,  the  sternal  and  interscapular  spaces,  axilla, 
and  inguinal  regions,  but  may  affect  any  part  of  the  body."  *  The  lesions 
upon  the  scalp  may  be  of  the  nature  of  a  dry  seborrhoea  with  yellow 
greasy  crusts,  or  like  pit3Tiasis.  Upon  the  body,  the  eruption  is  scaly,  with 
red  macules  or  papules,  or  it  may  be  accompanied  by  greasy  crusts  like 
those  seen  upon  the  scalp.  The  skin  is  not  usually  thickened  and  the 
lesions  are  not  elevated.  Itching  in  most  cases  is  only  moderate,  and  it 
may  be  absent ;  but  in  some  of  the  most  severe  cases  it  is  marked  and  ac- 
companied by  tingling.  An  extensive  weeping  surface  is  never  seen.  All 
the  crusts  are  soft  and  contain  fatty  matter.  The  lesions  are  not  deep, 
and  the  disease  frequently  shifts  from  one  part  of  the  body  to  another, 
often  coming  out  very  rapidly.  In  most  cases  the  patches  are  rather 
sharply  defined  and  have  rounded  borders. 

Pustular  Eczema  of  the  Scalp. — This  condition,  often  called  "  simple 
impetigo,"  is  less  frequently  seen  in  infants  than  in  children  from  two  to 
five  years  old.  There  are  usually  jDresent  from  half  a  dozen  to  fifty 
greenish-yellow  crusts,  matting  the  hair,  usually  discrete,  but  sometimes 
coalescing  to  form  a  mask  over  half  the  scalp.  There  is  very  little  itch- 
ing, in  some  cases  none  at  all.  The  lymph  glands  are  invariably  enlarged. 
There  is  frequently  continued  auto-infection,  and  in  this  way  the  disease 
may  be  prolonged  indefinitely.  It  is  possible,  too,  that  infection  may 
spread  to  other  children. 

Intertrigo. — This  term  is  rather  indiscriminately  applied  to  any  erup- 
tion which  develops  upon  two  moist  surfaces,  which  are  in  contact.  It 
is  often  regarded  as  a  form  of  eczema,  although,  as  Elliot  has  well 
pointed  out,  there  are  seen  several  processes  which  are  quite  distinct 
from  one  another.  The  most  frequent  is  a  simple  erythema ;  in  other 
cases  there  is  an  eczema  resulting  from  traumatism  or  the  decomposition 

*  Morrow's  System  of  Gen  ito- Urinary  Diseases,  Sy philology,  and  Dermatology, 
vol.  iii,  D.  Appleton  &  Co.,  1895. 


912  DISEASES  OF  THE  SKIN. 

of  secretions,  or  a  seborrhoeic  inflammation.  Intertrigo  is  seen  in  the 
folds  of  the  groin,  between  the  scrotum  and  the  thighs,  between  the  but- 
tocks, about  the  anus,  in  the  axillae,  in  the  neck,  or  behind  the  ears.  Its 
essential  causes  are  moisture,  friction,  want  of  cleanliness,  and  sometimes 
infection.  The  disease  is  generally  seen  in  its  worst  form  about  the 
thighs,  genitals,  and  buttocks ;  it  sometimes  covers  the  sacrum  and  ex- 
tends down  to  the  middle  of  the  thighs.  There  is  an  intense  uniform 
redness,  and  in  some  cases  the  epidermis  is  denuded  over  large  areas,  and 
the  surface  is  moist.  There  is  no  thick  crusting  and  little  or  no  itching. 
Intertrigo  is  usually  easy  to  control  except  in  very  poorly  nourished  or 
marantic  children,  among  whom  it  is  especially  frequent. 

Diagnosis  of  Eczema. — This  is  usually  quite  an  easy  matter.  In  the 
majority  of  cases,  the  disease  affects  the  face  or  the  scalp,  and  its  appear- 
ances are  typical.  Eczema  of  the  body  or  extremities  may  be  confounded 
with  scabies  or  syphilis,  and  occasionally  with  other  forms  of  skin  disease. 
Scabies  resembles  eczema  in  its  intense  itching  and  multiform  lesions; 
but  in  the  former,  one  may  often  find  evidences  of  its  presence  in  other 
members  of  the  family ;  the  parts  most  frequently  affected  are  the  flexures 
of  the  wrists,  the  elbows,  the  skin  between  the  fingers,  the  margins  of  the 
axillae,  the  lower  part  of  the  abdomen  and  back,  and,  in  boys,  the  penis ; 
and  by  careful  examination  with  a  lens  some  of  the  characteristic  burrows 
are  certain  to  be  discovered. 

Syphilis  is  likely  to  be  confounded  with  papular  eczema  of  the  but- 
tocks. The  latter  affects  the  parts  near  the  anus,  and  the  irritation  may 
lead  to  the  development  of  spots  closely  resembling  mucous  patches.  The 
local  appearances  may  at  times  be  indistinguishable  from  syphilis,  and  the 
diagnosis  is  to  be  made  only  by  the  other  symptoms  present.  In  syphilis 
the  characteristic  eruption  is  seen  usually  upon  the  face,  hands,  legs,  and 
sometimes  the  palms  and  soles ;  there  is  no  itching  and  very  little  evi- 
dence of  inflammation ;  the  eruption  is  dark-coloured,  and  occurs  as  small 
circumscribed  spots;  there  are  usually  present  other  symptoms,  such  as 
the  coryza,  the  syphilitic  cachexia,  and  enlargement  of  the  spleen. 

The  diagnosis  from  pediculosis  and  ringworm  of  the  scalp,  rarely  pre- 
sents any  difficulties. 

Prognosis. — All  cases  of  chronic  eczema  are  tedious.  There  is  only  a 
slight  tendency  to  spontaneous  improvement,  and  very  little  to  spontane- 
ous recovery  during  infancy.  In  a  given  case,  the  prognosis  depends  upon 
the  duration  of  the  disease,  its  severity,  and  very  much  upon  the  co-opera- 
tion of  the  mother  or  nurse.  The  results  obtained  depend  not  only 
upon  the  particular  line  of  treatment  adopted,  but  upon  how  well  it  is  car- 
ried out.  Usually  it  must  be  continued  for  several  months.  Eczema  of 
the  face  is  especially  intractable  when  occurring  in  children  suffering  from 
chronic  indigestion  and  constipation.  Intertrigo  is  in  most  cases  easily 
cured,  unless  the  patient  is  suffering  from  marasmus. 


ECZEMA.  913 

Treatment. — It  is  never  dangerous  to  cure  an  eczema,  and  always  de- 
sirable to  do  so,  in  spite  of  the  strong  prejudice  to  the  contrary,  which 
still  exists  in  the  minds  of  the  laity  and  in  some  members  of  the  medica  I 
profession.  The  general  tendency  is  to  treat  the  eczema  rather  than 
the  patient  who  is  suffering  from  it.  A  Judicious  combination  of  gen- 
eral and  local  measures  is  necessary  for  the  best  results.  One  should 
first  seek  to  discover  and  correct  what  is  wrong  with  the  child's  diges- 
tion, assimilation,  and  elimination ;  unless  nutritive  disturbances  can 
be  removed,  local  treatment  will  give  only  temporary  relief.  External 
causes  also  must  be  investigated.  The  local  measures  employed  must  be 
chosen  with  reference  to  the  condition  present;  stimulating  applica- 
tions should  not  be  ordered  for  an  acutely  inflamed  skin,  nor  sedative 
applications  in  very  chronic  conditions. 

Diet. — A  thorovigh  investigation  into  the  food  is  necessary,  not  only 
as  to  its  character,  but  as  to  quantity  and  preparation,  the  manner  and 
frequency  of  feeding,  etc.  If  the  patient  is  a  nursing  infant,  an  examina- 
tion of  the  nurse's  milk  is  indispensable  to  intelligent  treatment.  If  the 
child  is  very  fat  and  well  nourished,  it  is  generally  the  case  that  the  fat  of 
the  milk  is  too  high  and  must  be  reduced  according  to  the  rules  given 
elsewhere  (page  171),  the  most  important  thing  being  to  exclude  from 
the  nurse's  diet  malt  liquors  and  alcohol  in  all  forms,  and  reduce  the 
amount  of  meat.  In  a  smaller  number  of  cases  the  trouble  is  with  the 
proteids  of  the  milk ;  there  will  then  be  other  signs  of  indigestion,  such 
as  colic,  the  appearance  of  curds  in  the  stools,  etc.  The  amount  of  food 
should  be  reduced  by  lengthening  the  period  between  the  nursings,  and 
shortening  the  time  which  the  child  is  allowed  to  remain  at  the  breast 
at  one  nursing.  Plain  water,  or  better,  some  alkaline  water,  should  be 
given  freely  between  the  nursings.  In  children  fed  upon  cow's  milk,  the 
trouble  may  be  with  the  sugar,  the  proteids,  or  the  fat.  The  phj'sician 
should  try  the  effect,  first  of  giving  a  milk  which  is  low  in  proteids  and 
moderately  high  in  fat  (e.  g.,  formula  G  or  H,  page  207)  afterwards,  one 
in  which  both  fat  and  proteids  are  low  (e.  g.,  formula  II  or  III,  page 
192). .  These  and  other  changes  are  to  be  made  in  the  manner  described 
in  the  chapter  on  Infant  Feeding.  During  the  latter  part  of  the  first  and 
the  entire  second  year,  the  usual  error  is  that  of  overfeeding  with  in 
most  cases  an  excessive  use  of  solid  food,  especially  farinaceous  articles. 
The  diet  should  then  be  much  reduced,  and  the  amount  of  farinaceous 
food  restricted,  potatoes  and  oatmeal  being  absolutely  prohibited.  The 
diet  which  suits  most  children  best  is  one  composed  of  milk,  beef  juice, 
broth,  fruit,  eggs,  and  a  little  red  meat,  with  the  addition  in  some  cases 
of  rice,  wheat,  or  barley.  In  severe  and  obstinate  cases,  however,  as  com- 
plete a  change  in  diet  as  possible  is  sometimes  the  best  prescription.  Any 
form  of  indigeslidii  which  exists  is  to  be  managed  according  to  the  spe- 
cial indications  in  each  case. 


914  DISEASES  OF   THE  SKIN. 

The  diet  of  older  children  needs  to  be  watched  no  less  closely  than 
that  of  infants.  The  general  rules  laid  doAvn  elsewhere  for  feeding  after 
the  second  year  (pages  216-218)  should  be  observed.  The  great  majority 
of  cases  do  best  upon  a  diet  which  is  largely  fluid,  and  composed  princi- 
pally of  milk  or  some  of  its  substitutes — kumyss  or  matzoon. 

Elimination  by  the  kidneys  should  be  stimulated  by  the  very  free  use 
of  water,  to  which  it  is  well  to  add — especially  in  cases  with  a  gouty  tend- 
ency— the  citrate,*  or  acetate  of  jDotassium,  from  ten  to  twenty  grains 
daily. 

Attention  to  the  condition  of  the  bowels  is  of  the  greatest  impor- 
tance. To  overcome  the  tendency  to  constipation  is  in  many  cases  to 
cure  the  eczema.  Suggestions  under  this  head  will  be  found  in  the  chap- 
ter on  Chronic  Constipation  (page  120).  Special  importance  is  to  be 
attached  to  the  occasional  use  of  a  purge  of  calomel,  one  half  to  one 
grain  being  given  every  third  or  fourth  night.  The  best  effects  from 
this  are  seen  in  over-fed  children.  It  has  a  favourable  effect  upon  the 
kidneys  as  well  as  upon  the  bowels.  The  bowels  must  not  only  be 
opened,  they  must  be  kept  freely  open  by  the  daily  use,  if  necessary,  of 
some  of  the  milder  laxatives,  such  as  phosphate  of  sodium,  rhubarb,  or 
cascara.  Sometimes  nothing  acts  so  well  as  castor  oil,  which  may  be 
given  in  from  half  a  teaspoonful  to  teaspoonful  doses  every  night  for  two 
or  three  weeks  at  a  time.    It  should  be  administered  in  emulsion. 

When  the  disease  occurs  in  flabby,  auEemic,  or  poorly-nourished  chil- 
dren, iron  and  bitter  tonics  are  recjuired,  and  occasionally  alcohol  and 
cod-liver  oil.  In  other  words,  the  child's  general  condition  should  be 
treated  just  as  if  no  eczema  existed.  Arsenic  is  indicated  in  a  chronic  or 
recurring  form  of  eczema  with  dry,  scaly  eruption.  It  is  in  no  sense  a 
specific  remed}',  but  sometimes  of  great  value. 

The  general  management  of  cases  is  important.  The  skin  must  be 
carefully  protected  by  an  ointment  whenever  the  child  is  in  the  open  air ; 
if  the  weather  is  very  cold,  or  there  are  high  winds,  children  with  active 
eczema  should  not  go  out,  but  take  the  fresh  air  indoors.  Xever  should 
an  eczematous  surface  be  washed  with  plain  water,  and  much  less  with 
castile  soap  and  water,  so  frequently  employed  by  the  ignorant.  Where 
washing  is  necessary,  it  may  be  done  with  bran  water,  milk  and  water, 
or  starch  and  water,  to  which  borax  (a  teaspoonful  to  the  quart)  may  be 
added.  The  clothing  should  not  be  so  excessive  as  to  keep  the  child  con- 
stantly in  a  perspiration.  Xapkins  should  not  be  washed  in  strong  soda 
solutions,  nor,  in  case  of  eczema  of  the  buttocks,  should  they  ever  be 
used  a  second  time  after  being  simply  dried. 

*  While  the  citrate  can  not  be  depended  npon  as  a  diuretic,  unless  dispensed  from 
a  newly  opened  bottle,  it  is  generally  to  be  preferred,  as  being  more  easily  admin- 
istered. 


ECZE.MA.  915 

In  eczema  of  the  face  it  is  absolute!}' necessary  to  prevent  tlie  child 
from  scratcliing  the  jiarts.  The  use  of  a  mask  is  not  always  sufficient, 
nor  the  wearing  of  mittens ;  nor  is  the  local  application  of  anti-pruritic 
lotions  or  ointments  invariably  successful.  In  severe  cases  mechanical 
restraint  is  absolutely  indispensable.  The  most  satisfactory  method  is  to 
surround  the  arms  at  the  elbows  by  pasteboard  splints,  and  hold  them  in 
place  by  bandages.  This  allows  free  use  of  the  hands,  but  makes  it  abso- 
lutely impossible  for  the  child  to  reach  the  face. 

Local  treatment. — Local  treatment  is  always  necessary,  for  not  only 
are  the  causes  sometimes  entirely  external,  but  the  condition  may  persist 
after  the  original  internal  cause  has  been  removed.  There  are  several 
indications  to  be  met  by  local  treatment  at  different  stages  in  the  disease : 
(1)  To  remove  crusts  and  other  inflammatory  products;  (2)  to  allay  con- 
gestion and  acute  inflammation ;  (3)  to  relieve  itching ;  (4)  to  protect  the 
delicate  new  skin  which  is  forming;  (5)  to  prevent  infection  ;  (0)  to  stimu- 
late the  skin  in  the  chronic  stages  of  the  disease. 

Preparatory  to  the  use  of  any  application,  the  scales,  crusts,  and  other 
products  of  inflammation  must  be  softened  and  removed  in  order  that  the 
diseased  surface  may  be  reached.  In  most  cases  it  is  sufficient  to  soften 
the  crusts  by  the  use  of  olive  oil  for  twelve  or  twenty-four  hours,  and  then 
remove  them  by  soap  and  warm  water.  If  the  crusts  are  very  hard  and 
thick,  they  can  be  softened  by  a  jjoultice.  During  the  stage  of  acute  in- 
flammation only  sedative  applications  should  be  used.  One  of  the  best  of 
these  is  a  lotion  of  zinc  and  calamine : 

]^  Pulv.  calaminas  preparatae 3  ij 

Zinci  oxidi 3  ss. 

GlycenniP 3  j 

Liquor  caleis 3  ij 

Aquae  rosae §  viij. 

A  piece  of  muslin  should  be  dipped  in  this  solution,  and  applied  to 
the  affected  part,  being  kept  in  place  by  a  bandage.  If  there  is  much 
itching,  one  per  cent  of  carbolic  acid  may  be  added. 

Another  plan  of  treatment,  where  there  is  much  secretion,  is  to  keep 
the  siirface  covered  with  equal  parts  of  boric  acid  and  starch  or  dolomol 
powder.  An  application  which  is  often  successful  in  allaying  the  in- 
tense burning  and  itching  is  black  wash.  This  is  applied  several  times  a 
day  in  full  strength  or  diluted  and  allowed  to  dry  on,  after  which  a  pro- 
tective ointment  is  used. 

A  soothing  application  in  general  eczema  is  one  composed  of  equal 
parts  of  lime  water  and  sweet-almond  oil ;  sometimes  this  nuiy  I)e  advan- 
tageously followed  by  smearing  the  body  with  a  thick  starch  \n\Ao  iind 
allowing  it  to  dry  on. 

As  a  simple  protective  ointment,  one  containing  starch,  zinc  oxide,  or 
bismuth,  either  alone  or  in  combination,  may  be  used.  An  excellent  for- 
mula is  Lassar's  paste : 


916  DISEASES  OF  THE  SKIN. 

5  Acidi  salicylic! gr.  x 

Zinci  oxidi 3  ij 

Amyli 3  ij 

Vaseline 1  j 

Later,  when  the  inflammation  is  less  acute  and  the  itching  severe, 
nothing  is  so  generally  useful  as  a  combination  of  tar  and  zinc,  as  in 
the  following : 

5  Ungt.  picis  liquidae 3  iij 

Zinci  oxidi 3  iss. 

Ungt.  aquae  rosse 3  vi 

For  more  chronic  cases,  the  amount  of  tar  may  be  increased.  All 
ointments  used  should  be  spread  upon  muslin,  and  kept  in  close  contact 
with  the  inflamed  part  by  means  of  a  bandage  or  mask.  Little  or  noth- 
ing is  accomplished  by  simply  rubbing  the  ointment  upon  the  afEected 
part.  Where  it  is  difficult  to  keep  a  mask  applied,  or  in  situations 
where  it  is  impossible  to  use  the  ointment,  Pick's  paste  may  be  tried : 

5   Pulv.  tragacanthae 3  j 

Glycerinae 3  iss. 

Aquse  rosae ^  iv 

To  this  may  be  added  zinc  oxide  gr.  xl  and  carbolic  acid  gr.  v,  or  tar  TTl,  x. 
A  similar  basis  for  ointments,  made  from  gum  tragacanth  has  been  sug- 
gested by  Elliot  and  is  known  as  bassorin  paste.  It  may  be  combined 
with  tar,  zinc,  salicylic  acid,  or  resorcin. 

The  methods  of  treatment  above  mentioned  are  especially  applicable 
to  eczema  of  the  face  and  scalp.  For  pustular  eczema  of  the  scalp  the 
best  application  is  the  white-precipitate  ointment,  which  should  be  com- 
bined with  three  or  four  parts  of  vaseline.  This  is  excellent  also  for  small 
eczematous  patches  upon  the  body,  but  it  is  not  to  be  used  over  a  large 
surface. 

In  intertrigo,  the  treatment  should  have  reference  to  the  pathological 
condition  which  is  present.  Cases  of  simple  erythema  usually  yield 
promptly  to  cleanliness  and  the  free  use  of  absorbent  antiseptic  powders, 
such  as  boric  acid  and  starch  in  equal  parts,  or  if  the  skin  is  very  sensi- 
tive, aristol  or  dolomol  with  aristol  may  be  used.  If  there  is  an  acute 
dermatitis,  the  calamine  and  zinc  lotion  may  be  used,  and  later  some 
protecting  ointment.  When  infection  has  been  added,  lotions  of  resor- 
cin or  ichthyol,  one  half  or  one  per  cent  strength,  should  first  be  applied, 
and  the  skin  then  covered  with  one  of  the  powders  mentioned ;  both  are 
to  be  repeated  as  often  as  the  parts  are  wet  by  urine  or  soiled  by  faeces. 
It  is  important  in  all  cases  that  the  diseased  surfaces  should  be  kept 
separated,  which  is  best  done  by  starch  or  aristol  and  absorbent  cotton. 
All  napkins  should  be  immediately  removed  when  soiled. 

In  cases  of  chronic  eczema,  where  the  skin  remains  thickened,  red. 


FURUNCL'LOSIS.  91 Y 

scaly,  and  itching,  stimulating  applications  are  to  be  used,  such  as  the 
tincture  of  green  soap  or  stronger  preparations  of  tar  than  those  men- 
tioned.   They  should  be  applied  every  three  or  four  days. 

In  the  seborrhceic  form  of  eczema,  whether  affecting  the  face,  scalp, 
or  body,  nothing  is  so  generally  useful  as  resorcin : 

5  Resorcin gr.  x 

Ungt.  aquae  rosse 5  j 

This  may  also  be  advantageously  combined  with  bassorin  paste. 

FURUNCULOSIS. 

A  furuncle,  or  boil,  is  a  circumscribed  inflammation  of  the  subcuta- 
neous cellular  tissue,  usually  beginning  in  a  hair  follicle,  and  usually 
ending  in  suppuration.  When  severe,  it  may  result  in  necrosis  of  the 
follicle,  which  forms  the  "  core,"  or  the  necrotic  process  may  extend  to 
the  surrounding  tissues  for  a  variable  distance.  The  ordinary  boil  need 
not  be  described,  as  it  presents  nothing  peculiar  in  early  life.  The  con- 
dition, however,  which  is  characteristic  of  young  children  is  the  forma- 
tion of  small  ones  in  great  numbers.  It  is  to  this  more  especially  that 
the  term  furunculosis  is  applied.  The  principal  location  of  these  small 
abscesses  is,  in  nearly  all  cases,  the  scalp,  face,  and  shoulders,  although 
they  may  be  found  upon  any  part  of  the  body.  They  are  sometimes 
numbered  by  hundreds,  and  appear  in  crops  for  a  period  of  several 
months.  In  size,  they  usually  vary  from  a  pea  to  an  almond,  and  they 
rarely  contain  a  core.  Infants  are  much  more  often  the  subjects  of  this 
disease  than  are  those  who  have  passed  the  second  year.  In  the  great 
majority  of  cases  the  condition  is  not  serious,  yet,  occurring,  as  it  often 
does,  in  infants  who  are  already  suffering  from  extreme  malnutrition 
or  marasmus,  whose  tissues  possess  but  little  resistance,  the  process  may 
develop  into  a  gangrenous  dermatitis,  which  may  prove  fatal. 

Furunculosis  is  seen  in  children  who  are  in  other  respects  apparently 
healthy,  even  robust;  but  the  majority  are  in  a  more  or  less  debilitated 
condition,  and  often  are  the  subjects  of  digestive  disturbances.  The  dis- 
ease is  quite  frequent  in  syphilitic  infants ;  but  these  simple  abscesses 
are  to  be  sharply  distinguished  from  those  which  result  from  the  break- 
ing down  of  gummata  of  the  skin.  Want  of  cleanliness  of  the  skin  is  a 
factor  of  some  importance  in  producing  the  disease.  Furunculosis  may 
be  associated  with  eczema.  The  exciting  cause  in  all  cases,  as  shown  by 
all  recent  investigations,  is  the  entrance  of  the  staphylococcus  pyogenes 
aureus,  sometimes  with  other  organisms,  into  the  follicles  of  the  skin. 

Treatment. — The  internal  treatment  is  to  be  directed  toward  any  dis- 
turbance of  digestion  or  general  nutrition  which  is  ])resent.  General 
tonics  are  indicated  in  most  cases,  particularly  iron,  arsiMiic  and  the  com- 
pound syrup  of  the  hypophosphites.     But  little  reliance  can  be  plared 


918 


DISEASES   OF   THE   SKIX. 


upon  internal  remedies,  sucli  as  sulpliide  of  calcium,  for  the  purpose  of 
arresting  this  disease.  Local  treatment  shonld  hare  for  its  first  object 
thorough  cleanliness  of  the  skin.  This  is  best  secured  by  frequently  bath- 
ing the  parts  affected  with  a  saturated  solution  of  boric  acid.  Single 
furuncles  may  often  be  aborted  by  the  frequent  application  of  spirits  of 
camphor,  or  a  few  applications  of  tincture  of  iodine,  or  by  touching  them 
with  pure  carbolic  acid.  The  last  mentioned,  although  eflBcient.  can  hardly 
be  intrusted  to  the  hands  of  a  mother  or  nurse.  A  remedy  which  has  been 
used  with  considerable  success  is  a  plaster  of  salicylic  acid.  In  my  ex- 
perience the  best  plan  of  treating  the  multiple  small  furuncles,  is  to  delay 
incision  until  they  have  pointed,  then  to  incise  freely  and  empty  the  follicle 
completely  by  compression.  It  is  then  washed  out  thoroughly  with  a 
solution  of  bichloride  (1  to  2,000),  and  small  pledget  of  absorbent  cotton 
applied  till  the  bleeding  has  ceased.  After  this  the  part  should  be  covered 
with  simple  collodion  or  that  in  which  iodoform  has  been  dissolved.  Where 
the  abscesses  are  of  large  size  and  upon  the  scalp,  it  is  wise  to  make  com- 
pression by  applying  a  snug  bandage  for  a  day.  It  is  very  exceptional  for 
abscesses  so  treated  to  refill.  When  the  suppuration  is  more  diffuse  and 
there  is  necrosis  of  the  cellular  tissue,  ichthyol,  either  in  the  form  of  an 
ointment  or  lotion  (one  to  five  per  cent  strength),  is  one  of  the  best  appli- 
cations.    Early  and  free  incisions  must  be  practised  in  all  such  cases. 

GAXGREXOUS   I)ERAIATITIS. 

This  is  not  a  frequent  disease,  and  is  seen  almost  exclusively  in  in- 
fancy. It  may  be  primary  or  it  may  follow  other  diseases,  and  hence  has 
been  described  under  many  different  names — viz.,  varicella  gangrenosa^ 
ecthyma  gangrenosa,  pemphigus  gangrenosa,  etc. 

The  lesion  consists  in  small,  discrete  areas  of  inflammation  of  the  skin, 
ending  in  necrosis.  In  the  primary  cases  there  is  usually  first  seen  a  vesi- 
cle, about  as  large  as  a  pea,  with  a  dusky  areola :  it  increases  in  size  and 
becomes  a  pustule.  Crusts  form  which  are  quit-e  adherent,  and  on  re- 
moving them  a  loss  of  tissue  is  seen.  The  ulcers  usually  have  sharp  but 
not  undermined  edges,  often  presenting  a  "  punched-out  "  appearance. 
By  the  coalescence  of  several  small  ones,  ulcers  an  inch  or  more  in  diame- 
ter are  sometimes  formed. 

The  primary  form  of  gangrenous  dermatitis  occurs  in  wretched, 
poorly-nourished  infants,  and  is  most  often  seen  upon  the  buttocks.  In 
this  location  it  may  be  mistaken  for  syphilis.  The  secondary  form 
is  more  common,  and  usually  follows  varicella,  less  frequently  vaccinia, 
measles,  or  pemphigus.  My  own  experience  with  this  disease  has  been 
confined  to  cases  following  varicella.  In  such,  the  lesion  is  usually  seen 
upon  the  upper  half  of  the  body,  especially  upon  the  neck  and  chest.  It 
follows  the  ordinar}'  lesions  of  varicella  and  continues  usually,  in  spite 


IMPETIGO  CONTAGIOSA.  919 

of  treatment,  from  one  to  four  weeks,  in  most  cases  ending  fatally.  The 
disease  always  occurs  in  infants  of  poor  vitality,  often  in  those  suffering 
from  marasmus,  and  is  seldom  seen  outside  of  institutions.  It  may  be 
accompanied  by  fever,  and  other  severe  constitutional  symptoms. 

For  the  production  of  the  disease,  two  factors  are  necessary :  first,  the 
constitutional  condition  referred  to ;  and,  secondly,  the  entrance  of  pyo- 
genic germs,  usually  the  streptococcus  pyogenes. 

Treatment. — Every  means  possible  should  be  employed  to  build  up  the 
general  health  of  the  infant  by  tonics,  fresh  air,  careful  feeding,  etc.  Lo- 
cally, strict  cleanliness  and  antiseptic  applications  are  necessary.  The  best 
application  is  a  solution  of  bichloride  (1  to  5,000),  or  an  ointment  of  ich- 
thyol  or  iodoform. 

IMPETIGO    CONTAGIOSA. 

Impetigo  contagiosa  is  a  disease  characterized  by  the  formation  of  dis- 
crete vesiculo-pustules,  occurring  most  frequently  upon  the  hands  and 
face.  Cases  are  usually  seen  in  groups  affecting  several  children  in  one 
family  or  institution.  It  may  be  communicated  from  one  person  to 
another,  and  spread  by  auto-inoculation  from  one  part  of  the  body  to 
another. 

One  rarely  has  an  opportunity  to  see  the  disease  until  vesicles  have 
formed.  These  are  usually  from  one  fourth  to  one  half  an  inch  in  diame- 
ter, and  are  flaccid,  never  distended.  Later,  their  contents  become  slightly 
yellowish  ;  then  they  rupture  and  dry,  forming  thick  yellow  crusts,  which 
have  the  appearance  of  being  "  stuck  on,"  the  surrounding  skin  being 
quite  healthy.  After  the  crusts  fall  off,  a  small  red  patch  remains,  which 
slowly  fades.  The  true  skin  is  not  involved,  except  in  poorly-nourished, 
cachectic  subjects,  as  a  result  of  continued  local  irritation,  like  scratching. 
Under  such  conditions  ulceration  may  occur.  Instead  of  the  small  vesic- 
ulo-pustules described,  bullse  from  one  to  two  inches  in  diameter  may 
form,  filled  first  with  serum,  afterward  with  sero-pus.  Very  little  inflam- 
mation is  seen  about  these  patches,  and  in  most  cases  the  intervening  skin 
is  normal. 

The  favourite  seat  of  the  eruption  is  the  face,  especially  about  the  chin, 
next  the  hands,  the  neck,  the  feet  and  legs,  the  forearms,  and  the  scalp; 
it  is  rarely  seen  upon  the  abdomen,  and  never  upon  the  back.  There  may 
be  only  half  a  dozen  vesiculo-pustules,  or  from  thirty  to  forty  may  be 
present.  The  smaller  ones  sometimes  coalesce  and  form  others  of  consid- 
erable size.  Itching  is  never  a  prominent  symptom,  and  in  most  cases  it 
is  absent  altogether. 

The  usual  duration  of  impetigo  contagiosa  is  two  or  three  weeks;  it, 
however,  runs  no  regular  course,  and  by  continued  auto-inoculation  may 
last  much  longer  than  thi^;. 

The  studies  of  Gilchrist  (Baltimore)  ])oint  to  a  streptococcus  of  low 
virulence  as  the  cause  of  this  disease.    P^uropean  investigators,  however, 


920  DISEASES  OF  THE  SKIN. 

have  with  considerable  uniformity  found  the  staphylococcus  pyogenes 
aureus  in  the  vesicles.  Impetigo  contagiosa  may  occur  in  any  child, 
but  is  seen  most  frequently  in  one  who  is  poorly  nourished. 

The  diagnosis  is  not  often  difficult,  and  is  made  by  the  following  fea- 
tures— viz.,  the  occurrence  of  several  cases  together,  the  isolated  vesiculo- 
pustules  situated  upon  the  face  and  hands,  the  slight  itching,  and  the 
prompt  cure  by  local  measures  only.  The  bullous  form,  however,  is  fre- 
quently confounded  with  pemphigus ;  many  cases  in  which  the  diagnosis 
of  pemphigus  is  made  are  examples  of  impetigo. 

Treatment. — This  is  simple  and  usually  very  effective.  The  crusts 
are  to  be  softened  and  removed  by  thoroughly  washing  the  part  with  soap 
and  water  or  a  bichloride  solution,  after  which  the  white  precipitate  oint- 
ment, combined  with  three  parts  of  vaseline,  should  be  applied. 

URTICARIA. 

Urticaria  is  a  frequent  disease  in  early  life,  and  presents  some  features, 
particularly  in  infants  and  young  children,  which  are  quite  different  from 
those  seen  in  adults.  This  is  due  to  the  fact  that  papules  and  vesicles, 
and  occasionally  pustules,  are  associated  with  the  wheals.  As  the  wheals 
quickly  subside,  it  frequently  happens  that  the  other  lesions  mentioned 
are  the  only  ones  present.  This  fact  has  given  rise  to  considerable  con- 
fusion in  names,  and  the  urticaria  of  infancy  has  been  called  lichen 
urticatus^  urticaria  papulosa,  strophulus,  etc.  It  is  now  pretty  generally 
agreed  that  the  clinical  picture,  which  is  a  familiar  one,  belongs  to  a  single 
disease,  and  that  this  is  urticaria. 

The  initial  lesion  is  the  wheal,  but  on  account  of  the  extreme  suscepti- 
bility of  the  skin  in  young  children,  the  process  is  more  intense  than  in 
older  patients,  so  that  it  may  result  in  the  formation  of  an  inflammatory 
papule  or  a  vesicle.  In  a  few  hours  the  wheals  may  subside,  and  only  the 
papules  or  vesicles  remain,  and  without  a  good  history  the  disease  may  be 
a  very  obscure  one.  The  papules  and  vesicles  occur  with  greatest  fre- 
quency upon  the  hands  and  feet,  particularly  the  palms  and  soles.  The 
more  severe  form  of  the  disease  in  poorly  nourished  children  is  sometimes 
accompanied  by  a  pustular  eruption,  and  there  may  even  be  deep  ulcera- 
tion (ecthyma).  The  usual  appearance  of  the  eruption  is  a  number  of 
small  inflamed  red  papules  whose  tops  are  covered  with  scabs,  the  result  of 
scratching.  The  eruption  may  be  limited  to  the  extremities  or  it  may  be 
general.     It  is  as  a  rule  more  severe  in  regions  accessible  to  scratching. 

There  is  usually  severe  itching,  which  leads  to  loss  of  sleep,  and  often 
in  this  way  the  disease  affects  the  general  health  of  the  child.  The  urti- 
caria of  older  children  does  not  differ  essentially  from  the  same  disease  in 
adults. 

The  character  of  the  eruption  in  urticaria  and  even  its  distribution 
strongly  suggest  scabies ;  and  unless  one  has  had  an  opportunity  to  witness 
the  development  of  the  lesions,  a  differential  diagnosis  may  be  very  difficult, 


SCABIES.  921 

as  almost  every  lesion,  except  the  wheal,  may  be  identical  in  both  diseases. 
Other  cases  may  resemble  varicella. 

Urticaria  in  early  life  is  most  frequently  the  result  of  some  disturbance 
in  the  digestive  tract.  Almost  any  sort  of  derangement  may  produce  it, 
the  exciting  cause  varying  with  the  patient.  Exceptionally,  it  may  result 
from  other  forms  of  irritation,  such  as  dentition  or  intestinal  worms,  and 
it  has  been  ascribed  to  malarial  poisoning. 

Treatment. — The  milder  forms  of  urticaria  usually  respond  quickly  to 
treatment ;  but  when  it  is  severe  and  has  existed  for  several  weeks,  it  is 
one  of  the  most  troublesome  and  intractable  skin  diseases  of  childhood. 
The  treatment  is  to  be  directed  primarily  toward  the  condition  of  the 
digestive  organs.  Children  should  be  put  upon  a  milk  diet,  and  even 
milk  may  need  to  be  partially  peptonized.  The  bowels  should  be  kept 
freely  open  by  calomel,  a  nightly  dose  of  castor  oil,  or  a  morning  dose  of 
magnesia.  If  the  urine  is  excessively  acid  and  scanty,  alkaline  diuretics 
should  be  given.  The  drugs  most  useful  for  the  indigestion  with  which 
urticaria  is  associated  are  salicylate  of  soda  and  nitro-muriatic  acid,  each 
of  which  is  to  be  given  after  meals. 

All  local  causes  of  irritation,  such  as  rough  flannel  underclothing, 
should  be  removed.  The  sleep  may  be  so  much  disturbed  as  to  require 
the  use  of  trional  or  bromide  and  chloral.  The  two  remedies  which  are 
of  most  value  for  the  disease  itself  are  antipyrine  and  atropine ;  they  may 
be  used  separately  or  in  combination,  and  should  be  administered  in  mod- 
erately large  doses. 

The  local  irritation  and  itching  may  be  relieved  by  a  lotion  of  menthol 
(gr.  ij,  water  f  j),  by  a  very  dilute  solution  of  the  subacetate  of  lead  or 
carbolic  acid,  or  by  a  mixture  of  vinegar,  or  the  fluid  extract  of  hamamelis, 
and  water.  Where  pustules  are  present,  the  white-precipitate  ointment 
may  be  used,  combined  with  four  parts  of  vaseline ;  in  the  papular  and 
vesicular  forms,  an  ointment  of  ichthyol  or  naphthol,  one  per  cent  strength. 
In  many  cases  the  improvement  in  the  general  health  by  the  use  of  tonics, 
change  of  air,  etc.,  will  accomplish  more  than  any  measures  directed 
especially  to  the  relief  of  the  urticaria. 

SCABIES. 

Scabies  is  a  contagious  disease  due  to  the  burrowing  into  the  skin  of 
the  female  acarus,  with  secondary  lesions  which  result  from  scratching. 
This  disease  is  not  a  common  one  in  New  York,  even  among  dispensary 
patients,  while  among  the  better  classes  it  is  extremely  rare. 

The  burrowing  of  the  acarus  is  usually  where  the  skin  is  thinnest — 
viz.,  between  the  fingers,  on  the  flexor  surfaces  of  the  wrists,  the  axilla?, 
and,  in  males,  the  genitals.  It  is  not  seen  upon  the  face,  except  in  infancy, 
when  it  may  be  infected  by  contact  with  the  breasts  of   the  mother. 


922  DISEASES  OF   THE  SKIX. 

The  lesion  excited  by  the  acarus  is  iTSiially  a  papule  or  a  vesicle,  some- 
times a  pustule.  In  some  cases  no  evidences  of  inflammation  are  present, 
but  in  infants  and  young  children  they  may  be  marked — pustular  erup- 
tions being  frequent  and  often  extensive,  especially  upon  the  hands  and 
feet.  The  characteristic  burrow  is  from  one  fourth  to  one  half  inch  in 
length,  and  appears  as  a  fine  brown  or  black  line,  at  the  end  of  which  the 
acarus  may  be  discovered  as  a  small  white  speck.  The  burrows  are  often 
difficult  to  find  in  infants.  They  are  generally  to  be  seen  along  the  inner 
border  of  the  hand  and  between  the  fingers.  The  intensity  of  the  in- 
flammatory lesions  varies  greatly  in  different  cases ;  in  some  they  are  very 
few,  while  in  others,  particularly  in  delicate,  cachectic,  and  neglected  chil- 
dren, they  are  sometimes  very  severe,  so  that  the  skin  of  the  affected 
part  is  nearly  covered  with  pustules.  These  secondary  lesions  are  due  to 
infection  by  the  streptococcus  or  staphylococcus.  A  pustular  eruption 
upon  the  hands  should  always  suggest  scabies.  The  lesions  which  result 
from  scratching  may  be  found  on  any  accessible  portion  of  the  body. 
There  are  usually  at  first  linear,  bloody  marks,  but  after  a  time  these 
may  not  be  visible.    In  little  children  urticaria  is  often  associated. 

The  diagnosis  of  scabies  is  usually  quite  easy,  as  several  children  in  a 
family  are  likely  to  be  affected,  particularly  if  they  occupy  the  same  bed. 
The  diagnostic  features  of  the  eruption  are  the  presence  of  papules,  vesi- 
cles, or  pustules,  especially  upon  the  hands,  wrists,  and  genitals.  A  care- 
ful examination  with  a  lens  will  usually  disclose  some  of  the  character- 
istic burrows,  or  even  the  acarus.  In  infancy,  scabies  may  be  easily  con- 
founded with  the  vesicular  form  of  urticaria,  unless  the  development  of 
the  lesions  has  been  observed. 

Scabies  may  always  be  cured,  provided  sufficient  precautions  are  taken 
to  prevent  re-infection.  This  necessitates  boiling  or  baking,  not  only  the 
patient's  clothes,  but  all  the  bedding  as  well. 

Treatment. — This  should  always  be  begun  by  a  hot  bath,  in  order  to 
soften  the  epithelial  scales  about  the  burrows.  The  body  should  be  thor- 
oughly scrubbed  with  soap  and  water,  preferably  with  a  nail-brush,  the 
bath  being  continued  for  at  least  half  an  hour.  It  is  well  to  do  this  at 
night.  After  the  bath,  the  body  is  anointed  with  the  parasiticide,  which 
should  be  thoroughly  rubbed  into  the  skin,  clean  clothing  applied,  and 
the  child  put  into  a  perfectly  clean  bed.  In  the  morning  the  ointment 
may  be  washed  off,  but  none  of  the  clothing  previously  worn  should  be 
put  on.  This  treatment  is  to  be  repeated  on  two  or  three  successive 
nights,  and  if  thoroughly  done  it  will  effect  a  cure.  The  ordinary  sulphur 
ointment  is  too  irritating  for  use  in  little  children,  and  one  of  the  fol- 
lowing may  be  substituted  :  naphthol,  15  parts ;  creta  preparata,  10  parts ; 
vaseline,  100  parts  (Kaposi) ;  or,  precipitated  sulphur,  1  part ;  balsam  of 
Peru,  1  part ;  vaseline,  8  parts ;  or  the  simple  balsam  of  Peru  may  be  ap- 
plied without  dilution,     xifter  the  use  of  the  parasiticide  there  is  generally 


TINEA  TONSURANS.  923 

required  for  a  few  days,  some  soothing  application  like  those  mentioned 
in  the  chapter  upon  Eczema. 

TINEA  TONSURANS— RING-WORM  OF  THE  SCALP. 

Ringworm  of  the  scalp  is  a  very  frequent  disease  in  institutions  for 
children,  often  occurring  as  an  epidemic.  According  to  Crocker,  the 
primary  lesion  consists  in  a  red  papule  surrounding  a  hair,  which  soon 
increases  to  a  small  circular  patch ;  this  spreads  at  its  outer  margin, 
gradually  increasing  in  size  until  it  is  from  one  to  two  inches  in  diameter, 
but  rarely  larger  than  this.  Sometimes  several  of  the  patches  coalesce. 
These  affected  areas  always  have  rounded  borders,  and  are  sharply  out- 
lined. Here  the  hairs  are  very  brittle,  and  often  broken  off  close  to  the 
scaljj,  so  that  it  may  appear  to  be  bald.  Where  they  have  not  fallen  off, 
the  hairs  have  lost  their  lustre.  The  stumps  of  the  broken  hairs  point  in 
all  directions. 

The  fungus  which  produces  the  disease  is  the  triclwiyliyton  tonsurans. 
It  penetrates  the  shaft  of  the  hair,  both  tbe  spores  and  the  mycelium 
being  seen  under  the  microscope.  The  spores  are  present  in  great  num- 
bers in  the  hair,  but  the  mycelium  is  most  abundant  in  the  scales.  The 
amount  of  inflammation  found  in  the  diseased  areas  varies  much  in  the 
different  cases.  There  may  be  only  a  scaliness  of  the  scalp,  or  a  formation 
of  pustules  in  the  hair  follicles,  the  hairs  loosening  and  falling  out  in  con- 
sequence. In  young  infants  where  the  hair  is  scanty  and  thin,  the  dis- 
ease resembles  tinea  circinata — i.  e.,  it  is  superficial,  and  the  hair  follicles 
are  often  not  involved.  Children  of  all  ages  are  liable  to  tinea  ton- 
surans. It  flourishes  particularly  in  those  who  are  dirty  and  poorly 
cared  for. 

The  diagnostic  feature  of  the  disease  is  the  presence  of  scaly  patches, 
with  loss  of  hair.  The  patches  are  usually  circular,  and  by  examination 
with  a  lens  the  stumps  of  broken  hairs  are  seen  all  over  the  diseased 
area.  By  a  microscopical  examination  the  fungus  is  discovered.  In 
typical  cases  the  diagnosis  is  easy  if  the  process  is  at  all  advanced,  but 
there  are  many  atyjjical  forms  and  many  mild  cases  where  the  recogni- 
tion of  the  disease  is  difficult.  The  symptoms  are  often  masked  by  the 
inflammatory  conditions  present.  The  disease  may  be  confounded  with 
seborrhoea ;  but  in  the  latter  the  lesion  is  diffuse,  never  sharply  defined ; 
there  is  general  thinning  of  hair  over  the  scalp,  and  never  the  stumpy, 
broken  hairs.  Psoriasis  has  points  of  resemblance,  but  it  is  usually  found 
on  other  parts  of  the  body,  especially  the  knees  and  elbows,  and  upon  the 
scalp  the  patches  are  more  numerous  and  smaller.  In  eczema  the  loss  of 
hair  in  circumscribed  patches  is  never  seen,  nor  are  the  broken  stumps. 

Tinea  tonsurans  is  always  curable,  provided  the  patient  can  be  kept 
under  close  surveillance,  and  treatment  thoroughly  carried  out.  There  is 
no  tendency  to  spontaneous  recovery.     In  a  recent  case,  treatment  must 


924  DISEASES  OF  THE  SKIN. 

usually  be  continued  for  one  or  two  months,  and  in  chronic  cases,  from 
six  months  to  one  year,  with  the  closest  watchfulness. 

Treatment. — The  great  difficulty  in  treatment  is  to  get  the  parasiticide 
deeply  enough  into  the  scalp  to  reach  the  fungus,  since  this  is  often  at  the 
very  bottom  of  the  hair  follicles.  As  a  first  step,  the  hair  should  be  cut 
short  all  over  the  patch  and  for  at  least  an  inch  beyond  it ;  this  is  neces- 
sary in  order  to  get  at  the  diseased  part  and  to  detect  new  foci  of  infection 
early — if  possible  before  the  fungus  has  extended  deeply  into  the  follicles. 
The  parasiticide  should  be  applied  not  only  upon  but  around  the  patch, 
and  the  entire  scalp  should  be  washed  thoroughly  two  or  three  times  a 
week.  To  prevent  the  disease  spreading,  all  the  scales  are  to  be  kept  soft- 
ened by  the  use  of  carbolic  soap.  The  hair  should  not  be  brushed,  as  this 
tends  to  scatter  the  spores  and  spread  the  disease.  All  patients  while 
under  treatment,  should  wear  a  cap  of  muslin  or  oiled-silk,  or  one  lined 
with  paper,  in  order  to  prevent  infecting  others.  In  institutions,  affected 
children  should  invariably  be  isolated. 

To  destroy  the  fungus  almost  every  germicide  on  the  list  has  been 
advocated  at  one  time  or  another,  which  proves  that  the  disease  is  a  very 
obstinate  one,  and  that  no  one  application  is  invariably  successful.  Those 
which  have  the  sanction  of  the  widest  use  are  the  tincture  of  iodine,  the 
bichloride,  white  precipitate,  and  oleate  of  mercury,  kerosene,  creosote, 
and  croton  oil.  As  a  vehicle  for  ointments,  lanoline  is  greatly  to  be  pre- 
ferred to  vaseline  or  lard ;  according  to  Crocker,  the  addition  of  three 
parts  of  lanoline  to  one  part  of  olive  oil  is  much  better  than  lanoline 
alone.  Most  of  the  germicides  mentioned  are  used  in  the  strength  of  one 
to  five  per  cent,  according  to  the  age  of  the  child  and  the  irritability  of 
the  scalp.  In  an  epidemic  of  ring-worm  in  the  New  York  Infant  Asylum 
the  following  combination  of  bichloride  and  kerosene  proved  extremely 
satisfactory  :  ten  grains  of  the  bichloride  were  dissolved  in  alcohol,  and 
to  this  were  added  two  and  a  half  ounces  each  of  olive  oil  and  kerosene. 
This  was  applied  every  day,  being  thoroughly  rubbed  into  the  diseased 
patches,  and  the  whole  scalp  saturated  with  it.  Considerable  irritation 
usually  resulted,  and  every  few  days  the  parasiticide  was  omitted  and  some 
simple  emollient  applied  until  the  irritation  had  in  a  measure  subsided. 
In  some  of  the  cases,  the  tincture  of  iodine  was  alternated  with  the  bichlo- 
ride and  kerosene.  Twenty-six  cases  were  treated  after  this  plan  and  all 
cured,  the  average  duration  of  treatment  being  eight  and  a  half  weeks.* 

Epilation  is  necessary  in  many  cases  as  an  accessory  to  the  application 
of  germicides,  particularly  in  older  children. 

*  A  full  report  of  these  eases  was  made  by  C.  Gr.  Kerley,  M.  D.,  in  the  New  York 
Medical  Journal,  October  10,  1891. 


ACUTE  OTITIS.  925 

CHAPTER  VI. 
ACUTE  OTITIS. 

Otitis  is  a  frequent  affection  during  infancy  and  early  childhood,  at- 
tacks usually  occurring  in  the  cold  season.  Of  all  the  inflammatory  con- 
ditions which  may  be  met  with  in  early  life,  there  is  perhaps  none  which 
more  frequently  gives  rise  to  obscure  febrile  symptoms  than  this. 

Etiology. — Acute  otitis  is,  as  a  rule,  a  secondary  disease,  and  is  gen- 
erally preceded  by  some  infectious  process  in  the  rhino-pharynx.  The 
usual  avenue  of  infection  is  through  the  Eustachian  tube.  Downie 
(Glasgow)  gives  the  following  statistics  of  501  cases  of  tympanic  involve- 
ment : 

Originated  during  measles 131  cases,  or  26'1  per  cent. 


"       scarlet  fever 

..     63 

"   12-6    " 

"       whooping-cough. . . 

..     15 

"       "     30    "      " 

"       mumps 

..       3 

'       "     0-6    "      ' 

"       simple  catarrh 

..   147 

'       "    29-4    "      ' 

"       dentition 

. .   101 

'       "  200    "      ' 

Syphilitic  . . . 

8 

"     1-6    " 

Doubtful 

..     33 

'       "     6-7    "      ' 

501  100-0 

The  most  severe  forms  of  otitis  usually  follow  scarlet  fever,  epidemic 
influenza,  measles,  diphtheria,  or  pneumonia.  The  entrance  of  fluids 
through  the  Eustachian  tube  from  the  nasal  douche  or  nasal  syringing 
may  cause  acute  otitis.  It  sometimes  results  as  an  extension  of  inflam- 
mation from  meningitis,  especially  the  cerebro-spinal  form. 

The  micro-organisms  concerned  in  the  production  of  acute  otitis 
vary  with  the  condition  of  which  it  is  a  complication.  With  scarlet  fever, 
measles,  influenza,  or  simple  catarrh,  the  streptococcus,  the  pneumo- 
coccus,  or  the  staphylococcus  may  be  found  either  separately  or  together, 
inflammations  associated  with  the  organism  last  mentioned  being  usu- 
ally of  a  milder  character  than  with  the  other  two.  In  cases  complicat- 
ing diphtheria,  the  Klebs-Loefller  bacillus  may  be  found  with  any  of  the 
forms  mentioned,  or  ma}^  occur  alone.  In  chronic  cases  any  of  the 
pyogenic  organisms  may  be  present,  and  not  very  infrequently  the  tuber- 
cle bacillus. 

Lesions. — The  ordinary  course  of  events  in  the  pathological  process  is, 
first,  acute  hypera?mia  and  swelling  of  the  nnicous  membrane  of  the 
rhino-pharynx,  which  extends  into  the  Eustachian  tube,  causing  ob- 
struction more  or  less  complete.  The  inflammatory  process  may  be  lim- 
ited to  the  tube,  or  it  may  extend  to  the  mucous  membrane  lining  the 
middle  ear. 

There  are  two  varieties  of  acute  inflammation  of  the  middle  ear:  (1) 
60 


926 


DISEASES   OF   THE  EAR. 


The  catarrhal  form,  which  usualh'  accompanies  simple  catarrh  of  the 
rhino-phar^-nx  or  complicates  measles.  This  is  an  inflammation  of  the 
mucous  membrane  merely,  and  its  products  are  serum  and  mucus  or 
muco-pus.  It  is  not  usually  accompanied  by  great  pain  or  followed  by 
serious  consequences.  It  is  generally  confined  to  the  lower  part  of  the 
tympanic  cavity,  and  is  the  form  more  frequently  seen  in  infants.  (2) 
The  phlegmonous  form,  which  affects  older  children  principally.     This 


Hour 

1 

2 

3 

i 

6 

- 

s 

9 

10 

11 

12 

13 

li 

.    ' 

1 

!  ' 

1       1 

loi 

101 

ids' 

102 
101 

100 

c 
99 

O 

98 

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Riijht-E 

ir-Dramf-lncisc-d 

/ 

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-7J 

5t4i 

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1        /  \           [^ 

A 

\-\— 

-\ f~\ /- 



\   /\ 

/ 

\    1 

\/     > 

/ 

\/^ 

-X^*^ 

.' 

Fig.  170. — Temperature  chart  of  acute  otitis  following  influenza,  in  a  child  three  years  old. 

is  a  much  more  serious  inflammation,  and  is  often  excited  by  the  in- 
fectious catarrh  of  scarlet  fever,  diphtheria,  or  epidemic  influenza.  In 
this  variety  micro-organisms  flnd  their  way  into  the  middle  ear  in  great 
numbers,  and  set  up  an  inflammation  of  a  more  or  less  virulent  type, 
which  may  involve  not  only  the  mucous  membrane  lining  the  tjTnpanum, 
but  also  the  cellular  tissue  in  the  upper  part  of  the  tympanic  cavity. 

The  catarrhal  form  of  inflammation  frequently  subsides  in  a  few  days 
with  proper  treatment,  the  only  result  being  a  slight  deafness,  which 
is  temporary.  The  phlegmonous  form  causes  a  stoppage  of  the  Eusta-. 
chian  tube,  rupture  or  sloughing  of  the  tympanic  membrane  and  dis- 
charge of  the  products  of  inflammation,  or  rarely  pus  finds  an  outlet  by 
burrowing  between  the  cartilages.  The  inflammatory  process  may  ex- 
tend to  the  bones,  causing  necrosis  of  the  ossicles  or  the  bony  walls  of 
the  tympanum.  The  remote  results  are  periostitis  and  necrosis  of  the 
petrous  bone,  pach}-meningitis,  infectious  thrombosis  of  the  lateral 
sinus,  general  purulent  meningitis,  and  cerebral  abscess.  These  wUl  be 
considered  under  Complications. 

Symptoms. — These  are  usually  few  in  number,  but  present  great  varia- 
bility as  regards  their  combination  and  intensity.  The  two  most  con- 
stant symptoms  are  pain  and  fever.  In  a  typical  case  in  an  infant,  there 
is  generally  at  the  beginning  some  discharge  from  the  nose,  slight  con- 


ACUTE  OTITIS. 


927 


gestion  of  the  pharynx  and  tonsils,  and  a  temperature  of  100°  to  102°  F. 
There  is  nothing  characteristic  about  this  catarrh.  After  two  or  three 
days  the  objective  sjanptoms  subside,  but  the  infant  continues  to  be  rest- 
Jess,  worries  much  of  the  time,  wakes  frequently  at  night  with  a  start, 
nurses  poorly,  and  if  the  thermometer  is  used,  it  is  found  that  the  tem- 
perature remains  elevated,  usually  from  100°  to  103°  F.  (Fig.  170).  The 
infant  seems  decidedly  ill,  and  yet  no  very  definite  symptoms  are  pres- 
ent. Sometimes  there  is  marked  tenderness  about  the  ear,  and  the  child 
refuses  to  lie  upon  the  affected  side,  or  shows  signs  of  pain  when  the  ear 
is  touched.  After  a  week  or  ten  days  a  discharge  is  found  in  the  auditory 
canal,  and  usually  there  follows  a  rapid  subsidence  of  the  constitutional 
symptoms.  In  some  cases  there  is  seen  only  a  high  temperature,  ranging 
from  101°  to  104°  F.,  which  persists  for  several  days  without  outward 
evidences  of  pain  or  other  signs  of  inflammation,  the  discharge  being  the 
first  symptom  which  leads  the  physician  to  suspect  disease  of  the  ear. 
In  other  cases  there  is  marked  dulness,  apathy,  anorexia,  and  sometimes 
nausea  and  vomiting,  but  for  several 
days  no  evidence  of  pain;  the  tempera- 
ture may  be  but  little  elevated.  Thus, 
in  most  of  the  attacks  seen  in  infancy, 
pain  is  not  very  marked,  and  it  is  this 
which  so  often  leads  to  the  great  ob- 
scurity of  the  symptoms. 

In  older  children  the  symptoms  are 
more  characteristic.  Pain  is  usually 
-sharp  and  severe,  and  is  complained  of 
early  in  the  attack.  The  temperature  is 
nearly  always  elevated  two  or  three  de- 
grees, and  occasionally  it  is  103°  or  104° 
F.  (Fig.  171),  with  severe  headache,  ex- 
treme restlessness,  and  even  delirium 
or  convulsions,  so  that  meningitis  may 
be  suspected. 

The  inflammation  does  not  neces- 
sarily go  on  to  suppuration  and  rupture. 
There  are  even  more  frequently  seen, 
accompanying  ordinary  head-colds  or 
mild  attacks  of  influenza,  cases  in 
which    the    pain    is    quite    severe    for 

twenty-four  or  thirty-six  hours,  and  accompanied  even  by  a  moderate 
elevation  of  temperature,  and  yet  which  rapidly  subside  without  further 
symptoms.  In  these  cases  the  pain  is  too  constant  and  too  prolonged  to 
be  an  attack  of  neuralgia.  They  are  simply  cases  of  a  mild  form  of  in- 
flammation. 


Day 
Hour 

1 

2 

3 

i 

5 

0     1 

M 

105° 
101° 
103° 
102° 
101° 
100° 
99° 

Bot 

h-& 

1-D 

mil!. 

Ixl 

- 

r 

-J  \ 

J         1 

1  ~ 

~ 

a 

z 

z 

I 

- 

_ 

z 



- 

-, 

_ 

y 

P 

1 

kz 

z 

- 

z 

z 

I 

z 

~ 

z 

-Z 

— 

— 

— 

— 

-1- 

— 

— 

— 1 

— 

_y  [ 

^ 

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^- 

98 

- 

- 

r 

u 

r 

zz 

z 

- 

r 

r 

-T— : 

rr 

- 

— 

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- 

-- 

- 

- 

— 

- 

- 

- 

- 

_ 

— 

_ 



_ 



1 

_ 



_ 

_ 

_ 

,_ 

_ 

Fig.  171. — Temperature  chart  of  acute 
otitis  aborted  by  early  paracentesis. 
Boy  nine  years  old  ;  attack  followed 
a  mild  catarrh ;  severe  pain  in  both 
ears  began  in  afternoon  of  second 
day.  Both  drum  membranes  found 
acutely  congested  and  bultrinp ;  in- 
cision followed  by  free  ha'morrhaire 
and  immediate  relief  of  pain.  Ears 
syringed  with  bichloride  solution; 
no  suppuration  occurred ;  patient  woU 
on  filth  day. 


928  DISEASES  OP  THE  EAR. 

In  infants  suffering  from  malnutrition  or  marasmus,  otitis  not 
infrequently  comes  on  without  an}'  objective  sj'mptoms,  the  first 
thing  noticed  being  the  discharge.  This  association  of  otitis  with  maras- 
mus is  to  be  attributed  to  the  frequency  of  swelling  of  the  adenoid 
tissue  in  the  pharyngeal  vault,  upon  which  the  catarrhal  process 
depends. 

Of  the  individual  symptoms,  fever  is  the  most  constant,  and  is  present 
in  all  except  the  cases  of  marasmus  just  mentioned.  The  usual  range  of 
temperature  is  from  100°  to  102°  F. ;  exceptionally  it  may  be  from  103° 
to  105°  F.  The  course  of  the  temperature  is  irregular  and  remittent. 
After  spontaneous  rupture  or  incision  of  the  drum  membrane  the  tem- 
perature usually  falls,  but  often  not  immediately;  occasionally  it  con- 
tinues almost  as  high  as  before  for  twenty-four  hours.  Pain  is  more 
marked  in  older  children  than  in  infants :  first,  because  in  the  latter  the 
drum  membrane  is  not  so  firm,  yields  more  readily,  and  ruptures  earlier; 
and,  secondly,  because  the  inflammation  is  usually  of  the  catarrhal  and 
not  the  phlegmonous  type.  Tenderness  is  sometimes  elicited  by  pressure 
just  in  front  of  the  external  auditory  meatus ;  there  may  be  increased 
sensitiveness  of  all  parts  of  the  ear  and  even  of  the  whole  side  of  the  head. 
Children  not  infrequently  complain  of  noises  in  the  ear.  One  little  girl 
with  obscure  symptoms  and  high  temperature,  first  called  attention  to 
her  ear  b}^  the  remark,  that  she  "  heard  pussy  in  the  room.""  A  sense  of 
discomfort  resembling  that  which  is  felt  when  the  ears  are  stopped,  fre- 
quently leads  children  to  pick  at  them.  Cerebral  symptoms  are  infre- 
quent, and  occur  chiefly  in  cases  not  receiving  proper  early  treatment; 
ithey  are  practically  limited  to  the  phlegmonous  form  of  inflammation, 
and  they  may  indicate  meningeal  congestion,  less  frequently  localized 
meningitis  or  thrombosis. 

The  local  appearances  in  the  early  stage — ^provided  a  view  of  the 
tympanic  membrane  can  be  obtained — are  marked  redness  and  conges- 
tion ;  later  there  is  distinct  bulging  of  the  membrane.  If  perforation  has 
taken  place,  its  site  may  or  may  not  be  visible,  but  its  existence  may 
always  be  assumed,  if  there  is  pulsation  of  the  membrane,  if  bubbles  of 
air  are  seen  deep  in  the  canal,  if  the  perforation  whistle  occurs  upon 
blowing  the  nose  or  inflating  the  ear,  and,  finally,  if  much  mucus  or 
pus  is  present,  as  inflammation  of  the  external  canal  almost  never  causes 
much  discharge.  A  discharge  is  not  present  until  perforation  has  taken 
place.  The  pus  in  rare  cases  may  burrow  between  the  cartilages  and  open 
externally  behind  or  at  the  side  of  the  ear.  In  the  catarrhal  form  it  is 
at  first  sero-mucus,  whitish  in  colour,  rather  thick.  Cjuite  profuse,  and 
usually  continues  when  once  established ;  later  it  is  usually  purulent. 
In  the  phlegmonous  form  it  is  always  purulent,  generally  less  abundant, 
and  liable  to  a  sudden  arrest  with  an  exacerbation  of  the  constitutional 
symptoms. 


ACUTE   OTITIS.  929 

Diagnosis. — In  typical  cases  characterized  by  pain  and  temperature, 
this  is  usually  easy,  particularly  in  older  children.  Otitis  in  infancy  is 
frequently  obscure,  sometimes  because  the  patient  is  too  young  to  direct 
attention  to  the  seat  of  pain,  but  more  often  because  the  pain  is  slight  or 
absent.  The  temperature  is  almost  invariably  elevated,  and  the  usual 
problem  presented  is  to  discover  a  cause  for  this  fever.  In  the  ab- 
sence of  definite  otoscopic  signs,  one  must  rely  upon  the  presence  of 
faucial  congestion,  a  history  of  a  previous  acute  catarrh,  restlessness  at 
night,  and  the  absence  of  signs  in  the  throat,  lungs,  or  digestive  tract, 
which  might  explain  the  fever.  Local  tenderness,  deafness,  or  noises 
in  the  ears  are  of  much  significance  when  present,  but  they  are  often 
wanting.  Otitis  is  so  common  a  cause  of  high  temperature  in  infants 
during  the  cold  season,  that  one  should  always  be  on  the  lookout  for  it, 

Prognosis. — The  ordinary  catarrhal  form  of  acute  otitis  is  not  often 
followed  by  serious  consequences,  unless  there  are  repeated  attacks.  The 
phlegmonous  form,  especially  when  it  complicates  scarlet  fever,  is  always 
serious,  and  in  the  majority  of  cases  it  is  followed  by  some  degree  of  im- 
pairment of  the  sense  of  hearing. 

Complications  and  Sequelae.* — Eemote  consequences  are  most  likely 
to  be  seen  in  cases  following  scarlet  fever,  probably  because  of  their 
severity,  particularly  when  early  treatment  has  been  neglected. 

Mastoiditis. — This  is  the  most  frequent  complication  of  acute  otitis. 
In  infancy  the  mastoid  process  is  small  and  contains  but  a  single  cavity, 
the  mastoid  antrum,  which  communicates  directly  with  the  vault  of  the 
tympanum.  It  is  probable  that  in  every  severe  case  of  acute  suppurative 
otitis  there  is  some  pus  in  the  antrum.  This  is  usually  discharged  into 
the  middle  ear  after  the  tympanic  membrane  is  incised  or  ruptures  spon- 
taneously. The  principal  cause  of  mastoid  involvement  in  children  is 
want  of  proper  care  in  acute  otitis,  particularly  allowing  these  cases  to 
take  their  natural  course  instead  of  securing  early  drainage  by  incision 
of  the  drum  membrane.  Mastoiditis  may  follow  otitis  from  any  cause, 
but  particularly  that  from  influenza. 

The  important  S3anptoms  of  acute  mastoiditis  are  fever,  mastoid 
tenderness,  and  swelling.  If  mastoiditis  develops  rapidly  after  acute 
otitis  the  temperature  may  be  high — 103°  to  105°  F. ;  if  it  develops 
gradually  and  appears  late  the  temperature  may  be  scarcely  above  100°. 
Abrupt  cessation  of  an  ear  discharge  should  always  arouse  suspicion. 
It  is  always  a  difficult  matter  in  a  child  to  determine  the  presence  of  a 
slight  amount  of  mastoid  tenderness,  but  persistent  tenderness  of  one 
side  is  always  significant.  It  may  not  be  present  at  the  tip  of  the  mastoid 
process,  and  is  often  most  marked  close  behind  the  auricle  just  over  the 
antrum.     The  early  swelling  is  due  to  oedema;  later  there  may  be  an 

*  See  Pitt's  Gulstonian  Lectures,  1890. 


930 


DISEASES  OF   THE   EAR. 


I'm.  172, 


wmcr  acute 


accumulation  of  pus.  This  presents  a  very  characteristic  swelling,  caus- 
ing the  ear  to  stand  out  on  the  head  (see  Fig.  173).  Post-auricular 
abscess  is  usually  due  to  spontaneous  rupture  in  the  outer  bony  wall  just 

over  the  antrum,  and  it  may  occur 
where  there  has  been  no  discharge 
from  the  ear.  The  characteristic 
otoscopic  appearances,  according  to 
Bacon,  are,  bulging  of  Shrapnell's 
membrane,  and  drooping  of  the  up- 
per posterior  wall  of  the  external 
meatus. 

Meningitis.  —  This  may  be  a 
cause  of  death  in  young  children. 
There  may  be  a  localized  pachy- 
meningitis with  the  formation  of 
pus — an  epidural  abscess — or  less 
frequently  general  purulent  menin- 
gitis. It  may  be  secondary  to  other 
lesions,  such  as  thrombosis  of  the 
lateral  sinus,  or  the  rupture  of  a 
cerebral  abscess,  but  is  usually  due 
to  the  passage  of  pus  through  the 
roof  of  the  tympanum,  or  along  the 
internal  auditory  meatus.  Meningitis  is  more  frequent  as  a  complication 
of  old  cases,  but  may  develop  soon  after  the  early  acute  symptoms.  Its 
onset  is  usually  sudden,  and  its  duration  rarely  more  than  a  week. 

Cerebral  Abscess. — This  is  due  to  a  direct  extension  of  the  infectious 
process  from  the  bone,  veins,  or  dura  mater.  In  about  two  thirds  of  the 
cases  the  abscess  is  in  the  temporo-sphenoidal  lobe.  The  next  most 
frequent  seat  is  the  lateral  lobe  of  the  cerebellum.  Korner  states  that 
disease  of  the  mastoid  and  middle  ear  leads  to  cerebral  abscess,  and  dis- 
ease of  the  labyrinth  to  cerebellar  abscess.  Abscesses  may  be  compli- 
cated by  thrombosis  or  by  meningitis.  They  are  often  latent  until  just  be- 
fore death,  which  more  frequently  occurs  from  the  development  of  puru- 
lent meningitis  than  from  any  other  cause.  They  are  rare  except  in 
otitis  of  long  standing. 

Thrombosis  of  the  lateral  sinus  occurs  as  a  condition  antecedent  to 
meningitis  or  abscess,  or  without  them.  It  usually  develops  suddenly, 
with  recurring  chills  and  a  high  temperature,  which  is  subject  to  sud- 
den and  wide  fluctuations. 

The  labijrinth  is  not  frequently  involved,  although  cases  are  recorded 
by  Pye,  Phillips,  and  others,  in  which  the  necrosis  and  discharge  of  the 
entire  labyrinth  has  occurred  after  scarlet  fever.  In  most  of  these  cases 
the  deafness  was  complete,  and  in  several  vertigo  was  present. 


-Mastoid  abscess  t'c 
otitis. 


ACUTE  OTITIS.  931 

Facial  paralysis  rarely  occurs  in  the  acute  cases,  but  accompanies  a 
considerable  proportion  of  the  chronic  ones.  It  is  due  to  an  extension 
of  the  inflammatory  process  from  the  bone  to  the  seventh  nerve,  where 
it  passes  through  the  canal.  The  symptoms  are  those  of  ordinary  periph- 
eral facial  palsy. 

Treatment. — If  the  case  is  seen  in  the  early  stage,  the  inflammation 
may  sometimes  be  cut  short  by  local  blood-letting,  the  use  of .  heat, 
and  free  catharsis.  Blood-letting  is  not  to  be  advised  in  the  case  of 
infants,  but  may  be  used  in  older  children.  Either  leeches  or  wet  cups 
may  be  employed.  They  should  be  applied  Just  in  front  of  and  close  to 
the  tragus.  Dry  heat  is  to  be  preferred  to  moist  heat,  both  as  a  means 
of  arresting  inflammation  and  of  relieving  pain.  It  may  be  applied  by 
means  of  a  bag  of  hot  water,  salt,  or  bran,  or  by  a  hot  brick  or  soap- 
stone.  These  should  be  placed  beneath  a  thin  pillow,  upon  which  the 
child's  head  rests.  If  the  child  will  not  lie  upon  his  hot  pillow,  a  small 
bag  of  salt  or  hot  water  may  be  bound  over  the  ear,  which  has  been  first 
covered  by  cotton.  Perhaps  the  best  of  all  is  Bench's  device  of  filling  the 
tip  of  the  finger  of  a  kid  glove  with  salt,  and  inserting  this  into  the  canal 
after  heating;  cotton  should  be  applied  over  it.  Neither  oil  nor  oil 
and  laudanum  should  be  dropped  into  the  ear,  as  is  so  often  done  in  do- 
mestic practice ;  but  there  is  no  objection  to  a  few  drops  of  a  f our-per-cent 
solution  of  cocaine,  which  often  relieves  intense  pain.  If  the  child  is 
not  comfortable  in  the  course  of  a  couple  of  hours  after  the  blood-letting 
or  dry  heat,  an  opiate  should  be  given.  This  not  only  relieves  suffering, 
but  has  a  favourable  influence  upon  the  inflammation. 

A  return  of  the  severe  pain,  or  its  continuance  in  spite  of  ordinary 
measures,  with  a  steadily  high  temperature,  are  indications  for  operative 
interference.  If  to  the  above,  cerebral  symptoms  are  added,  operation  is 
imperative.  An  early  incision  of  the  drum  membrane  is  usually  fol- 
lowed by  a  discharge  of  blood  only;  but  tension  is  relieved  and  with  it 
the  pain  disappears,  and  the  inflammation  often  quickly  subsides  with- 
out the  formation  of  pus.  (See  Fig.  171.)  Much  suffering  is  thereby 
avoided,  and,  as  the  wound  heals  quickly,  much  less  damage  is  done  than 
by  allowing  the  disease  to  go  on  to  a  spontaneous  rupture.  Later  opera- 
tion may  be  required  either  for  the  relief  of  pain  or  the  evacuation  of 
pus,  in  order,  if  possible,  to  prevent  the  disease  from  spreading  to  the 
bony  parts. 

After  incision  or  spontaneous  rupture  of  the  drum  membrane,  the 
pain  usually  ceases,  although  the  temperature  may  not  fall  to  normal  for 
twenty-four  or  thirty-six  hours,  even  with  good  drainage.  The  discharge 
is  now  the  principal  object  of  treatment.  Nothing  else  is  necessary  than 
to  keep  the  ear  perfectly  clean.  The  canal  should  not  be  plugged  with 
cotton,  nor  should  it  be  stopped  by  the  insufflation  of  powders.  It  should 
be  syringed  with  a  solution  of  bichloride  (1  to  5,000),  or  a  saturated 


932  DISEASES   OF   THE  EAR. 

solution  of  boric  acid^  or  simply  with  boiled  water.  All  these  fluids 
should  be  used  as  warm  as  can  be  borne,  and,  if  the  discharge  is  purulent 
and  abundant,  as  often  as  every  two  or  three  hours — in  all  eases  several 
times  a  da3^  A  bulb  ear-syringe  of  soft  rubber  is  the  most  satisfactory 
instrument  for  general  use.  It  is  a  mistake  to  keep  the  ears  covered 
by  a  thick  mass  of  cotton  or  flannel,  as  is  so  often  done.  In  the  house 
no  protection  is  necessary.  A  sudden  rise  in  the  temperature  usually 
means  that  drainage  is  imperfect ;  if  it  is  accompanied  by  pain,  a  second 
incision  may  be  necessary.  If  the  temperature  remains  high,  one  should 
be  on  the  lookout  for  mastoid  disease  or  other  complications. 

In  most  cases  the  discharge  ceases  in  from  one  to  three  weeks ;  should 
it  continue  longer,  some  measures  for  checking  it  may  be  used.  Dench 
advises  as  better  than  other  applications,  the  use  of  a  few  drops  of  a  1-to- 
3,000  solution  of  bichloride  in  65  per  cent  alcohol,  after  syringing.  It 
should  be  applied  with  a  medicine  dropper.  Where  the  discharge  has 
become  fetid,  syringing  once  a  day  with  a  solution  of  peroxide  of  hydro- 
gen (1  to  4,  or  even  stronger)  is  often  useful.  A  persistent  discharge 
often  depends  upon  the  fact  that  the  child's  general  condition  is  poor, 
and  improvement  in  this  will  do  more  to  stop  the  discharge  than  any 
variation  in  local  treatment. 

One  attack  of  otitis  is  frequently  the  precursor  of  many  others.  Chil- 
dren sometimes  have  one  or  more  attacks  every  winter  for  several  years. 
Such  children  are  usually  those  who  are  very  prone  to  catarrhal  colds,  and 
in  most  of  them  will  be  found  adenoid  vegetations  in  the  pharynx.  In 
order  to  get  rid  of  this  tendency  to  attacks  of  otitis,  such  growths  should 
be  removed  and  all  other  associated  pathological  conditions  treated. 
The  nose  should  be  kept  as  clean  as  possible  by  frequent  use  of  the  hand 
atomizer  with  some  mild  cleansing  solution,  such  as  Dobell's  or  Seller's. 
The  rhino-pharynx  may  be  touched  once  in  three  or  four  days  with  a 
solution  of  nitrate  of  silver  (10  to  20  grains  to  the  ounce). 

Cold  sponging  about  the  neck  and  chest  should  be  employed,  as  well 
as  every  means  to  reduce  the  susceptibility  to  acute  catarrh.  The  remote 
dangers  from  these  recurring  attacks  are  often  overlooked.  They  may 
be  the  beginning  of  a  chronic  condition,  the  full  effects  of  which  are  not 
seen  until  adult  life  is  reached,  both  the  physician  and  the  parents  often 
thinking  that  all  danger  has  passed  when  the  acute  symptoms  have  sub- 
sided. 

When  symptoms  pointing  to  acute  mastoiditis  are  present,  early  free 
incision  of  the  drum  membrane  is  indicated  even  though  there  may  be  no 
bulging,  but  only  marked  congestion.  For  the  mastoid  inflammation, 
nothing  can  be  worse  than  poulticing.  In  the  early  stage,  when  only 
tenderness  exists,  a  mastoid  ice-bag  should  be  applied  continuously  for 
thirty-six  or  forty-eight  hours.  In  addition,  in  older  children  the  arti- 
ficial leech  may  be  placed  over  the  antrum  or  mastoid  tip.     With  these 


ACUTE   OTITIS.  933 

measures  the  symptoms  often  subside.  Operation  is  to  be  advised  in  all 
cases  of  post-^iuricular  abscess,  and  in  other  eases  accompanied  by  marked 
swelling  over  the  mastoid.  Whether  operation  should  be  done  when  the 
only  local  symptom  is  acute  tenderness  is  questionable.  This  must  be 
decided  in  part  by  the  otoscopic  appearances  and  in  part  by  the  consti- 
tutional symptoms.  Severe  pain,  high  temperature,  and  delirium  are  all 
reasons  for  operation,  as  is  also  persistent  acute  tenderness  of  one  side. 
One  should,  however,  be  particularly  careful  not  to  overlook  pneumonia, 
which  is  so  often  a  cause  of  the  continued  high  temperature,  especially 
in  cases  following  influenza.  My  own  feeling  is  that  the  otologist  is  in- 
clined to  operate  too  early  and  too  often,  especially  in  the  case  of  in- 
fants and  very  young  children. 

It  is  now  the  unanimous  opinion  of  surgeons  that  the  operation  for 
acute  mastoiditis  should  not  be  simply  an  incision  to  drain  an  abscess  or 
relieve  tension,  but  the  mastoid  process  should  be  opened  and  all  dis- 
eased bone  thoroughly  removed  as  the  only  effective  means  of  preventing 
involvement  of  the  lateral  sinus  or  the  cranium. 

The  treatment  of  chronic  otitis  and  of  the  associated  conditions  is 
largely  surgical,  and  belongs  to  the  specialist;  but  it  is  extremely  im- 
portant that  the  general  practitioner  should  be  familiar  with  their  symp- 
toms, and  realize  the  danger  from  these  neglected  cases,  not  only  to  the 
function  of  hearing,  but  also  to  life  itself.  The  essential  thing  in  treat- 
ment is  to  operate  sufficiently  to  secure  free  drainage,  and  to  permit 
thorough  cleansing  of  the  parts.  Too  much  can  not  be  said  against  the 
expectant  treatment  of  these  cases,  or  against  the  practice  of  prolonged 
poulticing. 


SECTION  IX. 
THE  SPECIFIC  INFECTIOUS  DISEASES. 

AccuEATE  classification  of  the  infectious  diseases  is  at  the  present 
time  impossible,  but  there  are  two  quite  distinct  groups  into  which,  with 
one  or  two  exceptions,  those  here  considered  may  be  placed. 

The  first  group  includes  scarlet  fever,  measles,  rubella,  varicella,  and 
pertussis.  The  nature  of  the  specific  poison  in  each  of  these  is  as  yet 
unknown.  They  are,  strictly  speaking,  contagious;  for  it  is  practically 
certain  that  any  of  them  may  be  contracted  by  proximity  to  a  person 
suffering  from  the  disease,  without  actual  contact.  In  no  one  of  these 
diseases  is  the  poison  given  off  in  a  single  definite  discharge,  and  in  no 
one  is  there  a  characteristic  visceral  lesion.  Mumps  resembles  the  mem- 
bers of  this  group  in  all  points  except  the  one  last  mentioned.  These 
peculiarities,  together  with  the  fact  that  thus  far  the  poison  of  each  of 
these  diseases  has  resisted  all  attempts  at  isolation,  render  it  not  improb- 
able that  these  poisons  are  some  other  variety  of  micro-organisms  than 
bacteria. 

In  the  second  group  may  be  placed  diphtheria,  typhoid  fever,  and 
tuberculosis,  in  each  of  which  the  specific  poison  is  a  known  form  of  bac- 
terium. Each  of  these  diseases  is  associated  with  definite  and  character- 
istic visceral  lesions.  The  poison  is  discharged  from  the  body  in  a  certain 
well-understood  manner  from  the  tissues  which  are  affected  b)'  the  dis- 
ease, and  in  no  other  way.  These  diseases  can  not  be  contracted  by  prox- 
imity to  a  diseased  person,  but  only  by  receiving  into  the  body  the  specific 
germs,  either  by  contact  with  a  person  suffering  from  the  disease  or  con- 
tact with  something  upon  which  the  special  germs  of  the  disease  have 
been  discharged.  In  other  words,  though  communicable,  they  are  not, 
strictly  speaking,  contagious. 

Syphilis,  influenza,  and  malaria  have  not  been  included  in  either  of 
the  above  groups.  Syphilis  must  still  be  placed  in  the  doubtful  class, 
although  its  general  characteristics  ally  it  with  the  second  group.  In  its 
communicabilit}^,  influenza  resembles  the  first  group,  although  there  is 
now  little  doubt  that  it  is  due  to  a  form  of  bacterium — Pfeiffer's  bacil- 
lus. Malaria  belongs  in  a  class  by  itself,  differing  in  nearly  all  its  essen- 
tial features  from  the  other  diseases  of  this  general  group,  as  its  specific 
cause  is  a  form  of  protozoon. 

934 


SCARLET   FEVER.  935 

CHAPTER  I. 
SCARLET  FEVER. 
Synonym :  Scarlatina. 

ScAELET  FEYEK  is  an  acute,  contagious,  self-limited  disease,  one 
attack  usually  protecting  the  individual  through  life.  The  period  of  in- 
cubation is  usually  from  two  to  six  days ;  that  of  invasion,  from  twelve 
to  twenty-four  hours;  that  of  eruption,  from  four  to  six  days;  that  of 
desquamation,  from  three  to  six  weeks.  The  disease  may  be  communi- 
cated at  any  time  from  the  first  symptom  of  invasion  throughout  des- 
quamation, and  sometimes  even  during  the  existence  of  purulent  dis- 
charges from  the  nose  or  other  mucous  membranes.  It  is  usually  ushered 
in  by  vomiting,  high  fever,  and  sore  throat,  and  is  characterized  by  an 
erythematous  rash  appearing  first  upon  the  neck  and  spreading  rapidly 
over  the  entire  body.  Its  chief  complications  are  otitis  and  membranous 
inflammations  of  the  pharynx,  which  frequently  extend  to  the  nose,  more 
rarely  to  the  larynx.  The  most  important  sequelae  are  otitis  and  ne- 
phritis. 

Etiology. — Analogy  leads  to  the  belief  that  scarlet  fever  is  due  to  a 
micro-organism,  but  as  yet  its  nature  has  not  been  discovered.  The 
■complications  are  usually  associated  with  the  development  of  a  streptococ- 
cus. Some  have  gone  so  far  as  to  claim  that  this  germ  is  the  cause  of  the 
disease.  From  present  knowledge,  however,  it  appears  rather  to  play 
the  role  of  a  secondary  or  accompanying  infection,  for  the  development 
of  which  the  mucous  membranes  of  a  person  sufEering  from  scarlet  fever 
seem  to  afford  most  favourable  conditions.  To  the  streptococcus  may  be 
ascribed  the  membranous  inflammations  of  the  tonsils  and  pharynx,  the 
otitis,  the  inflammation  of  the  lymph  nodes  and  the  cellular  tissue  of 
the  neck,  and  probably  also  the  nephritis,  endocarditis,  pneumonia,  and 
joint  lesions.  In  many  of  the  above  conditions  the  streptococcus  is  as- 
sociated with  other  pyogenic  germs,  and  in  some  cases  with  the  diph- 
theria bacillus. 

Predisposition. — The  susceptibility  of  children  to  the  scarlatinal 
poison  is  much  less  than  to  that  of  measles ;  still,  it  is  much  greater  than 
that  of  adults.  Billington  (New  York)  records  observations  made  in 
twenty-six  families  living  in  tenements  where  little  or  no  attempt  at 
isolation  was  made.  In  these  families  there  occurred  43  cases  of  scarlet 
fever;  but  47  other  children,  although  unprotected  by  previous  attacks 
and  constantly  exposed,  did  not  contract  the  disease. 

Johannessen  reports  that  of  185  children  under  fifteen  years  who 
were  exposed,  28  per  cent  contracted  the  disease ;  while  of  314  adults, 
only  5  per  cent  contracted  the  disease.    It  may  be  stated  that,  approxi- 


936  THE   SPECIFIC  INFECTIOUS  DISEASES. 

mately,  not  more  than  one  half  of  the  children  exposed  take  the  disease. 
The  susceptibility  is  not  great  in  early  infancy,  but  it  increases  until 
about  the  fifth  year,  after  which  it  steadily  diminishes.  Both  sexes  are 
equally  liable  to  scarlet  fever.  Epidemics  are  more  frequent  in  the  fall 
and  winter  than  in  summer,  and  cases  occurring  in  the  cold  months  are 
apt  to  be  more  severe.  Whitelegge,  in  6,000  eases,  found  the  highest 
mortality  in  the  month  of  October ;  and  in  Caiger's  report  of  1,008  cases 
this  was  also  the  month  showing  the  greatest  mortality. 

Incubation. — Of  113  cases  *  in  which  the  period  of  incubation  could 
be  accurately  determined,  it  was  as  follows : 


24  hours  or  less 6  cases. 

2  days 15      " 


28 

25 

6 

15 


8  days 2  cases. 

9  "     

11  "     

14  "     

21  "     


0 

" 

1 

case. 

1 

a 

1 

ii 

113 

cases. 

Thus  in  87  per  cent  of  these  it  was  between  two  and  six  days,  and 
in  66  per  cent  between  two  and  four  days.  The  incubation  is  rarely 
over  a  week ;  it  is  particularly  short  in  surgical  cases,  a  well-authenticated 
instance  being  on  record  in  which  it  was  but  six  hours.  Speaking  gener- 
ally, if,  after  exposure,  a  week  passes  without  symptoms,  the  chances  of 
infection  are  very  small.  A  short  incubation  is  more  frequently  seen  in 
severe  than  in  mild  cases. 

Mode  of  infection. — The  chief  source  of  infection  is  the  patient  him- 
self. It  is  somewhat  doubtful  whether  the  poison  of  scarlet  fever  can 
be  conveyed  by  the  breath,  but  it  may  be  by  discharges  from  the  mucous 
membranes  involved,  from  the  scales  during  desquamation,  and  prob- 
ably from  all  the  excretions  of  the  patient — urine,  fgeces,  and  perspira- 
tion. Infection  often  takes  place  from  the  carpets  or  furniture  of  the 
sick-room,  and  from  the  clothing  of  the  patient.  In  a  city  the  bed- 
clothing,  while  airing  in  the  window,  has  been  known  to  convey  the  dis- 
ease to  an  adjoining  house.  Instances  are  recorded  of  the  spread  of  scar- 
let fever  by  the  washing  of  infected  with  other  clothing.  Toys  or  books 
may  be  carriers  of  the  disease.  A  bouquet  of  flowers  sent  from  a  sick- 
room to  an  institution,  in  one  instance  proved  a  vehicle  of  infection. 
Cats,  dogs,  and  other  domestic  animals  are  known  to  have  conveyed  the 
disease.  Scarlet  fever  is  sometimes  spread  by  food,  particularly  by  milk 
(page  139).  It  is  possible,  under  these  circumstances,  that  a  disease 
resembling  scarlatina  existed  in  the  cows;  but  that  this  was  identical 
with  scarlatina,  as  seen  in  man,  was  not  demonstrated. 

*  Part  of  these  are  from  personal  observation,  but  the  great  majority  are  isolated 
eases  scattered  through  medical  literature,  occurring  under  circumstances  which  made 
it  possible  to  determine  the  exact  length  of  the  incubation. 


SCARLET   FEVER.  937 

The  transmission  of  the  disease  through  a  third  person  is  not  fre- 
quent, but  numerous  instances  of  it  are  on  record.  The  persons  most 
likely  to  carry  it  are  the  nurse  and  the  physician.  Physicians  have  in 
many  cases  carried  scarlatina  to  their  own  children,  but  only  when  there 
had  been  pretty  direct  contact  with  the  patient,  and  where  the  interval 
before  seeing  the  second  child  was  short.  The  clothing  of  the  nurse 
may  be  almost  as  infectious  as  that  of  the  patient.  The  transmission  of 
the  disease  by  one  who,  although  living  in  the  house,  does  not  come  in 
contact  with  the  patient  is  extremely  improbable.  An  instance  is  re- 
corded in  Allbutt  (ii,  129)  where  scarlatina  was  transmitted  through 
two  healthy  persons. 

Duration  of  the  infective  period. — There  is  no  evidence  to  show  that 
the  disease  is  communicable  during  the  period  of  incubation.  It  is 
slightly  contagious  from  the  beginning  of  invasion,  before  the  rash 
appears.  Infection  appears  to  be  most  active  at  the  height  of  the 
febrile  period — from  the  third  to  the  fifth  day — and,  next  to  this,  dur- 
ing the  stage  of  active  desquamation. 

In  simple  cases,  the  average  duration  of  the  contagious  period  may 
be  placed  at  six  weeks,  or  until  desquamation  is  complete.  However, 
physicians  generally  have  been  accustomed  to  place  too  much  stress  upon 
the  danger  from  the  scales,  and  too  little  upon  that  from  the  discharges 
from  the  mucous  membranes.  Early  infection  comes  chiefly  from  the 
throat,  nose,  or  possibly  the  breath.  Late  infection  may  arise  from  a 
purulent  otitis,  rhinitis,  chronic  pharyngitis,  suppurating  glands, 
eczema,  empyema,  and  possibly  also  from  the  urine  in  nephritis.  The 
infectious  nature  of  these  purulent  discharges  has  not  been  sufficiently 
recognised.  It  is  possible  for  them  to  convey  the  disease  during  a  period 
of  several  months.  One  case  is  recorded  in  which  scarlatina  was  com- 
municated through  a  purulent  nasal  discharge  after  eleven  weeks;  an- 
other in  which  the  opening  of  a  post-scarlatinal  empyema  in  a  surgical 
ward  was  follow^ed  by  an  outbreak  of  scarlet  fever. 

In  winter  especially,  a  chronic  pharyngeal  catarrh  may  long  contain 
the  germs  of  infection.  Ashby  found,  on  careful  investigation,  that  from 
two  to  four  per  cent  of  patients  discharged  from  a  scarlet-fever  hospital 
subsequently  conveyed  the  disease.  There  is  particular  danger  from  a 
child  who  has  recently  had  the  disease  sleeping  with  other  children. 
Line  records  a  case  in  which  this  was  the  means  of  conveying  the  disease 
after  fourteen  weeks,  and  when  the  patient  had  been  considered  per- 
fectly Nvell  for  three  weeks.  It  is  impossible  to  say  that  at  any  specified 
time  absolute  safety  exists.  All  patients  before  being  discharged  from 
a  hospital  or  released  from  quarantine  in  private  practice,  should  be  care- 
fully examined  as  to  the  condition  of  the  mucous  membranes,  and  quar- 
antine continued  as  long  as  catarrhal  inflammations  are  present.  The 
poison  of  scarlatina  clings  more  tenaciously  to  clothing,  upholstery,  and 


938  THE  SPECIFIC  INFECTIOUS  DISEASES. 

apartments  than  that  of  any  other  contagious  disease,  possibly  except- 
ing tuberculosis.  Authentic  cases  are  on  record  in  which  more  than  a 
year  had  elapsed  between  the  first  and  second  cases^,  where  the  source  of 
infection  seemed  certain. 

Lesions. — The  only  characteristic  lesions  of  scarlatina  are  those  of 
the  skin  and  the  mucous  membranes  of  the  mouth  and  throat.  The  skin 
is  the  seat  of  an  acute  dermatitis  of  variable  depth  and  intensity.  There 
is  first  acute  hypersemia,  followed  by  an  exudation  of  serum  and  cells  in 
the  corium,.  especially  about  the  blood-vessels  and  hair  follicles.  There 
results  a  death  of  the  epidermis  which  is  thrown  off  in  the  desquamation. 
The  mucous  membrane  of  the  mouth,  tongue,  and  throat  is  the  seat  of 
a  catarrhal,  membranous,  or  gangrenous  inflammation  which  rarely  in- 
vades the  larynx,  but  very  frequently  the  middle  ear  and  nose.  The  entire 
oesophagus  is  often  the  seat  of  an  intense  congestion.  From  the  ear  the 
infection  may  extend  to  the  mastoid  cells,  the  meninges,  or  the  brain, 
and  from  the  nose  to  the  accessory  sinuses,  particularly  the  antrum  of 
Highmore.  All  the  lymph  nodes  about  the  neck  may  be  involved,  the  in- 
fection ending  in  cell-hyperplasia,  suppuration,  or  necrosis.  The  cel- 
lular tissue  of  this  neighbourhood  ma)^  also  become  infiltrated,  this  being 
followed  sometimes  by  suppuration  and  occasionally  by  gangrene. 

The  most  constant  change  throughout  the  body,  according  to  Pearce 
(Boston),  is  hyperplasia  of  the  lymphoid  tissue,  which  is  seen  every- 
where. The  other  lesions  are  degenerations  due  to  the  scarlatinal  poison 
alone,  or  in  conjunction  with  the  various  forms  of  secondary  infection, 
or  to  the  latter  alone.  The  most  important  are :  fatty  degeneration  of 
the  heart;  areas  of  focal  necrosis  in  the  liver;  acute  degeneration  of 
the  kidney  or  acute  diffuse  nephritis;  proliferation  of  the  cells  of  the 
Malpighian  bodies  of  the  spleen;  broncho-pneumonia,  gangrene,  or  ab- 
scess of  the  lung;  pleurisy,  which  is  often  purulent;  endocarditis,  peri- 
carditis; abscesses  in  the  cellular  tissue  and  inflammation  of  the  joints. 
These  visceral  changes  will  be  considered  more  fully  under  Complica- 
tions. 

Symptoms. — Invasion. — As  a  rule,  the  invasion  of  scarlet  fever  is  ab- 
rupt, the  symptoms  at  the  onset  usually  being  directly  in  proportion  to 
the  severity  of  the  attack.  In  the  majority  of  cases  there  is  vomiting, 
a  rapid  rise  in  temperature,  and  soreness  of  the  throat.  Often  the  vomit- 
ing is  repeated ;  it  is  frequently  forcible,  and  without  nausea.  In  severe 
cases  the  rise  in  temperature  is  very  rapid,  to  104°  or  105°  F. ;  in  the 
mildest  cases  it  may  not  be  above  101°.  A  child  may  complain  of  sore- 
ness of  throat,  or  the  throat  symptoms  may  be  entirely  objective.  In 
most  severe  cases,  there  is  a  uniform  erythematous  blush  covering  the 
pharynx,  tonsils,  and  fauces,  but  on  the  hard  palate  there  are  minute 
red  points.  The  appearance  of  this  is  usually  coincident  with  the  rise 
in  temperature.    Occasionally  membranous  patches  may  be  seen  upon  the 


SCARLET  FEVER.  939 

tonsils  the  first  day,  but  not  generally  before  the  third  or  fourth  day.  In 
mild  cases  the  throat  shows  only  a  very  moderate  congestion.  Severe 
cases  are  sometimes  ushered  in  by  convulsions,  especially  in  very  young 
children.  Diarrhoea  is  not  uncommon  in  summer.  There  is  general 
prostration,  which  is  directly  proportionate  to  the  height  of  the  fever. 

Eruption. — This  usually  appears  from  twelve  to  thirty-six  hours  after 
the  first  symptoms  of  invasion ;  exceptionally,  not  until  the  third  or  even 
the  fifth  day.  A  later  appearance  than  this  is  somewhat  doubtful,  for 
the  rash  not  infrequently  recedes  and  reappears,  having  been  overlooked 
in  the  first  instance.  In  108  cases  observed  in  the  New  York  Infant 
Asylum,  the  duration  of  the  rash  was  as  follows : 

Two  days  or  less 5  cases. 

Three  to  seven  days 81      " 

Eight  to  eleven  days 16      " 

Over  eleven  days 4      " 

Recurring 2      " 

These  statistics  are  confirmed  by  the  observations  of  most  writers, 
that  the  rash  lasts  from  three  to  seven  days.  The  full  development  of 
the  rash  is  generally  seen  in  from  twelve  to  twenty-four  hours  from  its 
first  appearance,  and  not  infrequently  the  whole  body  is  covered  in  the 
course  of  four  or  five  hours.  Very  rarely  its  extension  is  so  slow  that 
it  is  two  or  three  days  before  the  body  is  covered.  Its  first  appearance 
is  almost  invariably  upon  the  neck  and  chest.  In  the  cases  of  moderate 
severity  the  typical  rash  is  seen.  Its  colour  is  red  rather  than  scarlet,  and 
on  close  inspection  is  seen  to  be  made  up  of  very  minute  points.  The 
rash  covers  the  entire  body,  including  the  face.  There  is  often  a  peculiar 
pallor  about  the  mouth,  in  striking  contrast  with  the  rest  of  the  face, 
which  is  quite  characteristic  of  the  disease. 

Variations  in  the  eruption  are  very  frequent,  and  often  extremely 
puzzling.  In  the  mild  cases  the  rash  is  not  seen  upon  the  face ;  it  is  often 
faint  upon  the  body,  and  may  be  present  only  upon  certain  parts ;  when 
the  rash  is  faint  or  scanty  it  is  usually  most  marked  in  the  groins  and 
axillae,  or  over  the  buttocks  and  back  of  the  thighs;  it  may  last  only  one 
day,  and  sometimes  may  be  so  slight  as  to  escape  notice  altogether.  It 
may  be  absent  in  some  very  mild  cases,  in  certain  others  where  the  throat 
symptoms  are  severe,  and  in  malignant  cases.  In  the  very  severe  cases 
many  irregularities  are  seen,  both  as  to  the  time  of  the  appearance  of 
the  eruption  and  its  character.  Sometimes  it  occurs  as  large,  irregular 
patches;  again,  it  is  macular,  closely  resembling  the  rash  of  measles; 
occasionally  it  is  of  a  dark  purplish  colour ;  and  very  rarely  it  is  haemor- 
rhagic.  Not  infrequently  an  eruption  of  fine  vesicles  is  seen,  especially 
on  the  chest  and  abdomen;  this  may  be  so  pronounced  as  to  make  the 
diagnosis  difficult.  It  is  seen  both  in  mild  and  severe  cases.  Much 
importance  is  attached  by  the  laity  to  the  early  disappearance  of  the 


940  THE  SPECIFIC   INFECTIOUS  DISEASES. 

rash,  an  especial  danger  being  believed  to  exist  because  the  disease  has 
"  struck  in."  A  well-developed  bright  rash  indicates  strong  heart  action, 
and  a  sudden  recession  of  the  rash  is  a  sign  of  heart  failure.  Often  a 
rash  which  is  faint  and  doubtful  in  character,  may  be  brought  out  fully 
by  a  hot  bath. 

With  the  eruption  at  its  height,  there  is  intense  itching  or  burning 
of  the  skin,  and  in  severe  cases  considerable  swelling,  chiefly  noticeable 
upon  the  hands  and  face. 

Desquamation. — Shortly  after  the  rash  has  faded,  about  the  eighth 
day,  there  begins  an  exfoliation  of  the  dead  epidermis,  known  as  des- 
quamation. This  is  even  more  characteristic  of  the  disease  than  the 
rash.  It  is  usually  first  seen  upon  the  neck  and  chest,  where  it  appears 
as  fine  'flakes.  The  desquamation  of  the  trunk  is  completed  in  from 
one  to  three  weeks.  If  baths  and  inunctions  are  being  used,  it  is  scarcely 
perceptible.  It  continues  longest  where  the  epidermis  is  thickest — viz., 
upon  the  hands  and  feet — and  here  it  lasts  from  four  to  seven  weeks,  and 
not  infrequently  eight  weeks.  The  appearance  of  the  fingers  and  toes 
during  desquamation  is  characteristic.  The  finger  tips  usually  peel  first, 
and  the  new  epidermis  is  pink  and  fresh-looking,  while  that  which  has 
not  yet  separated  is  of  dull  gray  colour  and  loosened  at  the  margin.  Oc- 
casionally the  epidermis  of  a  considerable  part  of  a  finger  may  be  loos- 
ened at  once,  so  that  a  partial  cast  may  be  thrown  off  like  the  finger  of 
a  glove.  Sometimes  the  patient  comes  under  observation  for  the  first 
time  during  desquamation,  the  history  of  the  early  symptoms  being 
doubtful  or  absent.  Such  desquamation  as  has  been  described,  occurring 
both  upon  the  hands  and  feet,  may  be  regarded  as  conclusive  evidence  of 
scarlet  fever,  no  matter  what  the  history  may  be. 

1.  The  mild  cases. — The  symptoms  may  be  so  slight  as  to  be  entirely 
overlooked,  nothing  being  noticed  until  desquamation  occurs.  Usually, 
however,  there  is  a  rather  abrupt  invasion,  with  vomiting  and  a  tempera- 
ture from  100°  to  103°  F.  The  tonsils  and  pharynx  are  congested,  while 
the  palate  shows  a  punctate  redness  somewhat  like  the  cutaneous  erup- 
tion. The  papillae  of  the  tip  and  borders  of  the  tongue  are  enlarged. 
Kearly  always  within  twenty-four  hours  the  rash  makes  its  appearance, 
generally  first  upon  the  neck  and  chest.  Very  often  it  is  not  seen  upon 
the  face,  but  is  abundant  on  the  rest  of  the  body.  The  rash  fades  on 
the  third  or  fourth  day,  and  has  disappeared  by  the  fifth  day.  There  is 
very  little  prostration,  the  child  often  being  with  difficulty  kept  in  bed. 

The  highest  temperature  is  coincident  with  the  full  eruption,  and 
is  seen  during  the  first  thirty-six  hours  of  the  disease.  It  gradually 
falls  to  normal  by  the  fourth  or  fifth  day.  Its  typical  course  is  shown 
in  Fig.  173.  In  the  mildest  cases  the  temperature  may  never  be  above 
100°  F. 

Desquamation  is  often  faint  over  the  body,  but  is  unmistakable  over 


SCARLET   FEVER. 


941 


DAY  OF 
DISEASE 

1 

2 

3 

4 

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6 

7 

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».    E. 

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M.JE. 

M. 

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M.JE. 

M. 

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M.'E. 

104°    I 

103°    - 

^102°    - 

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99°  : 

98°    - 

1 

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1 

the  hands  and  feet.     It  begins  about  the  end  of  the  first  week,  always 
being  most  marked  where  the  eruption  has  been  most  intense. 

The  mild  cases  are  usually  uncomplicated,  but  the  possibility  of  otitis 
and  of  late  nephritis  should  always  be  kept  in  mind,  as  these  may  occur 
even  with  the  mildest  attacks. 
The  difficulties  in  diagnosis  in 
mild  attacks  of  scarlet  fever  are 
often  great.  It  should  be  remem- 
bered that  these  cases  are  just  as 
contagious  as  severe  ones,  and 
that  from  a  mild  attack  a  severe 
one  is  often  contracted.  It  is 
frequently  by  these  mild  cases 
that  this  disease  is  spread  in 
schools.  In  dispensaries  I  have 
often  seen  patients  desquama- 
ting from  scarlet  fever,  who 
had  been  attending  school  regu- 
larly up  to  the  time  when  they 
were  brought  for  treatment  for 
nephritis  or  some  other  disease. 

2.  Cases  of  moderate  severity. 
— The  onset  is  sudden  with  vom- 
iting, which  is  usually  repeated, 
or  with  convulsions.  The  temperature  rises  rapidly,  and  by  the  end  of 
the  first  twenty-four  hours  has  reached  10-t°  or  105°  F.  The  rash  usually 
appears  within  the  first  twenty-four  hours,  and  its  intensity  is  directly 
proportionate  to  the  severity  of  the  attack.  Appearing  first  upon  the 
neck  or  chest,  it  extends  rapidly,  covering  the  entire  trunk,  extremities, 
and  often  the  face  in  a  few  hours.  It  is  usually  typical  in  appearance, 
being  made  up  of  minute  points,  but  giving  the  appearance  of  a  uniform 
blush,  which  has  been  compared  to  a  boiled  lobster.  Little  change  takes 
place  in  the  rash  for  four  or  five  days.  After  this  it  fades  quite  rapidly, 
and  disappears  by  the  seventh  or  eight  day. 

The  throat  resembles  that  of  the  mild  form,  except  that  the  redness  is 
more  intense  and  there  is  slight  swelling  of  the  tonsils,  fauces,  and  uvula, 
and  often  pain  upon  swallowing.  Occasionally  small  yellowish  patches 
are  seen  upon  the  tonsils  by  the  second  or  third  day,  but  these  can  be  wiped 
off  and  are  not  distinctly  membranous.  There  is  usually  a  moderate 
discharge  of  a  sero-purulent  character  from  the  nose.  The  lymphatic 
glands  at  the  angle  of  the  jaw  are  swollen  and  quite  tender.  The  tongue 
may  be  coated  in  the  centre  and  show  bright  red  points  at  its  borders 
and  tip,  or  it  may  be  quite  red  and  show  the  prominent  papillae  every- 
where— the  "strawberry  tongue";  while  not  exclusively  seen  in  scar- 
61 


Fig.  173. — Typical  temperature  curve  of  mild  scar- 
let fever;  uucoHipIicated ;  in  a  child  three 
years  old. 


942 


THE   SPECIFIC   IXEECTIOrS   DISEASES. 


latina  this  is  of  much  diagnostic  value  and  may  continue  several  days 
or  even  weeks. 

During  the  heiglit  of  the  fever  tliere  is  restlessness,  thirst,  and  not 
infrequently  slight  delirium.    The  temperature  reaches  the  maximum  by 


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Fig.  174. — Moderately  severe  scarlet  fever,  running  a  proloncred  course,  but  without  complica- 
tions ;  the  patient,  a  boy  two  and  a  half  years  old. 

the  second  or  third  dav.  and  usually  falls  gradually  after  the  fourth  or 
fifth  day,  but  even  in  uncomplicated  cases  the  fever  often  lasts  from  ten  to 
fourteen  days  (Fig.  1T4).  The  pulse  in  the  early  part  of  the  disease  is 
rapid  and  full,  but  later  it  may  be  weak.  There  is  much  prostration,  fre- 
quently followed  by  quite  a  marked  degree  of  auEemia. 

This  form  of  the  disease  rarely  proves  fatal  apart  from  complications, 
but  it  may  do  so  in  very  young  infants.  The  complications  seen  most 
frequently  in  this  form  of  scarlet  fever  are  broncho-pneumonia  or  pleuro- 
pneumonia and  otitis,  the  latter  being  usually  double  and  occurring  be- 
tween the  sixth  and  the  fourteenth  days.  Xephritis  is  the  only  common 
secjuel. 

3.  The  severe  cases. — The  severe  type  of  scarlet  fever  usually  declares 
itself  from  the  beginning.  The  incubation  is  short,  and  the  full  rash  may 
be  seen  within  a  few  hours  after  the  initial  symptoms.  It  covers  the  en- 
tire body,  including  the  face.  The  severity  of  the  infection  is  shown  by 
the  fact  that  the  temperature  is  higher  and  continues  for  a  longer  period. 
and  by  the  frequency  and  severity  of  the  complications,  particularly  those 
of  the  throat.  For  the  first  two  days  the  throat  may  present  nothing  dif- 
ferent from  what  is  seen  in  the  milder  cases.  By  the  third  or  fourth  day. 
however,  membranous  patches  often  appear  on  the  tonsils,  and  spread  to 
the  soft  palate,  uvula,  and  pharynx,  sometimes  to  the  nose  and  through 


SCARLET   FEVER. 


943 


the  Eustachian  tube  to  the  ear,  rarely  involving  the  larynx.  The  mucous 
membrane  of  the  mouth  is  intensely  congested,  and  often  partly  covered 
by  membrane;  there  are  sordes  on  the  lips  and  teeth,  and  there  may  be 
superficial  ulcers,  which  bleed  readily.  The  glands  of  the  neck  swell 
rapidly,  often  to  a  great  size,  and  the  cellular  tissue  about  them  is  infil- 
trated. The  head  is  thrown  back  to  relieve  the  dyspnoea  which  the  pres- 
sure from  this  swelling  occasions.  There  is  an  abundant  discharge  from 
the  nose  and  mouth;  the  breath  is  offensive,  often  fetid.  The  general 
symptoms  are  those  of  a  severe  septicsemia.  The  temperature  is  steadily 
high,  usually  between  103°  and  105°  F.,  the  fluctuations  being  usually 
narrow  for  the  first  week  or  ten  days.  In  cases  which  recover,  the  subse- 
quent course  is  greatly  modified  by  the  presence  of  complications  (Fig. 
175).  But  even  in  uncomplicated  cases  the  fever  often  lasts  three  weeks. 
In  fatal  cases  the  temperature  may  be  steadily  high  till  death  (Fig.  176), 
or  it  may  fluctuate  widely.  The  pulse  is  rapid,  weak,  and  irregular. 
There  is  complete  anorexia ;  both  food  and  stimulants  have  to  be  coaxed 
or  forced  down.  There  is  low  delirium  or  apathy,  and  sometimes  all  the 
symptoms  of  the  typhoid  condition  are  present. 

Signs  of  a  broncho-pneumonia  are  often  found  in  the  chest,  and  by 
the  end  of  the  first  week  or  early  in  the  second  the  ears  may  begin  to  dis- 


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Fig.  175. — Severe  scarlet  fever  complicated  by  double  otitis  and  nephritis;  primary  fever  pro- 
longed ;  otitis  began  on  the  thirteenth  day  ;  nephritis  on  the  nineteenth  day  ;  recovery  ;  the 
patient  a  girl  twenty  months  old. 


charge.  The  urine  is  rarely  free  from  allnimin.  but  the  amount  present  is 
not  usually  great;  there  may  be  hyaline  and  epithelial  casts,  and  some- 
times blood.  Ill  some  cases  the  throat  symptoms  predominate;  in  others, 
those  of  general  sepsis,  but  more  frequently  the  two  are  combined  and  are 


944 


THE   SPECIFIC  INFECTIOUS   DISEASES. 


directly  proportionate  to  each  other.    In  still  other  cases,  instead  of  the 

membranous  inflammation,  it  may  be  of  a  gangrenous  character,  and  ex- 
tensive sloughing  may  take 
place  in  the  throat,  and  even  in 
the  cellular  tissue  of  the  neck. 
The  duration  of  the  symp- 
toms in  fatal  cases  is  from  six 
to  fourteen  days.  There  is  gen- 
erally increasing  prostration 
and  finally  a  septic  stupor,  with 
death  from  exhaustion,  from 
heart  failure,  or  from  some 
complication  —  broncho  -  pneu- 
monia, pleurisy,  nephritis,  haem- 
orrhages following  sloughing, 
laryngitis,  pericarditis,  or  endo- 
carditis. In  cases  which  recover, 
the  acute  symptoms  nearly  al- 
ways continue  for  a  full  month; 
and  after  escaping  the  dangers 
of  sepsis  and  the  early  compli- 
cations, the  child  has  still  to  run 
the  gauntlet  of  all  the  late  com- 
plications —  nephritis,  pneumo- 
nia^ endocarditis,  pyaemia,  etc. 
A  case  may  prove  fatal  as  late  as 

the  end  of  the  seventh  week ;  nearly  all  such  results  are  due  to  nephritis 

or  to  its  complications. 

4.  Malignant  or  cerebral  cases. — These  are  rare  eases  which  are  more 
frequently  described  than  seen,  in  which  death  takes  place  usually  within 
the  first  forty-eight  hours.  The  system  is  overpowered  by  the  scarlatinal 
poison.  Such  cases  are  seldom  seen  except  in  severe  epidemics.  Under 
other  circumstances,  many  cases  are  diagnosticated  malignant  scarlet 
fever  which  have  no  connection  with  this  disease. 

The  onset  is  sudden  and  violent,  usually  with  convulsions,  the  child 
passing  in  a  few  hours  into  a  condition  of  deep  stupor,  with  great  prostra- 
tion and  hyperpyrexia,  the  temperature  ranging  from  105°  to  107°  F. 
Sometimes,  however,  the  temperature  does  not  go  above  100°  F.  The 
rash  appears  irregularly,  late,  or  not  at  all.  It  may  be  hgemorrhagic. 
There  are  frequently  repeated  convulsions,  cyanosis,  and  invariably  a 
fatal  termination.  The  autopsy  often  gives  no  satisfactory  explanation 
of  these  cases.  Death  occurs  apparently  from  scarlatinal  toxemia,  with- 
out any  characteristic  local  evidences  of  disease. 

5.  Surgical  scarlet  fever. — Patients  with  recent  wounds,  or  those  who 


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¥iQ.  176. — Severe  scarlet  fever,  septic  type ;  double 
otitis,  severe  membranous  angina ;  death  on 
the  ninth  day ;  the  patient  a  girl  seven  years 
old. 


SCARLET   FEVER.  945 

have  been  subjected  to  surgical  operations,  are  peculiarl}'  susceptible  to 
the  scarlatinal  poison,  and  are  almost  certain  to  contract  the  disease  upon 
exposure,  unless  protected  by  a  previous  attack.  Whether  the  infection 
takes  place  directly  through  the  wound,  or  whether  the  susceptibility  de- 
pends upon  the  diminished  resistance  of  the  patient,  is  still  an  open  ques- 
tion. Scarlet  fever  ma}^  occur  after  any  operation,  even  one  so  trivial  as 
tenotomy  or  circumcision.  Patients  with  burns  are  generally  believed 
to  be  especially  susceptible.  The  effect  of  scarlet  fever  upon  the  wound, 
and  some  of  its  peculiar  clinical  features,  are  illustrated  by  the  follow- 
ing cases  from  Walton  Browne  (Belfast)  : 

A  healthy  child  was  operated  upon  for  hare-lip ;  sixteen  hours  after- 
ward it  became  seriously  ill,  the  skin  was  covered  with  a  dark  scarlatinal 
rash,  and  death  quickly  followed.  Another  patient  who,  it  was  afterward 
learned,  had  been  recently  exposed  directly  to  scarlatina,  was  circum- 
cised for  congenital  phimosis.  In  thirty  hours  he  was  covered  with  a  scar- 
latinal rash  and  had  a  temperature  of  104°  F.  In  forty  hours  the  wound 
became  gangrenous  and  the  patient  passed  into  a  condition  of  coma,  in 
which  he  died  in  seventy  hours.  A  child  admitted  to  the  hospital  with  a 
lacerated  wound  of  the  leg  was  accidentally  placed  in  a  bed  next  to  one 
in  which  was  a  patient  who  had  just  developed  scarlatina.  The  ex- 
posure lasted  less  than  an  hour,  but  in  six  hours  the  child  was  taken  with 
vomiting,  high  fever  and  headache,  became  rapidly  comatose,  and  died  in 
fifteen  hours,  no  rash  having  appeared.  After  death,  however,  a  pur- 
puric rash  could  be  seen  upon  the  skin. 

Surgical  scarlatina  is  nearly  always  irregular  in  its  symptoms;  the 
incubation  is  very  short,  the  rash  usually  atypical,  and  the  general  symp- 
toms, particularly  those  relating  to  the  nervous  system,  especially  severe. 
There  may  or  may  not  be  throat  symptoms.  It  should  be  said  that  many 
writers  deny  that  surgical  scarlet  fever  is  anything  more  than  septiccemia 
with  an  er3^thematous  rash.  This  is  undoubtedly  true  of  some  cases 
reported  as  surgical  scarlet  fever;  but  it  certainly  is  not  the  explanation 
of  all.  That  some  of  these  are  cases  of  genuine  scarlet  fever  is  shown 
by  the  fact  that  they  have  been  known  to  communicate  that  disease,  and 
that  they  are  often  followed  by  nephritis  and  usually  by  desquamation, 
although  the  latter  is  not  invariable.  But  in  the  absence  of  throat  symp- 
toms, desquamation,  and  contagion,  the  diagnosis  of  scarlatina  should  be 
made  with  extreme  caution.  Care  should  be  taken  to  exclude  erythema- 
tous oru])tions  due  to  tbe  various  antiseptics  used  in  surgical  dressings. 

Relapses,  Recurrences,  and  Second  Attacks. — As  a  rule,  one  attack  of 
scarlatina  gives  immunity  through  life.  The  exceptions  are  very  few,  but 
some  of  them  are  well  authenticated.  Kinnicutt  (New  York)  observed 
two  attacks  within  eight  months  in  a  boy  of  five  years;  Pritehard  (Glas- 
gow) reports  the  case  of  a  patient  wlio  had  three  attacks  in  tiie  same  hos- 
pital within  two  years;  such  cases  are  certainly  extremely  rare. 


946  THE  SPECIFIC  INFECTIOUS  DISEASES. 

Eelapses  or  recurrences  within  a  brief  period  after  the  first  attack  are 
more  frequent.  There  are  to  be  excluded  the  cases  of  pseudo-relapses  in 
which  the  rash,  having  temporarily  subsided  for  two  or  three  days,  reap- 
pears ;  also  those  where  the  rash  varies  in  intensity  from  time  to  time ; 
and,  lastly,  the  cases  in  which,  occurring  late  in  the  disease,  it  is  due  to 
septicaemia  or  pya?mia.  True  relapses  are  usually  due  to  auto-infection, 
sometimes  to  a  new  accession  of  poison  from  without.  They  are  analo- 
gous to  the  relapses  of  typhoid  fever.  They  occur  most  frequently  during 
desc[uamation,  between  the  seventh  and  twenty-fourth  days.  There  may 
be  not  only  a  new  eruption  but  a  rise  of  temperature,  sore  throat,  and 
vomiting,  just  as  in  the  initial  attack.  These  recurrences  are  sometimes 
shorter  and  milder  than  the  first  attack,  but  this  is  by  no  means  uniform, 
since  Korner  mentions  eight  cases  where  the  second  attack  proved  fatal. 

In  considering  the  subject  of  second  attacks,  the  liability  to  errors  in 
diagnosis  must  be  borne  in  mind  and  only  cases  included  which  have  pre- 
sented typical  symptoms. 

Complications  and  Sequelae. — Throat. — Three  distinct  forms  of  an- 
gina are  seen  in  scarlatina :  simple  or  erythematous,  membranous,  and 
gangrenous. 

1.  Erythematous  angina. — This  can  hardly  be  ranked  as  a  complica- 
tion, as  it  is  nearly  as  constant  as  the  scarlatinal  rash.  Usually  there  is 
only  the  general  blush  over  the  entire  pharynx  with  the  fine  red  points 
upon  the  hard  palatej  but  there  may  be  seen  upon  the  tonsils  grayish- 
3'-ellow  spots  resembling  those  of  follicular  tonsillitis,  which  can  be  wiped 
off,  leaving  a  clean  surface.  This  simple  angina  is  at  its  height  with  the 
maximum  temperature,  and  fades  as  the  temperature  falls.  It  does  not 
often  exteuQl  to  adjacent  mucous  membranes. 

2.  Membranous  angina. — These  cases  were  formerly  classed  as  scarla- 
tinal diphtheria,  and  whether  this  process  was  identical  with  primary 
diphtheria  or  not,  was  for  a  long  time  a  subject  of  much  discussion.  Cul- 
tures have  shown  that  the  great  majority  of  these  inflammations  are  not 
true  diphtheria,  but  are  due  to  the  streptococcus. 

The  lesions  of  this  form  of  angina  are  considered  in  the  chapter  on 
Pseudo-Diphtheria.  Usually  on  the  second  or  third  day  of  the  disease 
an  exudation  appears  upon  the  tonsils,  and  in  the  milder  cases  it  covers 
only  the  tonsils.  In  the  most  severe  form  it  may  be  seen  within  twenty- 
four  hours  of  the  onset,  sometimes  before  the  eruption  appears.  Be- 
ginning upon  the  tonsils,  the  membrane  rapidly  spreads  to  the  entire 
pharynx,  the  mucous  membrane  of  the  nose,  the  mouth,  the  Eustachian 
tube,  and  even  to  the  middle  ear.  In  colour  it  may  be  gray,  greenish,  or 
almost  black.  There  is  so  much  swelling  of  the  throat  that  swallowing 
becomes  difficult.  The  infiltration  of  the  cellular  tissue  of  the  neck  and 
the  enlarged  lymphatic  glands  produce  great  external  swelling,  which 
may  extend  like  a  collar  from  ear  to  ear.    The  breath  has  a  foul  odour, 


SCARLET  FEVER.  947 

the  nasal  discharge  is  thin  and  fetid,  and  nasal  respiration  is  obstructed, 
so  that  the  mouth  is  open  constantly.  Exceptionally  the  larynx  is  in- 
vaded, with  the  usual  symptoms  of  membranous  croup. 

These  local  changes  are  accompanied  by  constitutional  symptoms  of 
great  severity,  Avhich  are  due  to  a  general  streptococcus  septicaemia; 
broncho-pneumonia  and  nephritis  are  very  frequent,  otitis  is  almost  con- 
stant, and  suppuration  of  the  lymphatic  glands  is  not  uncommon.  The 
eruption  is  often  irregular  and  late  in  appearing. 

The  frequency  with  which  diphtheria  coexists  with  scarlatina  depends 
much  upon  circumstances.  In  some  epidemics,  thirty  per  cent  of  the 
throats  showing  membrane  have  contained  the  diphtheria  bacillus ;  in 
others  the  proportion  is  much  smaller.  There  are  some  clinical  features 
by  which  the  two  types  may  sometimes  be  distinguished.  The  streptococ- 
cus angina  is  usually  seen  at  the  height  of  the  disease ;  true  diphtheria 
may  occur  at  any  time,  even  during  convalescence.  The  streptococcus 
angina  is  characterized  by  much  swelling,  redness,  and  oedema  of  tonsils 
and  fauces,  and  by  great  external  infiltration,  showing  a  marked  tendency 
to  invade  the  ears,  but  very  little  to  invade  the  larynx.  In  true  diphtheria 
the  evidences  of  inflammation  are  usually  much  less,  while  there  is  a  far 
greater  tendency  to  invasion  of  the  larynx.  Very  little  reliance  is  to  be 
placed  upon  the  appearance  of  the  membrane.  The  only  positive  means 
of  differentiation  is  by  cultures,  which  should  invariably  be  made  from 
the  throat  of  every  patient  admitted  to  a  scarlet-fever  hospital,  and  of 
every  case  in  private  practice  showing  any  exudate  upon  the  tonsils.  If 
the  first  culture  is  negative  and  the  throat  symptoms  increase,  repeated 
cultures  should  be  made. 

3.  Gangrenous  angina. — This  is  seen  only  in  the  worst  cases  of  scarlet 
fever.  The  process  may  be  gangrenous  from  the  outset,  or  preceded  by  a 
membranous  inflammation.  It  is  sometimes  insidious  in  its  develop- 
ment. There  is  a  fetid  odour  to  the  breath,  irritating  discharges  from 
the  nose  and  mouth,  with  very  great  glandular  swelling.  The  tonsils  are 
gray  or  gra3'ish-blaek  in  colour,  and  large  masses  of  necrotic  tissue  may  be 
removed  with  the  forceps  from  the  tonsils,  uvula,  fauces,  or  pharynx,  and 
sometimes  sloughing  occurs  in  the  cellular  tissue  of  the  neck.  Blood- 
vessels of  considerable  size  are  often  opened,  and  serious  or  even  fatal 
haemorrhage  may  result.  Little  or  no  tendency  to  a  reparative  process  is 
seen.  The  constitutional  symptoms  are  those  of  great  asthenia,  prostra- 
tion, and  profound  cachexia,  followed  almost  invariably  by  a  fatal  ter- 
mination. 

Lymph  nodes. — These  are  swollen  in  all  cases  accompanied  by  severe 
angina.  The  inflammation  may  be  simply  an  acute  hyperplasia,  or  it  may 
go  on  to  suppuration  or  necrosis.  Abscess  does  not  often  occur  at  the 
height  of  the  disease,  but  may  come  at  any  time  during  convalescence.  It 
may  be  confined  to  the  glands  or  be  complicated  by  suppuration  in  the 


948  THE  SPECIFIC  INFECTIOUS  DISEASES. 

cellular  tissue  of  the  neck.  Disease  of  these  glands  is  not  an  infrequent 
cause  of  torticollis. 

Cellulitis  of  the  necl^. — This  usually  occurs  toward  the  end  of  the  first 
week,  and  is  associated  with  grave  throat  symptoms.  Rapid  and  exten- 
sive infiltration  occurs,  the  skin  becomes  tense  and  brawny,  the  head  is 
held  back,  and  there  may  be  considerable  dyspnoea.  The  infiltration  may 
be  only  in  the  neighbourhood  of  the  lymphatic  glands  or  it  may  be  diffuse. 
Unless  relieved  by  early  incision,  the  diffuse  form  may  result  in  suppura- 
tion and  extensive  sloughing,  which  may  be  deep  enough  to  lay  bare  the 
large  vessels  of  the  neck.  This  is  a  complication  of  the  gravest  possible 
import.  Death  may  occur  from  septicaemia  before  or  after  sloughing  or 
from  hsemorrhage  due  to  opening  by  ulceration  of  the  external  carotid 
or  some  of  its  branches;  or  there  may  be  associated  thrombosis  of  the 
jugular  vein,  leading  to  thrombosis  of  the  lateral  sinus,  meningitis,  or 
pyi^mia. 

Ears. — The  otitis  is  due  to  direct  extension  of  the  infection  from 
the  rhino-pharynx.  It  is  the  most  frequent  complication  of  scarlatina, 
and  in  doubtful  cases  may  have  some  diagnostic  importance.  As  a  rule, 
the  younger  the  child  the  greater  the  liability  to  otitis.  It  is  more  fre- 
quent in  winter  than  at  other  seasons.  Like  all  complications,  it  varies 
greatly  with  the  epidemic,  and  is  closely  connected  with  the  severity  of 
the  throat  symptoms.  In  an  epidemic  occurring  in  the  New  York  Infant 
Asylum  in  the  spring  and  summer  of  1889  there  were  73  cases  of  scarla- 
tina and  not  one  of  otitis.  In  a  fall  and  winter  epidemic  in  the  same 
institution  two  years  later,  of  43  cases  20  per  cent  had  otitis.  Of  4,397 
cases  reported  by  Finlayson,  otitis  occurred  in  10  per  cent,  and  of  1,008 
cases  reported  by  Caiger,  in  13  per  cent.  In  Burkhardt's  statistics  the 
proportion  was  as  high  as  33  per  cent.  Of  cases  accompanied  by  severe 
throat  symptoms  otitis  is  present  in  fully  75  per  cent. 

As  a  rule,  both  ears  are  affected,  but  not  simultaneously,  or  at  least 
rupture  occurs  at  different  times.  This  is  most  frequent  early  in  the 
second  week,  but  may  occur  during  convalescence.  In  the  cases  where 
otitis  develops  at  the  height  of  the  disease  there  are  in  some  cases  no  new 
symptoms;  in  others  there  is  pain  and  deafness.  If  it  develops  at  a 
later  period  there  is  usually  a  rise  in  the  temperature,  Avhich  falls  after 
rupture  of  the  drum  membrane  takes  place.  The  otitis  is  sometimes  over- 
looked until  symptoms  of  pj^semia  or  meningitis  develop.  The  form  of 
inflammation  may  be  catarrhal  or  phlegmonous  (page  926),  the  latter 
being  often  accompanied  by  necrotic  changes. 

Bezold  makes  the  following  report  upon  185  cases  showing  the  results 
of  scarlatinal  otitis :  "  In  30  there  was  entire  destruction  of  the  mem- 
brana  tympani,  with  loss  of  one  or  more  bones  ;  in  59  the  perforation  com- 
prised two  thirds  or  more  of  the  membrane;  in  13  there  were  smaller  per- 
forations; in  44  there  were  granulations  or  polypi;  in  15  there  was  total 


SCARLET   FEVER.  949 

loss  of  hearing  on  one  side,  and  in  6  of  the  cases  upon  both  sides;  in  77 
of  the  cases  the  hearing  distance  for  low  voice  was  less  than  twenty 
inches." 

As  a  canse  of  permanent  deafness  and  deaf-mutism,  no  disease  of 
childhood  compares  in  importance  with  scarlet  fever.  May  (New  York) 
has  collected  statistics  of  5,613  deaf-mutes,  of  whom  572  owed  their  con- 
dition to  otitis  following  scarlet  fever. 

Kidneys. — Albuminuria  accompanies  nearly  all  the  severe  cases  of 
scarlet  fever.  In  many  this  is  simply  the  ordinary  febrile  albuminuria 
due  to  acute  degeneration  of  the  kidneys  (page  656).  In  those  with 
severe  throat  complications,  and  in  nearly  all  the  septic  cases,  there  is 
often  an  acute  diffuse  nephritis  with  interstitial  changes  especially 
marked.  This  occurs  at  the  height  of  the  febrile  process  and  is  rarely 
accompanied  by  dropsy ;  but  albumin,  casts,  and  even  blood  may  be  found 
in  the  urine.  The  most  severe  and  the  most  characteristic  renal  compli- 
cation, and  that  generally  designated  as  post-scarlatinal  nephritis,  is  a 
diffuse  nephritis,  with  changes  in  the  glomeruli  as  the  most  striking  fea- 
ture. It  usually  develops  during  the  third  or  fourth  week  of  the  disease, 
and  may  follow  mild  as  well  as  severe  cases.  It  is  accompanied  by  gen- 
eral dropsy;  the  urine  is  scanty  and  not  infrequently  suppressed,  and  it 
contains  a  large  amount  of  albumin,  blood,  and  great  numbers  of  casts 
of  all  varieties.  It  may  cause  death  by  the  occurrence  of  acute  urasmia, 
or  it  may  be  followed  by  permanent  damage  to  the  kidneys.  It  is  more 
fully  described  with  the  Diseases  of  the  Kidney. 

Joints. — Acute  articular  rheumatism  may  occur  coincidently  with  the 
development  of  the  scarlatinal  rash,  and  occasionally  during  convales- 
cence in  patients  who  have  a  predisposition  to  that  disease.  Acute  swell- 
ing of  the  joints  is  sometimes  of  pygemic  origin.  A  case  is  reported  by 
Henoch  in  which  this  was  due  to  an  infectious  thrombus  in  the  jugular 
vein,  associated  with  cellulitis  of  the  neck.  In  pyajmic  arthritis  the  large 
joints  are  usually  involved  and  the  lesions  are  apt  to  be  multiple.  Joint 
disease  may  occur  as  a  sequel  of  scarlet  fever,  where  it  is  secondary  to 
disease  of  the  bone  or  to  periarticular  abscesses  opening  into  the  joint. 

The  foregoing  include  but  a  small  proportion  of  the  joint  complica- 
tions seen  in  scarlet  fever.  The  most  frequent  and  most  characteristic 
form  of  inflammation  is  scarlatinal  synovitis,  often  improperly  called 
scarlatinal  rheumatism.  It  occurs  in  different  epidemics  with  varying 
frequency.  Carslaw  (Glasgow)  in  533  cases  of  scarlet  fever  met  with 
synovitis  in  60  patients.  It  is  seldom  seen  in  children  under  three  j'ears 
of  age,  and  is  most  frequent  after  five  years.  It  may  occur  in  mild  as 
well  as  in  severe  cases.  According  to  Ashby,  it  is  more  frequent  when 
the  febrile  stage  is  prolonged  owing  to  other  complications.  Synovitis 
develops  quite  uniformly  toward  the  end  of  the  first  or  the  beginning  of 
the  second  week.    The  symptoms  are  generally  mild,  and  arc  followed  by 


950  THE  SPECIFIC  INFECTIOUS  DISEASES. 

prompt  recovery.  Suppuration  is  rare.  x\ny  of  the  joints  may  be  at- 
tacked, but  those  of  the  wrist,  hand,  elbow,  or  knee  are  most  frequently 
affected.  Demme  (Berne)  has  reported  a  case  in  which  every  large  joint 
in  the  body  was  involved.  The  symptoms  are  redness,  moderate  pain, 
swelling,  which  is  usually  due  to  synovial  distention,  and  sometimes  a 
slight  rise  of  temperature.  The  duration  is  generally  but  three  or  four 
days,  and  in  most  cases  there  is  spontaneous  recovery.  This  disease  is 
distinguished  from  rheumatism  by  several  points :  it  is  not  more  fre- 
quent in  rheumatic  patients;  cardiac  complications  are  rare  as  com- 
pared with  those  seen  in  patients  with  genuine  rheumatism ;  in  some  epi- 
demics it  is  very  common,  and  in  others  seldom  seen;  there  is  little  or 
no  tendency  to  relapses;  anti-rheumatic  remedies  are  without  striking 
benefit;  it  does  not  skip  about  from  joint  to  joint,  and  usually  fewer 
joints  are  involved. 

Lungs. — The  pulmonary  complications  of  scarlet  fever  are  neither 
so  frequent  nor  so  important  as  those  of  measles.  Broncho-pneumonia 
is  usually  found  at  autopsy  in  septic  cases  where  death  has  occurred  later 
than  the  third  or  fourth  day,  but  it  is  not  generally  recognisable  so  early 
from  physical  signs. 

In  septic  cases  pleuro-pneumonia  sometimes  occurs  early  in  the  dis- 
ease and  at  other  times  late,  generally  associated  with  nephritis,  but 
occasionally  without  it.  It  is  always  a  serious  condition,  and  not  infre- 
quently a  direct  cause  of  death.  Empyema  may  follow  pleuro-pneumonia 
or  occ^ir  with  pyemia  or  nephritis,  but  with  the  latter,  simple  serous 
pleurisy  is  more  common.  CEdema  of  the  lungs  occurs  chiefly  with  ne- 
phritis, in  which  it  is  the  most  common  cause  of  death. 

Heart. — Cardiac  murmurs  are  frequent  at  the  height  of  the  disease, 
but  both  endocarditis  and  pericarditis  are  rare.  They  are  oftenest  seen 
in  septic  cases,  and  with  post-scarlatinal  nephritis.  Endocarditis  may  be 
simple  or  malignant,  and  may  lead  to  embolism  during  convalescence. 
Some  degenerative  changes  in  the  cardiac  muscle  are  probably  present 
in  all  the  severe  cases.  Acute  dilatation  may  result,  which  is  sometimes 
a  cause  of  death. 

Blood. — Leueocytosis  is  usually  present  and  reaches  its  maximum 
very  early  in  the  disease.  According  to  Sevestre,  it  follows  the  course 
of  the  eruption  rather  than  the  temperature.  It  is  increased  in  the 
presence  of  complications  of  a  suppurative  character.  A  slight  leueocy- 
tosis usually  occurs  with  a  mild  infection  ;  in  severe  cases  a  marked  leueo- 
cytosis is  a  good  prognostic  sign  indicating  a  good  reaction. 

Digestive  system. — Functional  disturbances  are  very  frequent,  and,  in 
fact,  are  seen  in  most  of  the  cases,  but  organic  changes  are  rare.  Vomit- 
ing is  the  mode  of  onset  in  the  majority  of  cases,  but  rarely  continues 
throughout  the  attack.  Late  in  the  disease  it  is  a  frequent  symptom  of 
ursemia.     Diarrhoea  may  be  associated  with  it  under  both  conditions. 


SCARLET   FEVER.  951 

The  tongue  is  nearly  always  coated,  and  clears  off  in  qnite  a  eliaracteristie 
way,  which,  with  the  prominent  papilla?,  gives  rise  to  the  "  strawberry  " 
appearance.  Catarrhal  stomatitis  is  a  very  frequent  complication,  and 
in  many  cases  of  severe  membranous  angina  the  same  process  is  seen  in 
the  buccal  cavity. 

Nervous  system. — Xervous  complications  and  sequelae  are  seen  less 
frequently  with  scarlatina  than  with  most  of  the  infectious  diseases  of 
such  severity.  Convulsions  are  frequent  at  the  outset,  and  generally  in- 
dicate a  severe  attack,  though  not  invariably  so.  Occurring  late  in  the 
disease,  they  are  usually  due  to  uraemia,  and  may  be  a  cause  of  death. 
Meningitis  may  occur  as  a  complication  of  otitis,  in  pygemic  cases,  and 
sometimes  with  post-scarlatinal  nephritis.  Paralysis  from  peripheral 
neuritis  is  rarely  seen.  Hemiplegia  sometimes  occurs  from  meningeal 
haemorrhage,  or  from  embolism  secondary  to  endocarditis  and  associated 
with  nephritis.  Chorea  was  noted  as  a  sequel  in  only  three  of  533  cases 
reported  by  Carslaw.  In  a  report  of  187  cases  of  epilepsy,  Wildermuth 
states  that  it  followed  scarlet  fever  in  12  cases.  Insanity  has  been  occa- 
sionally observed,  the  usual  form  being  acute  mania,  with  complete  re- 
covery in  a  few  weeks  or  months. 

Gangrene. — Cases  of  symmetrical  gangrene  after  scarlet  fever  have 
been  reported  by  Wilson  and  others.  The  parts  generally  affected  are 
the  buttocks,  thighs,  and  arms,  but  it  may  occur  almost  anywhere.  The 
pathology  of  these  cases  is  obscure.  The  process  usually  begins  in  sev- 
eral places  simultaneously,  or  in  rapid  succession,  and  advances  steadily 
till  death  occurs. 

Other  infectious  diseases. — Diphtheria  is  most  frequently  seen,  and 
may  be  present  even  when  there  is  no  distinct  membrane. 

Scarlatina  may  also  be  complicated  by  measles,  varicella,  or  ery- 
sipelas, and  occasionally  by  variola  or  typhoid  fever.  The  symptoms  are 
often  an  irregular  commingling  of  those  belonging  to  the  two  diseases. 
They  may  begin  simultaneously,  or  more  frequently  one  develops  as  the 
other  is  subsiding. 

Diagnosis. — The  characteristic  symptoms  of  scarlet  fever  are  the 
abrupt  onset,  usually  with  vomiting,  the  marked  elevation  of  tempera- 
ture, the  erythematous  condition  of  the  throat,  the  punctate  eruption  on 
the  hard  palate,  and  the  enlarged  papilla^  at  the  edges  and  tip  of  the 
tongue,  with  the  appearance  of  the  rash  within  twenty-four  hours.  The 
difficulties  of  diagnosis  usually  depend  upon  irregularities  in  the  erup- 
tion. 'J'he  variations  are  seen  in  the  mildest  and  in  the  most  severe  cases. 
In  the  former  the  rash  may  be  of  short  duration,  often  less  than  a  day, 
and  in  consequence  easily  overlooked;  or  it  may  be  present  only  upon 
certain  parts  of  the  body  instead  of  being  diffuse.  In  every  doul)tful 
case  the  groing,  axillae,  and  loins  should  be  closely  scrutinized  for  a  punc- 
tate eruption.    In  very  severe  attacks  also  the  rash  may  be  imcertain.    It 


952  THE  SPECIFIC  INFECTIOUS  DISEASES. 

may  appear  late  or  recede  after  being  fully  out,  or  be  htemorrhagic  or  in 
irregular  blotches  instead  of  a  uniform  blush.  In  all  cases,  too  much 
stress  should  not  be  placed  upon  the  rash  alone,  but  it  must  be  weighed 
in  connection  with  the  other  symptoms.  McCollom  (Boston)  has  called 
attention  to  a  valuable  sign  in  late  diagnosis — viz.,  the  white  line  seen 
at  the  junction  of  the  pulp  of  the  finger  and  finger-nail;  this  with  a 
characteristic  tongue  he  thinks  sufficient  for  a  positive  diagnosis. 

Desquamation  often  settles  what  previously  may  have  been  a  doubtful 
case.  A  doubtful  rash  followed  by  a  peeling  of  hands  and  feet  which 
is  characteristic  both  as  to  time  and  appearance,  is  surely  scarlatina. 
A  doubtful  rash  without  any  desquamation  being  seen,  though  closely 
watched,  is  probably  not  scarlatina.  The  circumstances  in  which  the  case 
occurs,  the  chances  of  exposure  or  the  history  of  a  definite  exposure,  or 
the  development  of  subsequent  cases,  are  all  important  factors  in  diag- 
nosis. In  some  puzzling  epidemics  the  length  of  the  incubation  may  be 
of  material  assistance  in  the  diagnosis ;  where  this  is  regularly  more  than 
a  week,  one  may  be  pretty  sure  that  he  is  not  dealing  with  scarlet  fever. 

Not  infrequently  there  are  seen  in  practice  single  cases,  and  some- 
times small  epidemics,  in  which  the  diagnosis  remains  uncertain  to 
the  end. 

Scarlet  fever  with  severe  throat  symptoms  and  doubtful  eruption  can 
be  distinguished  from  true  diphtheria  only  by  cultures,  which  should  be 
made  at  the  earliest  opportunity  and  repeated  if  the  first  result  is  un- 
certain. Measles  is  distinguished  from  scarlet  fever  by  the  length  of 
the  invasion,  the  catarrhal  symptoms,  and  the  slowly  spreading  eruption, 
but  most  of  all  by  Koplik's  spots  (see  Measles).  Much  more  difficult  is 
it  to  distinguish  between  mild  scarlatina  and  rubella.  In  rubella  the 
important  thing  is  that,  although  the  rash  may  be  well  marked,  often 
covering  the  body,  the  constitutional  symptoms  are  few  or  entirely  absent. 
In  scarlet  fever  with  an  eruption  of  the  same  inte.nsity  there  is  almost 
invariably  a  considerable  elevation  of  temperature,  usually  103°  or  103° 
F.,  and  a  bright  red  throat. 

There  are  so  many  skin  eruptions  which  may  resemble  that  of  scarlet 
fever,  that  it  is  always  hazardous  to  make  the  diagnosis  of  this  disease 
from  the  eruption  alone.  This  is  especially  true  of  sporadic  cases  occur- 
ing  in  infants;  there  is  seen  at  this  age  a  great  variety  of  eruptions, 
usually  associated  with  digestive  disturbances,  which  closely  simulate  a 
scarlatinal  rash;  but  most  of  them,  are  of  short  duration.  A  scarlatini- 
form  erythema  is  occasionally  seen  after  diphtheria  antitoxin,  also  in 
influenza,  typhoid  fever,  and  varicella,  which  may  cause  them  to  be  mis- 
taken for  scarlet  fever,  or  may  lead  to  the  conclusion  that  both  diseases 
are  present.  The  same  is  the  case  with  the  septic  erythema  occurring  in 
surgical  patients.  Belladonna,  quinine,  and  occasionally  antipj^rine,  may 
produce  eruptions  more  or  less  closely  resembling  that  of  scarlet  fever. 


SCARLET  FEVER.  953 

This  is  also  tme  of  some  cases  of  urticaria,  and  of  several  other  forms  of 
skin  disease.  There  is  little  doubt  that  many  of  the  cases  reported  as  re- 
lapsing scarlatina  are  really  examples  of  recurring  erythema,  particularly 
as  some  of  the  latter  are  followed  by  a  desquamation  which  is  very  similar 
to  that  after  scarlatina.  In  all  doubtful  conditions  great  importance  is 
to  be  attached  to  the  constitutional  symptoms. 

Prognosis. — The  mortality  of  scarlet  fever  varies  much  in  different 
epidemics.  In  some,  nearly  all  the  cases  are  of  a  mild  type,  and  the 
mortality  may  be  as  low  as  3  or  4  per  cent ;  in  others,  a  severe  or  malig- 
nant type  prevails,  and  it  may  be  as  high  as  40  per  cent.  The  disease 
is,  as  a  rule,  more  fatal  in  the  youngest  infants,  becoming  less  so  as  age 
advances.  This  is  well  shown  in  two  recent  epidemics  in  the  New  York 
Infant  Asylum.     There  were — ■ 

Under  one  year 29  eases ;  mortality,  55  per  cent. 

From  one  to  two  years 87      "  "  22      " 

"      two  "  three  "     28      "  "  7      " 

Over  three  years 23      "  "  0      " 

In  the  first  epidemic  the  general  mortality  was  13-5  per  cent;  in  the 
second  it  was  33  per  cent,  in  the  same  class  of  children. 

The  following  are  the  mortality  records  from  various  European 
sources : 

Ashby,  Manchester  Hospital 681  cases ;  mortality,  12  "2  per  cent. 

Koren,  a  single  epidemic 426     "  "  14'0       " 

Bendz,  Copenhagen 22,036     "  "  12*2       " 

Ollivier,  three  Paris  hospitals  for  five  years       893     "  "  14"0       " 

Fleischmann,  five  epidemics 1,356     "  "  10*0       " 

The  general  mortality  of  the  disease  may  therefore  be  assumed  to  be 
from  12  to  14  per  cent;  it  is,  however,  much  higher  than  this  among 
young  children,  as  shown  by  the  following  figures : 

New  York  Infant  Asylum.. .   116  cases  under  5  years;  mortality,  20  per  cent. 
Ashby,  Manchester  Hospital.  259     "        "       5     "  "         23       " 

Bendz not  stated    "       5     "  "         13 

Heubner 136  cases     "       7     "  "  30 

Fleischmann not  stated    "       4     "  "         43       " 

Under  five  years  of  age  the  average  mortality  from  scarlet  fever  is, 
therefore,  between  20  and  30  per  cent. 

The  fatal  cases  may  be  grouped  in  three  classes :  first,  those  due  to 
late  nephritis,  in  which  the  early  symptoms  of  the  disease  are  of  mod- 
erate severity  or  even  mild ;  secondly,  the  septic  cases,  usually  associated 
with  severe  throat  symptoms  and  dying  most  frequently  in  the  second 
week  from  exhaustion,  or  from  some  complication,  such  as  diphtheria, 
pneumonia,  pleurisy,  meningitis,  or  nephritis ;  thirdly,  the  malignant 
cases,  which  are  overpowered  by  the  poison  of  the  disease  in  the  first 
two  or  three  days  of  the  attack. 


954  THE  SPECIFIC   INFECTIOUS  DISEASES. 

Prophylaxis. — Even  the  mildest  cases  should  be  isolated  for  four 
weeks,  and  all  cases  until  desquamation  is  complete.  If  complications 
exist,  such  as  otitis,  rhinitis,  phar3^ngitis,  empyema,  or  suppurating 
glands,  the  quarantine  should  be  continued  until  these  conditions  are 
cured.  Patients  should  not  be  allowed  to  mingle  with  other  children  for 
at  least  a  month  after  all  symptoms  have  subsided,  and  should  be  for- 
bidden to  sleep  with  other  children  for  three  months.  Children  in  the 
house  who  have  not  been  exposed  to  the  disease  should  be  immediately 
sent  away ;  and  those  Mdiq  have  been  exposed,  separately  quarantined  for 
at  least  a  week.  After  recovery,  the  patient,  before  mingling  with  other 
children,  should  have  at  least  two  disinfectant  baths,  the  entire  body 
being  scrubbed  with  soap  and  water  and  then  washed  in  a  solution  of 
carbolic  acid  (1  to  50)  or  bichloride  (1  to  5,000),  and  every  particle  of 
clothing  changed.  The  hair  and  the  scalp  should  be  thoroughly  washed 
and  disinfected. 

The  nurse  should  be  quarantined  with  the  patient,  and  should  not 
mingle  with  other  members  of  the  family  until  a  complete  change  of 
clothing  has  been  made,  and  hands  and  face  thoroughly  disinfected.  The 
nurse  and  all  others  in  close  contact  with  a  severe  case  should  use  fre- 
quently an  antiseptic  gargle  and  a  nasal  spray.  The  room  should  be  in 
that  part  of  the  house  most  easily  quarantined,  usually  on  the  top  floor; 
during  the  attack  it  should  be  stripped  of  upholstery,  hangings,  and 
carpet,  and  should  be  freely  ventilated  and  kept  as  clean  as  possible. 
All  dust  should  be  removed  with  damp  cloths  which  should  afterwards 
be  burned;  the  floor  should  occasionally  be  sprinkled  with  a  bichloride 
solution  (1  to  1,000).  The  presence  in  the  room  of  vessels  filled  with 
antiseptic  fluids  is  of  little  or  no  practical  value.  The  same  may  be  said 
of  sheets  wet  in  carbolic  or  other  solutions  and  hung  about  the  room. 
Carbolic-acid  poisoning  has  been  knoAvn  to  result  from  this  practice. 
After  an  attack  it  should  be  remembered  that  the  room  is  probably 
a  greater  source  of  danger  than  the  patient.  Smooth  walls  should  be 
wiped  with  damp  cloths  wrung  out  of  a  bichloride  solution  {1  to  2,000). 
The  wood-work  should  be  washed  in  the  same  solution  and  the  floor 
scrubbed  with  it.  After  a  thorough  cleaning,  while  the  floor  is  still 
wet  and  walls  damp,  the  apartment  should  be  fumigated  with  sul- 
phur, or  better  with  formalin.  A  simple  method  of  using  formalin 
is  by  Schering's  lamp  and  tablets.  If  fumigation  is  to  be  efficient  the 
room  must  be  tightly  closed,  all  cracks  being  stopped  with  cotton,  and 
larger  openings  about  doors,  windows,  and  fire-places  sealed  by  pasting 
paper  over  them.  Bedding,  cushions,  pillows,  carpets,  etc.,  should  be 
hung  over  chairs  or  upon  lines  strung  about  the  room.  Books  should  be 
suspended  from  covers  so  that  the  leaves  are  exposed.  After  fumigation, 
the  room  should  remain  closed  for  twelve  hours.  After  a  severe  case,  the 
walls  should  be  painted  or  whitewashed,  or  if  papered,  the  wall-paper 


SCARLET   FEVER.  '  955 

should  invariably  be  renewed  and  the  wood-work  repainted.  Simply 
airing  a  room  after  an  attack  is  of  little  or  no  benefit.  An  instance  is  on 
record  of  a  patient  contracting  the  disease  in  a  room  in  which  the  win- 
dows had  been  open  constantly  for  three  months.  The  carpets,  bedding, 
hangings,  and  upholstery  are  best  disinfected  by  steam.  Where  this  is 
impossible,  after  a  severe  case  the  mattress  and  pillows  should  be  burned. 
Bedding,  blankets,  and  other  articles  should  be  boiled,  and  afterward 
exposed  to  sunlight  for  a  long  time  out  of  doors. 

The  bedclothes,  linen,  and  clothing  removed  from  the  patient  during 
an  attack,  should  be  put  at  once  into  a  solution  of  carbolic  acid  (1  to  20), 
or  zinc  sulphate  four  ounces,  common  salt  two  ounces,  and  water 
one  gallon,  and  afterward  boiled  at  least  two  hours  in  the  same  solution. 
Instead  of  handkerchiefs,  pieces  of  old  muslin,  surgeon's  gauze,  or  ab- 
sorbent cotton,  should  be  used  for  cleansing  the  nose  and  mouth  of  the 
patient  and  burned  immediately. 

The  physician  in  attendance  upon  a  case  should  leave  his  coat  and 
overcoat  in  an  anteroom,  and  put  on  a  long  gown  or  rubber  coat,  suffi- 
ciently large  to  cover  all  his  clothing.  This  should  always  be  worn  in  the 
sick-room,  and  boiled  or  disinfected  when  the  case  is  finished.  For  a  sin- 
gle visit  the  overcoat  may  be  worn  in  the  room,  but  the  clothing  should 
be  changed  before  visits  to  other  children  are  made.  After  every  visit  the 
physician's  hands  and  face  should  be  thoroughly  washed  with  soap  and 
then  with  a  disinfectant  solution.  A  physician  in  attendance  upon  scar- 
latinal patients  should  not  attend  obstetric  cases  or  other  patients  with 
recent  wounds.  The  great  liability  of  such  cases  to  contract  scarlatina 
should  never  be  forgotten.  If,  in  emergencies,  it  becomes  necessary  to 
attend  such  patients,  the  physician  should  change  all  his  clothing  and 
disinfect  his  hands,  face,  hair,  and  beard,  with  the  greatest  thoroughness. 

Schools  are  the  hot-beds  for  the  spread  of  scarlet  fever.  The  greatest 
sources  of  danger  are  the  mild  or  walking  cases  in  which  the  disease  has 
not  been  recognised,  and  the  clothing  of  patients  who  have  had  a  severe 
form  of  the  disease.  As  a  rule,  a  child  should  be  kept  from  school  six 
weeks  from  the  beginning  of  the  attack,  and  the  certificate  of  a  physician 
should  be  required  before  re-admission,  stating  not  only  that  the  des- 
quamation is  com])lete,  but  also  that  the  child  is  suffering  from  no 
sequelae.  Other  children  in  the  household  should  not  be  allowed  to  attend 
schools  of  any  kind  during  the  period  of  active  symptoms;  they  should 
be  kept  at  home  on  the  average  for  a  month.  This  precaution  is  neces- 
sary, first,  because  they  might  carry  the  disease  from  the  child  at  home; 
secondly,  because  otherwise  they  might  themselves  attend  school  while 
suffering  from  the  disease  in  a  very  mild  form  or  during  the  period  of 
invasion.  AMicn  (lie  sick  child  is  com])letely  isolated,  the  danger  from 
the  first  source  is  very  slight.  During  severe  epidemics  it  frequently 
becomes  necessary  to  close  all  schools. 


956  THE  SPECIFIC  INFECTIOUS  DISEASES. 

During  desquamation  the  spread  of  the  disease  may  be  in  a  measure 
prevented  by  the  free  use  of  inunctions  and  warm  antiseptic  baths.  All 
the  excreta  from  the  patient  should  be  disinfected  throughout  the 
disease,  best  by  a  carbolic  solution  (1  to  20).  If  cases  of  scarlet  fever 
are  to  be  transported,  this  should  be  done  only  in  a  vehicle  Avhich  can 
be  easily  disinfected.  Under  all  circumstances  as  few  persons  as  pos- 
sible should  come  in  contact  with  the  patient. 

In  general,  it  is  to  be  remembered  that  the  danger  is  first  from  the 
patient,  secondly  from  the  room,  and  thirdly  from  the  nurse.  Special  at- 
tention should  always  be  given  to  the  complete  and  immediate  isolation 
of  the  first  case  which  appears  in  an  institution  or  community,  which 
should  apply  to  mild  as  well  as  the  severe  forms  of  the  disease. 

Treatment. — There  is  as  yet  no  specific  for  scarlet  fever,  so  that  the 
treatment  is  one  of  symptoms  and  complications.  Mild  attacks  require 
no  medicine  whatever.  Children  should  be  kept  in  bed  for  at  least  a 
week  after  the  fever  has  subsided,  and  upon  fluid  diet  for  a  period  of  three 
weeks.  This  is  an  important  matter  in  the  prevention  of  nephritis. 
During  the  height  of  the  eruption,  the  intense  itching  of  the  skin  may 
be  allayed  by  sponging  with  a  weak  carbolic-acid  solution,  or  by  in- 
unctions with  vaseline,  or  by  the  free  use  of  rice  powder.  Plenty  of  fresh 
air  should  always  be  secured  in  the  sick-room.  As  soon  as  the  fever 
and  rash  have  disappeared,  daily  Avarm  baths  with  soap  and  water  should 
be  used,  after  which  the  entire  body  should  be  anointed  with  carbolized 
vaseline  or  a  one-per-cent  ichthyol  ointment,  or  boric  acid  and  vaseline, 
five  per  cent  strength,  with  the  two-fold  purpose  of  facilitating  desquama- 
tion and  disinfecting  the  scales.  In  case  the  skin  becomes  irritated  by 
this  treatment,  bran  baths  may  be  substituted  for  soap  and  water.  The 
diet  requires  careful  attention  in  all  cases.  With  the  exception  mentioned 
above,  it  should  be  regulated  as  in  other  forms  of  severe  illness  (page 
222). 

The  temperature  does  not  usually  require  interference  when  it  only 
occasionally  rises  to  104°  or  104-5°  F.  But  if  there  is  hyperpyrexia,  or  a 
temperature  which  ranges  from  104°  to  105-5°  F.  or  over,  antipyretic 
measures  are  called  for.  Cold  is  much  safer  and  more  certain  than  drugs. 
Sometimes  cold  sponging  is  sufficient,  but  ip  the  great  proportion  of  cases 
the  cold  pack  or  the  evaporation  bath  (pages  47,  48)  is  required.  These 
are  almost  as  efficient  as  the  tub  bath,  and  usually  meet  with  less  opposi- 
tion on  the  part  of  the  parents.  The  use  of  cold  in  the  reduction  of  tem- 
perature is  especially  indicated  in  septic  cases  with  typhoid  symptoms, 
and  in  those  with  pronounced  cerebral  symptoms.  Where  these  are  severe 
the  bath  should  always  be  used,  and  repeated  with  sufficient  frequency  to 
keep  the  temperature  below  104°  F. 

The  nervous  symptoms  are  frequently  better  controlled  by  ice  to  the 
head  and  by  cold  sponging  than  by- medication.    Antipyretic  drugs  may 


SCARLET  FEVER.  957 

be  relied  upon  to  control  restlessness  and  promote  sleep,  and  in  mild 
cases  to  effect  a  moderate  reduction  in  temperature  when  this  is  accom- 
jDanied  by  great  discomfort.  Phenacetine  is  usually  to  be  preferred.  For 
the  nervous  symptoms  occurring  in  nephritis,  as  stated  elsewhere,  opium 
is  to  be  used. 

As  soon  as  the  pulse  becomes  weak  or  rapid  and  irregular,  or  the 
first  sound  of  the  heart  feeble,  stimulants  should  be  given,  no  matter  at 
what  stage  of  the  disease.  In  mild  or  moderately  severe  cases  they  are 
not  generally  required.  In  septic,  or  malignant  cases,  or  in  those  ac- 
companied by  severe  angina,  adenitis,  or  cellulitis,  alcoholic  stimulants 
should  be  used  freely.  Digitalis  is  next  in  value  to  alcohol,  and  is  especially 
indicated  when  the  pulse  is  weak  and  the  tension  low.  The  fluid  extract 
may  be  given  to  a  child  five  years  old  in  minim  doses,  four  times  a  day 
in  the  beginning,  and  later,  if  necessary,  with  greater  frequency. 
Strychnine  is  also  useful,  and  may  be  combined  with  digitalis  or  given 
separately,  the  usual  initial  dose  being  gr.  ^^  to  a  child  of  five  years. 

The  erythematous  sore  throat  requires  no  treatment  except  the  use 
of  a  mild  antiseptic  gargle.  If  there  is  a  profuse  nasal  discharge,  gentle 
nasal  syringing  (page  56)  with  a  warm  saline  or  boric-acid  solution 
may  be  used  with  the  hope  of  preventing  infection  of  the  middle  ear.  The 
local  treatment  of  the  membranous  angina  is  the  same  as  that  of  other 
cases  of  pseudo-diphtheria.  Gangrenous  inflammation  of  the  tonsils  or 
palate  is  sometimes  benefited  by  injections  of  a  10-per-cent  solution  of 
carbolic  acid  in  glycerin,  but  most  such  cases  prove  fatal,  no  matter  what 
the  treatment. 

Milder  forms  of  adenitis  require  no  local  treatment.  T\n^ien  severe, 
the  glands  should  be  covered  with  ichthyol  ointment,  and  an  ice-bag 
applied  continuously.  Poulticing  almost  invariably  does  more  harm 
than  good,  and  favours  suppuration.  If  an  abscess  forms,  early  incision 
should  be  practised. 

It  is  doubtful  whether  otitis  can  be  prevented  by  any  form  of  local 
treatment.  My  experience  has  been  that  it  rarely  occurs  in  cases  with 
mild  throat  symptoms,  but  that  where  they  are  severe  it  almost  invari- 
ably follows,  whatever  the  treatment  employed.  The  indications,  how- 
ever, are  to  keep  the  rhino-pharynx  as  clean  as  possible  by  syringing  the 
mouth  and  nose.  The  indications  for  early  paracentesis  of  the  drum 
membrane  are  the  same  as  in  other  severe  forms  of  otitis.  The  treat- 
ment of  scarlatinal  nephritis  has  been  considered  in  the  chapter  devoted 
to  Diseases  of  the  Kidney.  Diffuse  cellulitis  of  the  neck  calls  for  free 
early  incisions  as  the  only  means  of  preventing  extensive  sloughing. 
The  use  of  the  streptococcus  serum  with  the  purpose  of  combating 
severe  septic  symptoms  has  not  yet  given  such  results  as  to  encourage 
one  to  continue  its  use. 

During  convalescence,  tonics,  particularly  iron  and  digitalis,  are 
62 


958  THE  SPECIFIC  INFECTIOUS  DISEASES. 

called  for.  The  urine  should  be  frequently  examined  for  a  long  time; 
antiseptic  gargles  and  a  nasal  spray  or  syringe  should  be  used  as  long 
as  a  purulent  discharge  from  the  nose  or  pharynx  continues. 


CHAPTEE  II. 

MEASLES. 
Synonyms :  Rubeola,  Morbilli. 

Measles  is  an  epidemic  contagious  disease,  more  widely  prevalent 
than  any  other  eruptive  fever ;  very  few  persons  reach  adult  life  without 
contracting  it.  One  attack  usually  confers  immunity.  It  is  highly  con- 
tagious even  from  the  beginning  of  the  invasion,  and  spreads  with  great 
rapidity  from  the  patient  to  all  susceptible  persons  exposed.  The  poison,, 
however,  does  not  cling  so  long  to  clothing  or  apartments  as  does  that  of 
scarlet  fever.  Measles  has  a  period  of  incubation  of  from  eleven  to  four- 
teen days;  a  gradual  invasion  of  three  or  four  days  with  symptoms  of 
an  acute  coryza ;  a  maculo-papular  eruption  which  appears  first  upon  the 
face  and  spreads  slowly  over  the  body,  and  which  lasts  from  four  to  six 
days.  This  is  followed  by  a  fine  bran-like  desquamation,  which  is  com- 
plete in  about  a  week.  The  mortality  is  low,  except  among  infants  and 
delicate  children,  in  whom  it  may  reach  30  or  even  40  per  cent.  In 
institutions  for  infants  and  young  children  no  disease  is  more  to  be 
dreaded  than  measles,  not  only  on  account  of  its  severity,  but  from 
the  frequency  with  which,  in  such  subjects,  it  is  complicated  by  broncho- 
pneumonia. 

Etiology. — The  essential  cause  of  measles  is  as  yet  unknown.  It  is 
generally  believed  to  be  due  to  a  micro-organism,  but,  as  in  the  case  of 
scarlatina,  all  attempts  to  isolate  it  have  thus  far  been  unsuccessful.  The 
poison  is  one  which  possesses  remarkable  powers  of  diffusion,  but  whose 
viability  is  much  less  than  that  of  most  of  the  pathogenic  germs  which 
are  known.  Only  a  short  exposure  is  required  to  communicate  the  dis- 
ease, and  even  close  proximity  to  a  patient  does  not  seem  necessary.  One 
instance  has  come  under  my  own  observation  where  measles  was  appar- 
ently conveyed  by  an  exposure  of  half  an  hour  across  a  hospital  ward,  a 
distance  of  at  least  fifteen  feet. 

Predisposition. — Very  young  infants  do  not  so  readily  contract  mea- 
sles, but  all  other  children  are  extremely  susceptible.  The  disease  broke 
out  in  a  cottage  of  the  New  York  Infant  Asylum  which  was  occupied  by 
twenty-three  children,  nearly  all  of  them  being  under  two  years  old; 
only  four  escaped,  all  these  being  under  five  months  old.  In  an  epi- 
demic reported  by  Smith  and  Dabney,  110  unprotected  children,  between 
the  ages  of  eight  and  eighteen  years,  were  exposed  and  only  two  escaped. 


MEASLES.  959 

In  the  iSTiirsery  and  Child's  Hospital,  during  the  epidemic  of  1892,  there 
were  62  children  over  two  years  of  age;  five  were  protected  by  a  previous 
attack  and  escaped;  of  the  remaining  57  children,  55  took  the  disease. 
There  were  also  in  the  institution  113  children  under  two  years  old;  of 
this  number  78  per  cent  took  the  disease;  but,  although  a  number  were 
exposed,  not  one  child  under  six  months  old  contracted  measles.  The 
age  of  the  persons  affected  depends  much  upon  the  length  of  time  since 
the  last  outbreak  of  the  disease.  In  an  epidemic  occurring  in  the  Island 
of  Guernsey,  where  the  disease  had  not  prevailed  for  many  years,  all  ages 
were  affected,  the  youngest  being  twelve  days  old,  and  the  oldest,  a  man 
and  wife,  each  aged  eighty  years.  Somer  has  reported  an  instance  of 
an  eruption  of  measles  appearing  in  a  child  twelve  hours  after  birth; 
the  mother  was  suffering  from  the  disease  at  the  time.  Gautier  has  col- 
lected six  additional  eases,  where  measles  either  existed  at  the  time  of 
birth  or  developed  within  a  few  hours  after  it. 

Except,  then,  in  early  infancy,  the  probabilities  are  very  strong  that 
every  child  exposed  to  measles  will  contract  the  disease.  Occasionally, 
however,  one  is  seen  who  seems  insusceptible  to  the  poison,  no  matter 
how  close  the  exposure. 

Epidemics  of  measles  are  more  frequent  and  more  severe  during  the 
spring  months.  They  are  least  frequent  and  mildest  during  the  autumn 
months. 

Incubation. — In  144  cases,*  in  which  the  period  of  incubation  could 
be  definitely  traced,  it  was  as  follows: 

Incubation  of  less  than  nine  days 3  cases. 

"  "   nine  or  ten  days 22      " 

"  "   eleven  to  fourteen  days.  95     " 

"  "   fifteen  to  seventeen  days 19     " 

"  "   eighteen  to  twenty-two  days 5      " 

Thus  in  &Q  per  cent  of  the  cases  the  incubation  was  between  eleven  and 
fourteen  days,  and  in  only  one  case  was  it  less  than  a  week.  The  con- 
stancy of  the  incubation  period  is  strikingly  shown  in  some  epidemics. 
Thus  in  the  one  reported  by  Smith  and  Dabliey  in  an  institution  in  Vir- 
ginia, exactly  eleven  days  after  the  rash  appeared  in  the  first  case,  the 
disease  developed  in  twenty  children — no  cases  having  occurred  in  the 
interval. 

Duration  of  the  infective  period. — This  is  much  shorter  than  in  scar- 
let fever,  and  the  average  duration  may  be  placed  at  three  weeks.  Haig- 
Brown  discharged  fifty-eight  cases  on  or  before  the  twenty-ninth  day 
of  the  disease,  and  in  no  instance  was  measles  spread  by  these  children. 

*  About  twenty-five  of  these  are  taken  from  my  own  records ;  the  remainder  are 
mainly  isolated  cases,  scattered  through  medical  literature.  The  incubation  is  reck- 
oned from  the  time  of  exposure  to  the  beginning  of  the  catarrh. 


960  THE  SPECIFIC  INFECTIOUS  DISEASES. 

Eansom,  however,  records  one  instance  in  which  it  was  communicated 
■thirty-one  days  after  the  appearance  of  tlie  rash. 

Measles  is  highly  contagions  from  the  beginning  of  the  catarrhal 
symptoms.  A  case  occurred  in  the  Babies'  Hospital  under  my  own  ob- 
servation, in  which  a  child  conveyed  the  disease  four  days  before  the  rash 
appeared.  Ransom  reports  another  precisely  similar.  An  instance  has 
been  related  to  me  by  Dr.  S.  W.  Lambert,  where,  of  thirteen  little  girls 
who  were  at  a  children's  party,  only  one  escaped  measles,  the  source  of 
infection  being  a  child  who  showed  no  rash  until  the  following  day ;  the 
child  who  escaped  had  previously  had  measles.  The  period  of  greatest 
contagion  is  still  a  matter  of  dispute,  the  general  belief  being  that  it  is 
coincident  with  the  highest  temperature,  the  full  eruption,  and  the  most 
severe  catarrhal  symptoms. 

With  the  fading  of  the  eruption  and  the  subsidence  of  the  catarrh,  the 
communicability  of  measles  diminishes  rapidly.  It  is  relatively  feeble 
during  desquamation,  and  soon  after  this  period  it  usually  ceases  alto- 
gether. It  is  generally  proportionate  to  the  severity  of  the  catarrhal 
symptoms,  and  where  these  are  protracted  it  is  probable  that  the  disease 
may  be  communicated  for  a  much  longer  period  than  that  mentioned. 

Mode  of  infection. — Measles  is  usually  spread  by  direct  contagion,  very 
infrequently  through  the  medium  of  clothing,  furniture,  or  a  third  person. 
Townsend  (Boston)  records  an  instance  in  which  one  family  moved  into 
a  tenement  house  on  the  same  day  on  which  it  was  vacated  by  another 
family  in  which  two  children  had  suffered  from  measles,  one  of  them 
fourteen  and  the  other  eighteen  days  previously.  The  apartments  were 
not  fumigated  or  disinfected,  and,  although  there  were  two  susceptible 
children  in  the  incoming  family,  they  did  not  contract  the  disease. 
Measles  rarely  if  ever  clings  to  apartments  for  weeks  or  months,  as  does 
scarlet  fever.  Many  instances  are  on  record  in  which  the  disease  has  been 
carried  by  a  third  person;  but,  after  all,  this  rarely  happens,  unless  the 
contact  both  with  the  sick  and  the  well  child  is  very  close  and  the  interval 
short.  It  is  very  seldom  that  measles  is  carried  by  a  physician  who  takes 
even  ordinary  precautions.  .  In  a  case  reported  by  Girom,  the  clothing 
of  a  patient  is  stated  to  have  conveyed  the  disease  nineteen  days  after  an 
attack,  but  this  must  be  regarded  as  very  exceptional. 

Lesions. — The  only  constant  lesions  of  measles  are  those  of  the  skin 
and  the  mucous  membranes,  chiefly  of  the  respiratory  tract.  According 
to  Neumann,  the  process  in  the  skin  is  of  an  inflammatory  character,  but 
is  more  superficial  than  in  scarlet  fever.  There  is  congestion,  accom- 
panied by  an  exudation  of  round  cells  about  the  small  blood-vessels,  and 
also  about  the  sweat  and  sebaceous  glands,  and  the  papilla.  To  this 
exudation  and  the  oedema,  the  swelling  of  the  skin  is  due.  It  occurs 
everywhere,  but  is  especially  noticeable  upon  the  face. 

The  changes  in  the  mucous  membranes  are  quite  as  much  a  part  of 


MEASLES.  961 

the  disease  as  are  those  of  the  skin.  There  is  a  catarrhal  inflammation 
affecting  the  conjunctivae,  nose,  pharynx,  larynx,  trachea,  and  large 
bronchi,  which  varies  in  intensity  with  the  severity  of  the  attack.  In  the 
most  severe  forms  in  infants  and  in  young  children,  this  inflammation 
extends  with  great  uniformity  to  the  small  bronchi,  and  usually  to  the 
air  vesicles,  causing  broncho-pneumonia.  In  severe  cases,  the  lesion  in 
the  pharynx  and  larynx  also,  instead  of  being  catarrhal,  mav  be  mem- 
branous; the  larynx  being  much  more  frequently  involved,  and  the  ears 
much  less  so,  than  in  scarlet  fever.  Freeman  has  described  areas  of  focal 
necrosis  in  the  liver  similar  to  those  found  in  diphtheria;  thev  were 
present  in  four  of  twelve  cases  examined.  The  lesions  of  the  lungs  and 
of  other  organs  will  be  more  fully  considered  under  Complications. 

The  bacteria  which  are  associated  with  the  lesions  of  the  respiratory 
tract  are  the  staphylococcus  and  the  streptococcus,  separately  or  together, 
and  either  form  may  be  associated  with  the  pneumococcus  (see  Bac- 
teriology of  Broncho-Pneumonia,  page  538).  The  poison  of  measles  pro- 
duces conditions  in  the  mucous  membranes  of  the  respiratory  tract  which 
are  especially  favourable  for  the  development  of  these  bacteria.  They 
are  present  in  the  mouth  in  great  numbers ;  they  may  cause  pneumonia, 
otitis,  and  other  local  inflammations,  and  the  pneumococcus  or  strepto- 
coccus may  produce  a  general  septicaemia. 

Symptoms. — Invasion. — As  a  rule,  the  invasion  of  measles  is  gradual, 
both  the  fever  and  catarrhal  symptoms  increasing  steadily  up  to  the  ap- 
pearance of  the  eruption.  The  characteristic  symptoms  of  the  invasion 
are  those  of  a  severe  coryza — suffusion  of  the  eyes,  increased  lachryma- 
tion,  photophobia,  sneezing,  and  a  discharge  from  the  nose.  The  hoarse, 
hard  cough  indicates  that  the  catarrhal  process  has  involved  the  larynx 
and  trachea,  as  well  as  the  visible  mucous  membranes.  Frequently  the 
patient  complains  of  some  soreness  of  the  throat,  and  on  inspection  there 
is  seen  moderate  congestion  of  the  tonsils,  fauces,  and  pharynx.  On  the 
hard  palate  are  frequently  seen  small  red  spots.  Much  more  character- 
istic are  the  minute  white  spots  upon  the  mucous  membrane  of  the  cheeks, 
known  as  Koplik's  sign  (see  Diagnosis).  The  constitutional  symptoms 
are  indefinite,  and  may  be  met  with  in  almost  any  disease.  There  is 
dulness,  headache,  pains  in  the  back,  and  the  usual  symptoms  of  malaise; 
there  is  rarely  vomiting  or  diarrhoea.  Drowsiness  is  a  frequent  symptom, 
and  is  regarded  by  the  laity  as  characteristic. 

The  exceptional  cases  in  which  the  invasion  is  abrupt  are  puzzling. 
There  may  be  a  sudden  accession  of  fever  with  vomiting,  and  even  con- 
vulsions, as  in  a  case  lately  under  my  observation.  Not  infrequent!}'', 
when  the  disease  prevails  epidemically,  the  invasion  is  sudden,  with  high 
fever  and  pulmonary  symptoms  which  are  so  severe  as  to  mask  every- 
thing else  until  the  rash  makes  its  appearance,  the  case  up  to  that  time 
being  often  regarded  as  one  of  primary  pneumonia  or  of  influenza.     The 


962  THE   SPECIFIC  INFECTIOUS  DISEASES. 

duration  of  the  stage  of  invasion — i.  e.,  from  the  beginning  of  the  ca- 
tarrh until  the  eruption — in  270  cases  of  which  I  have  notes,  was  as 
follows : 


1  day  or  less 35  eases. 

2  days 47     " 

3  *'    64     " 

4  "    64     " 

5  "    29      " 


6  days 20  cases. 

7  "    6      " 

8  "    2      " 

9  "    2      " 

10    "    1  case. 


From  this  table  it  will  be  seen  that  the  length  of  the  period  of  invasion 
varies  considerably — more,  I  think,  in  infants  and  very  young  children 
(most  of  these  were  under  three  years  old)  than  in  those  who  are  older. 
In  the  greater  number  of  cases  it  lasts  from  two  to  four  days. 

Eruption. — The  rash  usually  appears  on  the  third,  fourth,  or  fifth  day 
of  the  disease — in  the  largest  number  upon  the  fourth  day.  As  a  rule,  it 
is  first  seen  behind  the  ears,  on  the  neck,  or  at  the  roots  of  the  hair  over 
the  forehead.  It  appears  as  small,  dark-red  spots,  which  are  at  first  few, 
scattered,  and  not  elevated,  resembling  flea-bites.  In  twenty-four  hours 
the  macules  are  much  more  numerous,  and  many  of  them  have  become 
papules.  They  frequently  group  themselves  in  crescentic  forms.  They 
are  usually  separated  by  areas  of  normal  skin,  but  where  the  rash  is  in- 
tense they  are  frequently  coalescent.  From  the  time  of  its  first  appear- 
ance to  the  full  development  of  the  rash  on  the  face,  is  usuall}^  about 
thirty-six  hours,  but  may  be  from  one  to  three  days.  With  a  full  erup- 
tion there  is  considerable  swelling  of  the  face,  especially  about  the  eyes, 
and  the  features  are  sometimes  scarcely  recognisable.  On  the  second 
day  of  the  rash  it  begins  to  appear  upon  the  neck  beneath  the  chin,  the 
upper  part  of  the  chest  and  back ;  on  the  third  day  the  trunk  is  covered, 
and  scattered  spots  are  seen  upon  the  extremities.  The  rash  appears 
last  upon  the  lower  extremities,  and  by  the  time  it  is  fully  out  upon 
them  it  has  usually  begun  to  fade  from  the  face.  In  mild  cases  it  remains 
discrete,  but  in  severe  ones  it  is  frequently  confluent  upon  the  face  and 
upon  the  extensor  surfaces  of  the  extremities.  As  a  rule,  it  covers  the 
entire  body,  even  the  palms  and  soles. 

The  eruption  fades  slowly  in  the  order  of  its  appearance,  and  there  is 
left  behind,  in  typical  cases,  a  slight  brownish  staining  of  the  skin,  which 
often  remains  for  a  week  or  more.  The  duration  of  the  rash  is  from  one 
to  six  days,  the  average  being  four  days. 

There  are  many  cases  in  which  the  rash  does  not  follow  the  typical 
course  described:  (1)  Instead  of  spreading  graduall}^,  the  entire  body 
may  be  covered  in  a  few  hours.  .  (2)  The  rash  may  be  hasmorrhagic. 
This  condition  was  present  in  about  five  per  cent  of  my  cases.  The 
whole  eruption  may  be  hasmorrhagic,  or  it  may  be  so  only  upon  certain 
parts — usually  the  abdomen  or  extremities.  Under  such  circumstances 
small  petechial  spots  take  the  place  of  the  macules — the  "  black  measles  " 


MEASLES.  963 

of  the  older  writers.  It  is  in  most  cases  a  bad,  but  by  no  means  a 
fatal  symptom.  I  have  seen  it  in  several  eases  that  were  not  especially 
severe.  (3)  The  rash  may  be  very  faint,  and  of  short  duration,  being 
scarcely  elevated  at  all.  (i)  It  may  consist  of  very  minute  papules, 
closely  resembling  the  rash  of  scarlet  fever.  It  is  to  be  remembered,  how- 
ever, that  the  irregular  eruptions  of  scarlet  fever  much  more  frequently 
resemble  measles  than  vice  versa.  (5)  It  may  be  very  scanty,  and  late  in 
its  appearance ;  particularly  in  cases  of  great  severity  and  hyperpyrexia — 
the  so-called  malignant  cases.  (6)  Temporary  recession  of  the  erup- 
tion may  occur  at  any  time  during  the  height  of  the  disease,  and  is  usually 
due  to  heart  failure.  A  recurrence  of  the  eruption  after  it  has  run  its 
usual  course  is  something  which  I  have  never  seen ;  although  such  cases 
have  been  reported,  I  believe  them  to  be  very  exceptional. 

During  the  first  two  days  of  the  eruption,  the  local  and  constitutional 
symptoms  increase  in  severity,  both  usually  reaching  their  maximum  at 
the  time  of  the  full  development  of  the  rash  upon  the  face.  The  skin 
is  swollen,  and  the  seat  of  intense  itching  and  burning.  The  eyes  are 
very  red  and  sensitive  to  light,  and  there  is  swelling  of  the  conjunctivae 
with  an  abundant  production  of  mucus  or  muco-pus,  causing  the  lids  to 
adhere.  There  is  pain  on  swallowing,  also  swelling  of  the  glands  at  the 
angle  of  the  jaw  or  in  the  post-cervical  region.  The  cough  is  frequent 
and  very  annoying.  There  is  complete  anorexia,  and  often  diarrhoea. 
The  tongue  is  coated,  and  may  show  at  its  margin  enlarged  papillae, 
somewhat  resembling  the  "  strawberry "  appearance  of  scarlet  fever. 
As  the  rash  fades  the  temperature  declines  rapidly,  often  reaching  the 
normal  in  two  or  three  days.  The  catarrhal  symptoms  now  subside,  and 
soon  the  patient  is  convalescent.  Within  a  day  or  two  after  the  fever 
has  ceased,  the  rash  disappears. 

Desqvamation. — This  begins  almost  as  soon  as  the  rash  has  subsided, 
and  is  first  noticed  on  the  face  and  neck,  where  the  eruption  first  ap- 
peared. The  nature  of  the  desquamation  is  invariably  fine,  branny  scales, 
never  in  large  patches,  as  in  scarlet  fever.  It  is  often  quite  indistinct 
and  may  be  overlooked.  Its  usual  duration  is  from  five  to  ten  days.  It 
may,  however,  be  prolonged  for  two  weeks.  The  amount  of  desquamation 
varies  considerably  in  the  different  cases.  It  is  most  marked  in  those  in 
which  there  has  been  an  intense  eruption.  There  is  frequently  noticed 
at  this  time  an  odour  about  the  patient  which  is  quite  characteristic  of 
measles.  During  this  stage  the  cough  often  persists  and  the  eyes  remain 
weak  and  very  sensitive  to  light,  but  in  other  respects  the  patient  usually 
feels  perfectly  well. 

1.  The  mild  cases. — The  mildest  cases  are  distinguished  by  low  tem- 
perature, which  at  the  height  of  the  eruption  usually  reaches  102°  F.,  1)ut 
rarely  lasts  more  than  four  days.  Tbc  eruption  is  often  scanty,  and  is 
never  confluent.     The  swelling,  itching,  and  other  cutaneous  symptoms 


964 


THE  SPECIFIC  INFECTIOUS  DISEASES. 


are  wanting,  as  is  also  the  intense  red  colour  of  the  skin.  The  rash  is 
frequently  obscure,  and,  without  the  other  symptoms,  hardly  sufficient 
for  diagnosis.  The  catarrhal  symptoms  are  more  uniform  than  the  rash, 
but  these  are  very  mild  as  compared  with  the  usual  form.  The  duration 
of  the  rash  is  shorter,  desquamation  is  scarcely  perceptible,  and  there  are 
no  complications. 

2.  The  cases  of  moderate  severity. — The  co.urse  of  measles  is  much 
more  regular  in  children  over  three  years  old  than  in  infancy.     In  the 


DAY 

1 

2 

3 

i 

5 

c 

7 

8 

I 

(r 

I 
< 

106° 

105° 

10i° 

103° 

102° 

101° 

100° 

99° 
98° 

M     E 

M      E 

M     E 

M     E 

M      E 

M     E 

M     E 

M     E 

X 
X 

h 

r 

A 

^ 

./ 

J 

/ 

V 

^ 

/ 

\^ 

"N, 

V/ 

DAY 

1 

2 

3 

i 

5 

6 

7 

s 

9 

t 

I 
Z 

X 

106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 
98° 

M      E 

U      E 

M      E 

M     E 

M     E 

M     E 

M     E 

M     E 

M     E 

X 

X 

X 

A 

h 

J 

A 

V 

\h 

A 

1/ 

L 

J\ 

J 

WA 

\y\ 

^ 

V 

A 

V 

u 

Fig.  177. 


Fig.  178. 


Fig.  177. — Temperature  curve  in  uncomplicated  measles,  showing  the  gradual  rise  and  critical 
fall ;  patient  ten  years  old ;   x  =  first  eruption ;   J  =  full  eruption  on  the  face. 

Fig.  178. — Typical  curve  in  uncomplicated  measles,  with  gradual  rise  and  gradual  fall ;  patient 
three  years  old. 

former,  the  symptoms  of  invasion  come  on  gradually,  and  the  tempera- 
ture rises  steadily  until  the  appearance  of  the  eruption,  which  is  in  most 
cases  on  the  third  or  fourth  day  of  the  disease.  Figs.  177  and  178  repre- 
sent the  typical  tempera- 
ture curve  in  average  un- 
complicated cases.  Such  a 
curve  v>^as  seen  in  44  per 
cent  of  173  cases  in  which 
careful  observations  were 
made.  Sometimes  the  de- 
cline in  the  fever  is  very 
rapid,  almost  a  crisis,  as  in 
Fig.  177,  but  more  often  it 
falls  gradually,  as  in  Fig. 
178.  In  '  such  cases  the 
duration  of  the  fever  is 
from  five  to  nine  days,  the 
average  being  about  a  week.  The  other  symptoms  follow  very  closely  the 
course  of  the  fever.  The  maximum  temperature  is  nearly  always  coinci- 
dent with  the  full  rash  upon  the  face,  at  this  time  usually  being  in  un- 


DAY 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

t 

I 
Z 

X 
< 

106° 
•105° 
10i° 
103° 
■102° 
.101° 
•100° 
99° 
98° 

M     E 

M      E 

M      E 

M      E 

M      E 

M      E 

M     E 

M     E 

M     E 

M     E 

M     E 

M      E 

X 

X 

X 

X 

/ 

\ 

A 

\ 

A 

/ 

V 

\ 

\ 

/ 

\ 

\ 

\ 

/ 

V 

\ 

v 

V 

,/ 

\/\ 

V 

A 

V 

V 

\ 

/ 

FiQ,  179. — A  not  infrequent  temperature  curve  in  mea- 
sles, showing  abrupt  invasion,  but  subsequent  course 
typical ;  uncomplicated  case ;  patient  nine  months 


w 


MEASLES. 


965 


complicated  cases  from  103°  to  10-i°  F.  in  older  children,  and  104°  to  105° 
in  infants  and  young  children. 

A  not  very  -uncommon  temperature  curve  is  that  of  Fig.  179,  where 
the  onset  of  the  disease  is  marked  by  a  sudden  rise  to  102°  or  even  104° 
F.,  with  a  fall  nearly  or  quite  to  normal  on  the  second  day,  after  which 
the  fever  rises  graduall}^,  as  in  the  first  group.  This  curve  was  seen  in 
5  per  cent  of  my  cases. 

3.  The  severe  cases. — In  Fig.  180  is  shown  a  type  of  the  disease  which 
is  more  frequent  in  infants  than  in  older  children,  the  important  features 
being  the  late  eruption  and  the  continuance  of  the  high  fever  for  several 
days  after  the  rash  has  begun  to  fade.  Such  a  prolonged  course  and  so 
high  a  temperature  are  almost  invariably  due  to  some  complication, 
usually  broncho-pneumonia.  Where  the  pneumonia  goes  on  to  the  pro- 
duction of  areas  of  consolidation,  the  fever  usually  continues  for  three 
and  sometimes  for  four  weeks,  even  though  terminating  in  recovery. 


DAY 

1 

2 

3 

i 

5 

c 

7 

8 

9 

10 

11 

12 

13 

u 

15 

16 

17 

I 

I 
< 

M     E 

M    e 

M      E 

M      E 

M     E 

M     E 
X 

"." 

M      E 

M     E 

M     E 

M     E 

M     E 

M     E 

M     E 

M     E 

M      E 

M     E 

105° 
1M° 
103" 
102" 
101° 
100° 
99° 
98° 

X 

" 

A 

A 

/ 

1 

% 

\ 

/ 

\n 

f 

,/ 

F 

,/^ 

A 

A 

A 

h 

/ 

V 

\l 

V 

/ 

V 

V 

V  ' 

\ 

f\ 

/ 

J 

Y 

/ 

I 

,/ 

/ 

y 

y 

\ 

A 

/ 

^, 

y 

1/ 

V 

V 

V 

^/^ 

>(  ^ 

V 

Fig.  180. — Measles  with  prolonged  invasion;  continuance  of  high  temperature  after  full  erup- 
tion due  to  severe  bronchitis  and  diarrhoea ;  child  two  years  old. 


Figs.  181  and  182  illustrate  two  types  of  the  disease  which  are  often 
seen  when  measles  is  complicated  by  pneumonia.  In  cases  like  that  shown 
in  Fig.  181  the  onset  is  abrupt  with  high  temperature,  prostration,  and 
pulmonary  symptoms  not  unlike  those  of  primary  pneumonia.  A  tem- 
perature curve  resembling  this  was  seen  in  28  of  173  cases.  The  rash  is 
often  late  in  appearance;  it  is  faint  and  altogether  irregular;  it  may 
recede  after  the  first  day  and  reappear  after  an  interval  of  one  or  two 
days.  The  catarrhal  symptoms  are  not  marked,  but  the  whole  force  of 
the  disease  seems  to  be  expended  upon  the  lungs.  The  diagnosis  of  these 
cases  presents  great  difficulties,  and  very  often  it  would  not  be  made 
but  for  the  fact  that  there  are  other  cases  of  measles  in  the  family  or 
the  institution.  This  form  is  usually  seen  in  infants,  and  it  is  usually 
fatal. 

In  otiier  cases  marked  by  a  siuldon  severe  onset,  the  system  seems  to 
be  overpowered  by  the  poison  of  the  disease  itself.     There  is  profound 


966 


THE  SPECIFIC  INFECTIOUS  DISEASES. 


depression,  and  hyperpyrexia,  and  the  patient  may  die  from  toxemia  with 
cerebral  symptoms  before  the  appearance  of  the  rash  or  just  as  it  is  begin- 
ning to  show  itself.  Sometimes  the  pulmonary  symptoms  are  entirely 
wanting ;  at  others  the  rash,  if  it  appears,  is  hsemorrhagic. 

In  still  another  group  of  cases  the  onset  is  not  violent,  and  for  the 
first  two  days  the  attack  may  appear  to  be  of  only  average  severity ;  but 
there  may  then  develop,  often  quite  sudden- 
ly, pulmonary  symptoms  of  such  intensity  as 


DAY 

1 

2 

3 

i 

5 

c 

7 

8 

9 

10 

t 

X 
Z 
UI 

I 
< 

106° 
105° 
lOi- 
103" 
102° 
101° 
100° 
99° 
98° 

M     E 

M      E 

M      E 

M      E 

M    E 

M     E 

M     E 

M      E 

M      E 

M      E 

X 

J 

A 

/ 

A 

/ 

\ 

^\\ 

J 

V 

\r 

V 

1 

/ 

V 

V 

V 

V 

V 

/ 

V 

V 

1 

DAY                    1 

1 

2 

3 

i 

0 

M     E 

M     E 

M     E 

M     E 

M     E 

108 

„ 

I 

X 

106° 

B 

f 

l/ 

H 

105 

1 

J 

/ 

w 

\ 

I 
Z 

I 
< 

104 
103^ 

/ 

V 

/ 

I 

/^ 

/ 

102 
101° 

-T 

t 

100° 

/ 

99° 

98° 

1 

Fig.  181. 


Fig.  182. 


Fig.  181. — Fatal  attack  of  measles,  complicated  by  broncho-pneumonia;  very  severe  symptoms 

from  the  onset ;  patient  eighteen  months  old ;  death  on  tenth  day. 
Fig.  182. — Fatal  attack  of  measles,  complicated  by  broncho-pneumonia ;  early  invasion  mild, 

but  rapid  development  of  severe  symptoms  on  fourth  day  ;  rash  on  last  day ;  patient  eight 

months  old. 

to  cause  death  within  twenty-four  hours.     The  eruption,  if  seen  at  all, 
is  faint  and  not  characteristic  (Fig.  183). 

A  secondary  rise  in  the  temperature  after  it  has  once  fallen  to  normal 
was  seen  in  8  of  173  cases,  being  due  to  the  development  of  otitis,  ileo- 
colitis, or  pneumonia. 

Complications  and  Sequelae. — The  most  frequent  and  most  important 
complication  of  measles  is  broncho-pneumonia,  and  next  to  this  are  ileo- 
colitis, otitis,  and  membranous  larjmgitis.     Most  of  the  others  are  in- 
frequent; all  complications  are  relatively  rare  in  children  over  four. 
yep.rs  old. 

Lungs. — The  greatest  danger  in  measles  arises  from  pulmonary  com- 
plications, and  the  frequency  is  greatest  in  children  under  two  years  of 
age.  In  two  epidemics  in  the  Nursery  and  Child's  Hospital,  em- 
bracing about  300  cases,  nearly  all  in  children  under  three  3''ears  old, 
broncho-pneumonia  occurred  in  about  40  per  cent  of  the  cases.  Of  those 
who  had  pneumonia,  70  per  cent  died.  Fortunately,  such  a  record  as  this 
is  never  seen  outside  of  asylums  or  hospitals  for  young  children.  Of 
2,477  cases,  embracing  several  epidemics  of  measles  among  children  of 
all  ages,  pneumonia  occurred  in  10  per  cent.  My  own  experience  in  the 
post-mortem  room,  fully  bears  out  the  statement  of  Henoch,  that  a  cer- 


MEASLES.  967 

tain  amount  of  pneumonia  is  found  in  almost  every  fatal  ease.  Pneu- 
monia is  more  frequent  and  its  mortality  is  higher  in  spring  and  winter 
epidemics  than  in  those  occurring  at  other  seasons.  It  may  develop  at 
any  time  from  the  beginning  of  invasion  until  convalescence,  but  it 
mostly  frequently  begins  about  the  time  of  full  eruption. 

Lobar  pneumonia,  althougji  rare,  occasionally  occurs  as  a  complica- 
tion in  children  over  three  years  old.  In  some  epidemics  many  of  the 
cases  of  pneumonia  are  complicated  by  severe  pleurisy,  which  adds  much 
to  the  danger  from  the  disease.  This  form  is  frequently  followed  by 
empyema.  Pneumonia  is  always  to  be  suspected  when  the  temperature 
continues  high  after  the  full  appearance  of  the  rash. 

Bronchitis  of  the  large  tubes,  always  accompanied  by  tracheitis,  is 
seen  in  every  case  of  measles,  possibly  excepting  a  few  of  the  very  mild- 
est. This  is  so  constant  a  feature  as  hardly  to  be  ranked  as  a  complica- 
tion. In  nearly  all  of  the  severe  cases  the  bronchitis  extends  to  the  me- 
dium-sized and  smaller  tubes. 

Larynx. — K  mild  catarrhal  larj^ngitis  accompanies  almost  every  case 
of  measles.  Severe  catarrhal  laryngitis  is  present  in  about  ten  per  cent 
of  the  cases ;  it  may  give  symptoms  which  closely  resemble  those  of  mem- 
branous laryngitis,  and  the  two  are  no  doubt  often  confused.  (For  the 
points  of  differential  diagnosis  see  page  489.) 

Membranous  laryngitis  is  more  often  seen  as  a  complication  of 
measles  than  of  scarlet  fever.  It  is  especially  seen  in  the  epidemics  of 
institutions.  As  a  cause  of  death  in  older  children  it  ranks  next  to 
pneumonia.  When  it  develops  at  the  height  of  the  disease,  it  is  some- 
times due  to  the  streptococcus;  but  when  it  develops  at  a  later  period, 
it  is  usually  due  to  the  diphtheria  bacillus.  The  streptococcus  inflamma- 
tion is  in  most  cases  associated  with  similar  changes  in  the  pharynx  or 
tonsils,  but  not  always.  True  diphtheria,  occurring  as  a  complication 
of  measles,  not  infrequently  begins  in  the  larynx.  The  streptococcus  in- 
flammation may  be  as  serious  in  this  connection  as  is  true  diphtheria, 
from  the  probability,  which  amounts  almost  to  a  certainty,  of  the  devel- 
opment of  broncho-pneumonia.  No  complication  is  more  to  be  dreaded 
than  this.  The  diagnosis  between  the  true  and  pseudo-diphtheria  may 
sometimes  be  made  by  the  time  of  development,  but  only  with  certainty 
by  cultures.  I  once  saw  in  measles,  where  no  false  membrane  was  pres- 
ent in  the  rest  of  the  larynx,  a  necrotic  inflammation  with  almost  en- 
tire destruction  of  the  vocal  cords — a  condition  which  may  bo  compared 
to  that  seen  in  the  tonsils  or  epiglottis  in  scarlatina. 

Throat. — A  catarrhal  angina  is  part  of  the  disease,  and  is  as  charac- 
teristic of  measles  as  is  the  eruption  upon  the  skin.  There  is  acute  con- 
gestion and  swelling  of  the  tonsils,  uvula,  palate,  and  pharynx.  In  a 
certain  proportion  of  cases,  very  much  less  frequently  than  in  scarlatina, 
the  development  of  membranous  patches  is  seen  upon  the  tonsils  and  ad- 


968  THE   SPECIFIC   INFECTIOUS  DISEASES. 

jacent  nmcous  membranes.  These  occur  in  two  or  three  per  cent  of  the 
cases.  They  are  to  be  regarded  in  the  same  light  as  similar  conditions 
complicating  scarlet  fever,  with  these  differences,  that  in  measles  there 
is  much  greater  likeliliood  of  the  extension  of  the  disease  to  the  larynx, 
while  extension  to  the  nose  and  ears  is  much  less  probable.  True  diph- 
theria, however,  may  complicate  measles,  and  cases  of  membranous  in- 
flammation of  the  tonsils  or  pharynx  developing  late  in  measles  are 
ustally  due  to  the  Klebs-LoefQer  bacillus. 

Although  in  most  cases  the  inflammations  of  the  pharynx  and  tonsils 
which  accompany  measles  are  not  serious  when  they  are  due  to  the  strep- 
tococcus, they  are  sometimes  quite  as  severe  as  any  that  accompany  scarlet 
fever.  They  ma}'  cause  death  from  general  sepsis  apart  from  any  affec- 
tion of  the  larynx. 

Digestive  System. — Gastric  disorders  are  not  more  common  than  in 
other  febrile  diseases;  but  diarrhcea  is  very  frequent,  and  in  summer  it 
may  be  even  more  serious  than  the  pulmonary  complications.  All  forms 
of  diarrhoea  are  seen,  from  that  which  results  from  simple  indigestion  to 
the  severe  types  of  ileo-colitis.  This  complication  is  most  often  seen  in 
children  under  two  years  old.  The  most  severe  intestinal  symptoms  are 
not  usually  seen  at  the  height  of  the  primary  fever;  but,  beginning  at 
this  time,  they'  often  increase  in  severity,  and  are  most  marked  in  the 
second  and  third  weeks  of  the  disease. 

Catarrhal  stomatitis  is  present  in  almost  every  case  of  measles;  less 
frequently  the  herpetic  form  is  seen.  Ulcerative  stomatitis  is  not  uncom- 
mon, particularly  in  institutions.  One  of  the  worst  complications  of 
measles,  but  fortunately  a  rare  one,  is  gangrenous  stomatitis,  or  noma. 
This  usually  occurs  in  inmates  of  institutions,  or  in  children  with  bad 
surroundings  who  were  previously  in  wretched  condition.  It  is  nearly 
always  fatal. 

Gangrenous  inflammations  of  other  parts  of  the  body  are  sometimes 
seen  after  measles,  especially  of  the  ear,  the  vulva,  or  the  prepuce. 

Nervous  System. — I  have  seen  convulsions  at  the  onset  of  measles  in 
but  a  single  case.  During  the  progress  of  the  disease  they  are  not  so  rare', 
and  may  occur  in  connection  with  otitis,  meningitis,  or  severe  broncho- 
pneumonia— chiefly  in  infants. 

Meningitis  is  rare,  but  either  the  simple  or  the  tuberculous  form  may 
occur,  more  often,  however,  as  a  sequel  than  as  a  complication.  Insanity, 
usually  of  a  temporary  character,  occasionally  follows  measles.  In  the 
epidemic  of  108  cases  reported  by  Smith  and  Dabney.  insanity  was  noted 
three  times,  all  the  cases  terminating  in  recovery.  Epilepsy  and  chorea 
are  rare  sequelae. 

Ears. — Otitis  is  a  frequent  complication  in  some  epidemics ;  in  others 
it  is  seldom  seen.  In  one  hospital  epidemic  it  was  noted  in  14  per  cent 
of  the  cases.     This  epidemic  occurred  in  early  spring  and  affected  very 


MEASLES.  909 

young  children,  both  of  which  circumstances  are  favourable  for  the  devel- 
opment of  otitis.  Usually  both  ears  are  affected,  and  the  inflammation 
terminates  in  suppuration;  but  the  otitis  of  measles  is,  as  a  rule,  much 
less  serious  than  that  of  scarlet  fever,  and  much  less  frequently  leads  to 
permanent  impairment  of  hearing. 

Eyes. — Simple  catarrhal  conjunctivitis  accompanies  nearly  every  case 
of  measles.  In  the  severe  form  there  is  a  muco-purulent  catarrh,  which 
may  attain  any  degree  of  severity.  In  neglected  cases,  and  among  chil- 
dren who  are  poorly  nourished,  especially  in  asylums,  the  disease  is  apt  to 
extend  to  the  cornea.  In  a  very  large  number  of  cases  chronic  conjunc- 
tivitis persists  after  measles,  particularly  in  the  class  of  children  just 
mentioned. 

Lymph  nodes. — Swelling  of  the  lymphatic  glands  of  the  neck  is  fre- 
quent, but  not  generally  severe,  and  rarely  terminates  in  suppuration. 
In  a  considerable  proportion  of  cases  chronic  enlargement  persists  for 
months,  and  sometimes  the  glands  may  become  tuberculous.  Similar 
changes  and  similar  consequences  may  occur  in  the  glands  of  the  tracheo- 
bronchial group. 

Kidneys. — The  infrequency  of  renal  complications  in  measles  is  in 
striking  contrast  to  scarlet  fever.  Transient  febrile  albuminuria  is  not 
uncommon,  but  a  serious  degree  of  nephritis,  either  clinically  or  at  au- 
topsy, I  have  never  seen,  and  literature  furnishes  but  few  cases.  Demme 
and  Browning  have  each  reported  cases  of  nephritis  following  measles,  in 
which  death  occurred  from  uraemia. 

Heart. — Both  endocarditis  and  pericarditis  have  occurred  in  the 
course  of  measles,  but  they  belong  to  the  rare  complications.  The  same 
may  be  said  of  changes  in  the  muscular  walls  of  the  heart. 

Shin. — As  complications,  erysipelas,  furunculosis,  impetigo,  and  pem- 
phigus have  been  noted ;  but  all  are  rare. 

HcBmorrhages. — Associated  with  the  hasmorrhagic  type  of  the  erup- 
tion, severe  and  even  fatal  haemorrhages  may  occur  from  the  mucous 
membranes,  and  the  latter  are  sometimes  seen  without  the  hsemorrhagic 
eruption. 

Other  infectious  diseases. — Measles  in  institutions  is  often  compli- 
cated by  diphtheria.  Scarlet  fever  or  varicella  occasionally  occurs  during 
measles,  though  it  is  rare  that  the  two  eruptions  are  exactly  simultaneous. 
Epidemics  of  measles  and  whooping-cough  frequently  occur  together  or 
follow  each  other.  The  relation  of  measles  to  tuberculosis  seems  to  be 
particularly  close.  In  some  cases  general  or  pulmonary  tuberculosis 
follows  directly  in  the  wake  of  measles,  which  seems  to  furnish,  espe- 
cially in  the  lungs,  conditions  which  are  favourable  for  the  develop- 
ment of  latent  tuberculosis.  As  a  late  manifestation  the  most  com- 
mon one  is  tuberculosis  of  the  bones,  occurring  as  hip-joint  disease, 
caries  of  the  spine,  etc.     An  attack  of  measles  in  a  child  with  tuber- 


970  THE  SPECIFIC  INFECTIOUS  DISEASES. 

c-ulous  antecedents  should,  therefore,  always  be  looked  upon  with  ap- 
prehension. 

Diagnosis. — A  sign  of  the  greatest  diagnostic  value  is  the  buccal  erup- 
tion. Although  it  appears  that  this  was  described  many  years  ago  by 
Flindt,  of  Denmark,  it  is  to  Koplik,  of  Xew  York,  that  the  credit  belongs 
of  its  independent  discovery  and  publication  in  1896.  It  is  generally 
known  as  "  Koplik's  sign."  The  unit  of  the  eruption  is  a  bluish-white 
speck  upon  a  red  ground;  only  a  few  of  these  may  be  present  or  the 
mucous  membrane  may  be  fairly  peppered  with  them  (Plate  XVIII). 
Often  they  are  not  seen  except  by  careful  search  for  which  strong  sun- 
light is  necessary;  artificial  light  is  not  satisfactory.  The  spots  are  best 
seen  on  the  inside  of  the  cheeks  opposite  the  molar  teeth,  and  in  most 
cases  only  there;  but  they  may  be  present  on  almost  any  part  of  the 
buccal  mucous  membrane.  Their  diagnostic  value  is  due  to  the  fact 
that  they  are  nearly  always  present,  that  they  are  not  found  in  other 
diseases,  and  that  they  usually  appear  two  or  three  days  before  the  skin 
eruption.    They  generally  disappear  at  the  time  of  full  eruption. 

I  have  recently  had  an  opportunity  to  study  the  value  of  this  sign 
in  two  epidemics  of  measles  at  the  Xew  York  Foundling  Hospital.  Care- 
ful notes  were  kept  in  the  second  epidemic  of  18?  cases.  Koplik's  spots 
were  unmistakably  present  in  169  cases,  absent  in  8,  doubtful  in  10.  In 
78  cases,  fever,  rash,  and  Koplik's  spots  were  all  present  at  the  first  ob- 
servation. In  54  patients  the  sign  was  noted  one  day  before  the  rash ; 
in  25,  two  days  before ;  in  4,  three  days  before ;  in  3,  four  days  before ;  and 
in  2,  five  days  before.  In  2  the  spots  were  not  seen  until  after  the  skin 
eruption;  in  one  case  they  were  present  without  any  eruption.  As  this 
patient  had  been  exposed  and  had  a  prolonged  fever,  it  seems  fair  to. 
regard  the  case  as  one  of  measles.  In  only  one  case  was  the  buccal  erup- 
tion seen  before  any  elevation  of  temperature. 

These  facts,  amply  confirmed  by  other  observations,  indicate  that  Kop- 
lik's sign  is  of  value  in  enabling  us  to  make  a  diagnosis  from  one  to 
three  days  before  it  is  possible  by  the  skin  eruption,  also  in  furnishing 
a  new  means  of  distinguishing  measles  from  the  other  eruptive  fevers,  as 
well  as  from  rashes  due  to  drugs,  antitoxin,  etc. 

Other  important  symptoms  are  the  coryza,  the  gradual  rise  in  tem- 
perature, and  the  eruption  which  appears  first  upon  the  neck  and  face, 
and  slowly  extends  over  the  body.  Cases  which  present  the  greatest  diffi- 
culties in  diagnosis  are  usually  the  very  severe  ones  and  those  in  infants. 

Prognosis. — This  depends  upon  the  age  and  previous  condition  of 
the  patient,  the  character  of  the  epidemic,  and  the  season  of  the  year. 
Except  in  children  under  three  years  of  age,  the  deaths  from  measles  are 
few;  but  in  institutions  containing  young  children,  no  epidemic  disease 
is  so  fatal. 

The  general  mortality  of  the  disease  is  from  4  to  6  per  cent ;  but  in 


PLATE  XVIIl, 


Fig.  I. 


Fig.  II. 


Fig.   in. 


Fig.   IV. 


The     Pathognonionie   Sign   of  Measles  (Koplik's   Spots). 

Fig.  1. — The  discrete  measles  spots  on  the  buccal  or  labial  mucous  membrane,  showing 
the  isolated  rose-red  spot,  with  the  minute  bluish-white  centre,  on  the  normallv  colored 
mucous  membrane. 


Fig  2. — Shows  the  partially  diffuse  eruption  on  the  mucous  membrane  of  the  cheeks 
and  lips;  patches  of  pale  pink  interspersed  among  rose-red  patches,  the  latter  showing 
numerous  pale  bluish-white  spots. 

Fig.  3. — The  appearance  of  the  buccal  or  labial  mucous  membrane  when  the  measles 
spots  completely  coalesce  and  give  a  diffuse  redness,  with  the  myriads  of  bluish-white  specks. 
The  exanthema  on  the  skin  is  at  this  time  generally  fully  de\elopcd. 

Fir;.  1.— Aphthiius  stomatitis  apt  to  be  mistaken  for  measles  spots.  Mucous  membrane 
iKirmal  in  line.     Minute  iv/Ati'  f>(>i)i/s  are  surrounded  l)y  a  re<l  area,     .\lways  discrete. 


MEASLES.  9Y1 

epidemics  in  institutions  for  young  children  it  has,  in  my  experience, 
ranged  from  15  to  35  per  cent.  The  following  table  gives  the  figures  of 
an  epidemic  in  one  institution  in  1893: 

Prom  six  to  twelve  months 42  cases ;  mortality,  33  per  cent. 

"       one  to  two  years 51     "  "  50        " 

"      two  to  three  years 27    "  "  30        " 

"       three  to  four  years 20     "  "  14        " 

"      four  to  five  years 3     "  "  0        " 

In  any  single  case  the  important  symptoms  for  prognosis  are  the  tem- 
perature and  the  character  of  the  eruption.  An  initial  temperature  above 
103°  F.,  or  one  which  remains  high  until  the  eruption  appears,  is  a  bad 
symptom.  So  also  is  one  which  rises  after  a  full  eruption,  or  which  does 
not  fall  as  the  rash  fades.  The  following  table  shows  the  highest  tem- 
perature and  mortality  in  161  hospital  cases : 

Highest  temperature  not  over  102° 6  cases ;  mortality,  0  per  cent. 


102°  to  103-5° 
104°  "  104-5° 
105°  "  105-5° 
106°  or  over  . . 


14     " 

7 

49     " 

16 

65     " 

40 

27    " 

80 

A  favourable  eruption  is  one  of  a  bright  colour,  covering  the  body, 
remaining  discrete,  and  spreading  gradually.  It  is  unfavourable  for  the 
eruption  to  appear  late,  to  be  very  faint,  scanty,  or  hsemorrhagic,  or  to 
recede  suddenly,  as  this  is  usually  due  to  a  weak  heart. 

Of  51  fatal  cases,  the  cause  of  death  was  broncho-pneumonia  in  45, 
ileo-colitis  in  4,  and  membranous  laryngitis  in  2.  More  than  half  the 
deaths  occurred  during  the  second  week,  the  earliest  being  upon  the  fifth 
day  of  the  disease. 

The  ultimate  result  of  an  attack  of  measles  may  not  be  evident  for 
some  time.  Cases  in  which  the  temperature  persists  for  two  or  three 
weeks  without  assignable  cause  after  the  disease  is  apparently  over, 
should  be  watched  with  the  greatest  solicitude.  The  explanation  of  this 
is  most  frequently  to  be  found  in  the  lungs,  although  the  physical  signs 
are  often  obscure.  The  condition  may  be  either  subacute  pneumonia 
or  pulmonary  tuberculosis.  Even  though  the  attack  of  measles  may  not 
have  been  in  itself  severe,  seeds  are  often  sown  the  full  fruits  of  which 
are  not  seen  until  long  afterward.  Chronic  glandular  enlargements  which 
may  or  may  not  be  tuberculous,  chronic  bronchitis,  chronic  laryngitis, 
subacute  or  chronic  nasal  catarrh,  hypertrophy  of  the  tonsils,  and  adenoid 
.growths  of  the  pharynx — all  are  frequent  sequelae. 

Prophylaxis. — Measles  is  often  regarded  by  the  laity  as  so  mild  a 
disease  that  its  prevention  is  thought  of  little  importance,  and  no  effort 
is  made  to  limit  its  extension.  The  great  probability  that  every  person 
at  some  time  in  his  life  will  have  the  disease,  is  no  justification  of  un- 
necessary exposure.    Although  in  older  children  measles  is  usually  mild. 


972  THE  SPECIFIC  INFECTIOUS  DISEASES. 

this  is  not  so  in  infants,  who  should  be  carefully  protected  from  exposure. 
Special  care  should  also  be  taken  to  avoid  the  exposure  of  delicate  chil- 
dren or  those  with  a  strong  tendency  to  pulmonary  disease  or  to  tubercu- 
losis. In  institutions  it  is  of  the  utmost  importance  to  secure  prompt  and 
complete  isolation  of  the  first  case  which  appears. 

The  disease  being  usually  spread  by  the  patient  and  rarely  from 
apartments,  it  follows  that  while  early  isolation  is  more  important, 
there  is  not  required  the  same  thorough  cleansing  and  disinfection  which 
should  follow  every  case  of  scarlet  fever.  In  an  institution,  the  ward  or 
cottage  from  which  a  case  has  been  removed  should  be  quarantined  for 
at  least  sixteen  days  after  the  appearance  of  the  last  case,  and  absolute  se- 
curity can  not  be  said  to  exist  until  the  end  of  three  weeks.  The  same 
rule  should  be  applied  in  private  families  where  children  who  have  been 
exposed  should  be  quarantined  apart  from  the  patient,  but  not  sent  away. 
Under  ordinary  circumstances  the  quarantine  of  a  case  of  measles  should 
last  three  weeks  from  the  beginning  of  invasion.  It  should  be  contin- 
ued longer  if  there  is  pneumonia,  otitis,  or  a  nasal  discharge. 

Thorough  cleansing  and  disinfection  of  the  sick-room  should  be  done 
before  it  is  again  occupied  by  children,  and  it  should  remain  vacant  at 
least  two  weeks.  Children  should  be  kept  from  all  schools  while  the  dis- 
ease is  in  their  homes,  chiefly  because  they  are  otherwise  liable  to  spread 
the  disease  while  suffering  from  the  early  symptoms  of  invasion. 

Treatment. — Measles  is  a  self -limited  disease,  and  there  are  no  known 
measures  by  which  it  can  be  aborted,  its  course  shortened,  or  its  severity 
lessened.  The  indications  are  therefore  to  treat  serious  symptoms  as  they 
arise,  and,  as  far  as  possible,  to  prevent  complications,  which  are  the  prin- 
cipal cause  of  death. 

The  sick-room  should  be  darkened,  as  the  eyes  are  very  sensitive  to 
light.  Every  child  with  measles  should  be  put  to  bed  and  kept  there  with 
light  covering  during  the  entire  febrile  period.  There  can  be  no  possible 
advantage  in  causing  a  child  to  swelter  by  thick  covering,  under  the  delu- 
sion that  the  disease  may  be  modified  thereby.  The  food  should  be  light, 
fluid,  and  given  at  regular  intervals.  If  the  conjunctivitis  is  severe,  iced 
cloths  should  be  applied  to  the  eyes,  which  should  be  kept  clean  by  the  fre- 
quent use  of  a  saturated  solution  of  boric  acid,  the  lids  being  prevented 
from  adhering  by  the  application  of  vaseline  or  simple  ointment.  The 
intense  itching  and  burning  of  the  skin  may  be  relieved  by  inunctions  of 
plain  or  carbolized  vaseline.  The  cough,  when  distressing,  may  be  allayed 
by  heroin,  small  doses  of  opium,  either  in  the  form  of  codeine  or  the 
brown  mixture.  The  restlessness,  headache,  and  the  general  discom- 
fort which  accompany  the  height  of  the  fever  may  be  relieved  by  an 
occasional  dose  of  phenacetine  or  antipyrine.  As  soon  as  the  rash  has 
subsided,  a  daily  warm  bath  should  be  given,  followed  by  inunctions  to 
facilitate  desquamation  and  prevent  the  dissemination  of  the  fine  scales. 


MEASLES.  973 

The  important  indications  to  be  met  in  the  severe  cases  are  very  high 
temperature^,  cardiac  depression,  and  nervous  symptoms — dulness,  stu- 
por, sometimes  coma,  or  convulsions.  In  some  of  the  cases  there  is  in 
addition  dyspnoea  and  C3^anosis,  showing  severe  acute  pulmonary  con- 
gestion. For  the  nervous  symptoms  and  high  temperature,  nothing  is  so 
reliable  as  the  cold  baths  or  packs  (pages  47  and  48)  and  the  nearly  con- 
tinuous use  of  ice  to  the  head.  I  do  not  think  there  is  any  evidence  that 
the  use  of  cold  increases  the  liability  to  pneumonia ;  but  cold  extremities, 
feeble  pulse,  and  cyanosis,  when  associated  with  high  temperature,  call 
for  the  hot  mustard  bath,  although  ice  should  still  be  applied  to  the  head. 
The  indications  for  stimulants  and  the  methods  of  using  them  are  the 
same  as  in  broncho-pneumonia  (page  554),  which  is  usually  present  in 
cases  requiring  them. 

To  diminish  the  chances  of  pneumonia,  it  is  necessary  that  every 
patient  should  be  kept  in  bed  during  the  attack,  and  care  exercised  to 
avoid  exposure ;  that  the  chest  should  be  protected  with  flannel  and  rubbed 
daily  with  oil.  But  still  more  important  is  it  in  hospitals  and  institu- 
tions where  most  of  the  cases  of  pneumonia  occur,  to  allow  the  patients 
plenty  of  air  space,  never  crowding  them  together  in  small  wards.  If  pos- 
sible, cases  complicated  by  pneumonia  should  be  separated  from  simple 
cases.  The  pneumococcus  and  the  streptococcus  are  found  in  the  mouth 
in  such  numbers  that  systematic  disinfection  of  the  mouth  may  prove  of 
value. 

The  danger  of  diphtheria  as  a  complication  may  be  greatly  lessened 
if  during  epidemics  of  measles  in  institutions  every  case  receives  an  im- 
munizing dose  of  diphtheria  antitoxin.  This  plan  has  been  followed  at 
the  i^ew  York  Foundling  Hospital  for  several  years  with  most  striking 
benefit. 

The  bronchitis  and  broncho-pneumonia  of  measles  should  be  man- 
aged as  when  they  occur  as  primary  diseases,  since  the  coexistence  of 
measles  furnishes  no  new  indications.  The  same  is  true  of  the  diarrhoea, 
conjunctivitis,  and  otitis.  Membranous  laryngitis,  pharyngitis,  or  ton- 
sillitis should  be  treated  like  other  cases  of  pseudo-diphtheria.  Should 
cultures  show  the  presence  of  the  diphtheria  bacillus,  the  case  should  be 
treated  like  one  of  ordinary  diphtheria  in  the  same  situation. 

During  convalescence  the  eyes  should  be  used  very  carefully  for  at 
least  several  weeks.  Should  the  cough  and  slight  fever  persist,  with  or 
without  physical  signs  in  the  chest,  the  patient  should,  if  possil)Ie,  be 
sent  away  to  a  warm,  dry,  elevated  district,  as  the  development  of  tuber- 
culosis is  always  to  be  feared.  Cod-liver  oil  sliould  be  given  continuously 
throughout  the  succeeding  cool  season,  and  iron,  wine,  and  other  tonics 
according  to  indications.  The  cough  itself  should  be  treated  as  when  it 
follows  an  ordinary  bronchitis  (page  514),  creosote  being  more  generally 
useful  than  any  other  drug. 
G3 


974  THE   SPECIFIC   INFECTIOUS   DISEASES. 

CHAPTEE  III. 
RUBELLA. 

Synonyms :  German  measles ;  rotheln. 

Rubella  is  a  contagious  eruptive  fever  which  is  rarely  seen  except 
when  prevailing  epidemically.  It  is  characterized  by  a  short  invasion, 
with  mild,  indefinite  symptoms,  usually  lasting  but  a  few  hours,  and  by 
an  eruption  which  is  generally  well  marked  but  of  variable  appearance. 
The  constitutional  symptoms  are  very  mild,  and  the  disease  rarely  proves 
fatal,  not  often  being  even  serious.  For  a  long  time  rubella  was  con- 
founded with  measles  and  scarlet  fever,  as  the  eruption  sometimes  resem- 
bles one  and  sometimes  the  other  disease.  Its  identity  is  now  fully  estab- 
lished, and,  as  Striimpell  well  says,  its  existence  is  doubted  only  by  those 
who  have  never  seen  it.  The  following  peculiarities  have  been  stated 
by  Griffith  (Philadelphia),  who  has  written  more  fully  on  rubella  than  any 
other  American  writer,  and  to  whom  I  am  indebted  for  many  facts  in  this 
article : 

( 1 )  Eubella  is  a  contagious,  eruptive  fever,  and  not  a  simple  affection 
of  the  skin;  (2)  it  prevails  independently  either  of  measles  or  of  scarlet 
fever;  (3)  its  incubation,  eruption,  invasion,  and  symptoms  differ  ma- 
terially from  those  of  both  these  diseases ;  (4)  it  attacks  indiscriminately 
and  with  equal  severity  those  who  have  had  measles  and  scarlet  fever  and 
those  who  have  not,  nor  does  it  protect  in  any  degree  against  either  of 
them;  (5)  it  never  produces  anything  but  rubella  in  those  exposed  to  its 
contagion;  (6)  it  occurs  but  once  in  the  same  individual. 

Etiology. — Rubella  is  beyond  question  contagious,  but  is  decidedly 
less  so  than  either  measles  or  scarlet  fever;  so  that  some  observers  have 
doubted  its  contagion  altogether.  It  can  be  communicated  at  any  time 
during  its  course,  but  is  especially  contagious  during  the  early  stage. 
Epidemics  usually  prevail  in  the  winter  or  spring.  As  in  the  other 
eruptive  fevers,  a  striking  immunity  is  seen  in  infants  under  six  months 
old;  but,  with  this  exception,  all  ages  are  liable  to  the  disease. 

The  incubation  of  rubella  varies  considerably;  the  usual  period  is 
from  ten  to  sixteen  days,  although  the  limits  are  from  five  to  twenty- 
two  days. 

Symptoms. — Invasion. — This  is  rarely  more  than  half  a  day,  and  in 
many  cases  no  prodromata  whatever  are  noticed,  the  rash  being  the  first 
thing  to  attract  attention.  In  a  few  cases  there  are  mild  catarrhal  symp- 
toms, with  general  malaise  and  slight  fever.  At  other  times  there  may 
be  vomiting,  convulsions,  delirium,  epistaxis,  rigors,  headache,  or  dizzi- 
ness ;  but  all  are  to  be  regarded  as  very  exceptional. 

Eruption. — Frequently  a  child  wakes  in  the  morning  covered  with 
the  rash,  no  symptoms  having  been  previously  noticed.    It  generally  ap- 


RUBELLA,  9Y5 

pears  first  upon  the  face,  and  spreads  rapidly  to  the  whole  bod}',  the  lower 
extremities  being  last  covered.  Less  than  a  day  is  usually  required  for 
its  full  development.  Exceptionally  the  eruption  comes  first  upon  the 
chest  and  back,  and  sometimes  nearly  the  whole  body  is  covered  almost 
at  once.  The  rasli  is  occasionally  observed  in  the  roof  of  the  mouth 
before  it  is  visible  on  the  face.  In  a  considerable  number  of  eases  the 
entire  body  is  not  covered ;  but  the  rash,  is  more  constantly  seen  upon  the 
face  than  upon  any  other  part  of  the  body. 

Its  character  is  subject  to  considerable  variation.  The  eruption  is 
most  frequently  composed  of  very  small  maculo-papules ;  they  are  of  a 
pale-red  colour,  and  vary  in  size  from  a  pin's  head  to  a  pea.  The  spots 
are  usually  discrete,  but  may  cover  the  greater  part  of  the  body  where  it 
is  seen.  On  the  face  it  is  frequently  confluent,  and  often  appears  here 
as  large,  irregular  blotches  of  a  red  colour.  From  this  description  the 
rash  will  be  seen  to  resemble  that  of  measles  more  than  that  of  any  other 
disease.  Very  often,  however,  there  is  a  tolerably  uniform  red  blush 
which  bears  a  close  resemblance  to  the  rash  of  scarlet  fever ;  but  even  in 
such  cases  there  will  nearly  always  be  found  upon  some  part  of  the  body, 
usually  the  wrists,  fingers,  or  forehead,  some  typical  maculo-papules. 
Between  these  two  extremes  ajl  variations  are  seen.  The  colour  of  the 
eruption  is  sometimes  dark  red,  and  rarely  it  has  been  noted  to  be  hasmor- 
rhagic.  The  degree  of  elevation  above  the  surface  is  also  variable ;  some- 
times this  is  so  marked  as  to  give  to  the  skin  a  "  shotty  "  feel,  while  in 
others  the  elevation  is  scarcely  perceptible.  The  duration  of  the  erup- 
tion is  usually  three  days.  Occasionally  it  lasts  only  two  days,  and  it  may 
last  but  one ;  it  is  rare  for  it  to  remain  as  long  as  four  days.  It  fades 
in  the  order  of  its  appearance,  and  more  rapidly  than  the  eruption  of 
measles.  A  slight  brown  pigmentation  of  the  skin  sometimes  remains 
for  a  few  days  after  the  rash.. 

The  highest  temperature  is  coincident  with  the  full  eruption ;  this 
does  not  usually  exceed  101°,  and  often  it  is  only  100°  F.  As  a  rule, 
the  temperature  continues  but  two  days,  falling  as  the  eruption  fades. 
Very  often  the  fall  to  normal  is  abrupt.  Rarely  more  severe  cases  are 
seen  in  wliieh  the  fever  lasts  for  two  or  three  days,  lieiiig  1<M°  or  10-2°  F. 
during  the  invasion,  and  rising  to  103°  F.  or  more  during  the  full  erup- 
tion. The  other  symptoms  arc  in  most  eases  even  less  marked  than  the 
fever.  Occasionally  cataii'lial  syiii])toms  reseinbling  a  mild  attack  of 
measles  are  present,  or  a  sore  tliroat  suggesting  mild  scarlet  fever;  bufc 
more  frequently  all  these  symptoms  are  absent.  The  eruption  is  usually 
out  of  all  proportion  to  the  other  signs  of  disease. 

Swelling  of  the  pnst-cervieal  glands  is  one  of  the  most  constant  fea- 
tures of  rubella,  in  most  epidemics  it  is  seen  in  nearly  all  cases;  but 
as  a  symptom  for  differential  diagnosis  it  is  not  of  great  importance,  as 
it  is  not  uncommon  in  measles.    The  glandular  swelling  is  most  marked 


976  '    THE  SPECIFIC  INFECTIOUS  DISEASES. 

at  the  height  of  the  disease ;  it  is  never  very  great,  and  subsides  slowly 
without  suppuration.  Vomiting  and  diarrhoea  are  rare.  Swelling  and 
itching  of  the  skin  are  usually  present  and  sometimes  marked. 

Forchheimer  *  has  described  an  eruption  on  the  mucous  membrane 
of  the  throat,  or  "  enanthem,"  which  he  believes  to  be  characteristic. 
It  consists  of  minute,  bright,  rosy-red  points,  seen  as  a  rule  only  on  the 
uvula  and  soft  palate,  rarely  on  the  hard  palate.  This  is  of  short  dura- 
tion, being  present  only  in  the  first  twenty-four  hours. 

Desquamation. — This  is  exceedingly  variable.  It  is  sometimes  en- 
tirely wanting;  writers  who  have  observed  some  fairly  typical  epidemics 
have  stated  that  it  did  not  occur.  In  most  cases,  however,  some  des- 
quamation is  present,  though  it  may  be  so  slight  as  to  be  discovered  only 
by  a  close  examination.  It  is  usually  in  the  form  of  fine  scales  over  the 
body  and  extremities.  In  a  few  cases  it  is  more  pronounced,  and  may 
be  in  larger  flakes  or  patches. 

Prognosis. — There  are  few  diseases  so  free  from  danger  as  rubella. 
Complications  and  sequelee  are  very  seldom  seen,  and  when  present  are 
usually  of  the  mildest  character. 

Diagnosis. — The  principal  interest  attaching  to  rubella  is  in  its  diag- 
nosis. This  is  a  matter  of  extreme  difficulty,  and  often  it  is  an  impossi- 
bility. The  characteristic  thing  about  the  disease  is  a  well-marked  erup- 
tion with  very  few  other  symptoms.  Cases  so  closely  resemble  mild 
scarlet  fever  that  the  differentiation  by  symptoms  may  be  impossible;  it 
must  be  made  by  the  circumstances  under  which  it  occurs,  especially  a 
prevailing  epidemic.  Scarlet  fever  with  a  low  temperature  and  abundant 
rash  should  always  be  regarded  with  suspicion;  also  an  abundant  rash 
with  little  or  no  desquamation.  The  longer  period  of  incubation  in 
rubella  may  be  of  assistance.  Koplik's  spots  furnish  a  valuable  means  of 
distinguishing  measles  from  rubella.  These  difficulties  in  diagnosis  can 
be  appreciated  only  by  one  who  has  seen  epidemics  of  measles  and  scarlet 
fever  in  institutions,  and  has  watched  the  mild  course  of  undoubted 
cases  of  these  diseases  which  have  there  occurred. 

It  is  never  safe  to  make  the  diagnosis  of  rubella  unless  the  disease  is 
prevailing  epidemically.  Sporadic  cases  in  which  this  diagnosis  is  made 
are,  I  believe,  almost  invariably  instances  of  mild  measles  or  scarlet  fever. 
The  first  cases  of  rubella  in  an  epidemic  are  usually  overlooked.  The 
continued  absence  in  succeeding  cases  of  the  characteristic  symptoms  and 
complications  of  measles  or  scarlet  fever  should  suggest  to  the  physician 
that  he  is  probably  dealing  with  rubella. 

Treatment. — None  whatever  is  required  for  the  disease  excepting  iso- 
lation, which  should  be  complete  until  the  diagnosis  is  positively  deter- 
mined. The  individual  symptoms  and  complications  are  to  be  treated  as 
they  arise. 

*  Archives  of  PiBdiatrics,  1898,  721. 


VARICELLA.  9Y7 

CHAPTEE  IV. 

VARICELLA. 

Synonym :  Chicken-pox. 

Varicella  is  an  acute,  contagions  disease,  characterized  by  a  cuta- 
neous eruption  of  papules  and  vesicles  and  by  mild  constitutional  symp- 
toms, serious  complications  and  sequelae  being  very  rare.  Although  long 
confounded  with  varioloid,  its  existence  as  a  distinct  disease  has  been 
generally  admitted  for  many  years. 

Etiology. — It  is  well  established  that  the  contagium  of  the  disease  is 
contained  in  the  vesicles,  as  it  may  be  communicated  by  inoculation  with 
their  contents.  The  specific  poison,  however,  has  not  yet  been  isolated. 
Varicella  is  contracted  by  exposure  to  another  case  or  through  the  me- 
dium of  a  third  person.  It  affects  children  of  all  ages,  one  attack  being 
as  a  rule  protective.  It  is  very  contagious,  resembling  measles  in  this 
respect.  The  period  of  incubation  is  cjuite  uniformly  from  fourteen  to 
sixteen  days. 

Symptoms. — Slight  fever  and  general  indisposition  may  be  noticed 
for  twenty-four  hours  before  the  appearance  of  the  eruption,  but  in  most 
eases  the  eruption  is  the  first  symptom.  It  usually  appears  first  upon 
the  face  or  trunk,  as  small,  red,  widely-scattered  papules.  The  papules  in 
most  cases  come  in  crops,  new  ones  continuing  to  appear  for  three  or 
four  days,  even  upon  the  same  part  of  the  body.  The  earlier  ones  have 
generally  begun  to  dry  up  by  the  time  the  later  ones  appear,  so  that  all 
stages  of  the  eruption  may  be  present  at  one  time  in  the  same  region, 
this  being  one  of  its  diagnostic  features.  The  papules  are  at  first  very 
small,  but  gradually  increase  in  size,  and  are  surrounded  by  an  areola 
from  one  fourth  to  half  an  inch  in  width.  Many  of  them  go  no  further 
than  this  stage,  but  the  majority  become  vesicular.  The  vesicles  are 
usually  flat,  and  vary  a  good  deal  in  size — the  largest  being  about  one 
fourth  of  an  inch  in  diameter.  The  process  of  drying  up  generally  be- 
gins at  the  centre,  which  causes  a  slight  depression,  giving  the  vesicle 
a  somewhat  umbilicated  appearance.  The  areola  is  most  distinct  at  the 
time  of  the  fully-formed  vesicle,  and  fades  as  the  latter  dries.  Crusts 
now  form,  which  fall  off  in  from  five  to  twenty  days,  depending  upon 
the  depth  to  which  the  skin  has  been  involved.  In  the  majority  of  cases 
no  mark  is  left,  but  after  the  most  severe  attacks,  where  the  true  skin 
has  been  involved,  scars  remain,  and  occasionally  there  is  quite  deep 
pitting.  Such  marks  are  few  in  number,  and  are  most  likely  to  occur 
upon  the  face. 

Sometimes,  especially  upon  hands  and  feet,  the  vesicle  appears  with- 
out having  been  preceded  by  a  papule ;  often  there  is  no  areola,  and  the 


978  THE  SPECIFIC  INFECTIOUS  DISEASES. 

vesicle  resembles  a  drop  of  T\'ater  upon  healthy  skin.  In  most  cases  pus- 
tules are  not  seen,  but  they  may  develop  in  consequence  of  irritation  or 
infection,  the  result  of  scratching,  or  in  children  who  are  poorly  nour- 
ished. Under  these  circumstances  deeper  ulceration  ma}'  occur,  lasting 
for  weeks.  In  rare  cases  there  may  be  a  necrotic  inflammation  about  the 
site  of  the  pock,  a  condition  to  which  is  sometimes  given  the  name  vari- 
cella gangrenosa.  It  is  not  peculiar  to  varicella,  and  is  described  elsewhere 
under  the  head  of  Gangrenous  Dermatitis  (page  918). 

The  pocks  are  usually  most  abundant  over  the  back  and  shoulders. 
In  mild  eases  only  twenty  or  thirty  may  be  found  upon  the  entire  body, 
but  in  severe  cases  the  skin  in  certain  regions  may  be  nearly  covered. 
The  eruption  is  never  confluent.  The  pocks  are  usually  seen  on  the 
hairy  scalp,  and  often  on  the  mucous  membrane  of  the  mouth  or  pharynx 
- — a  point  of  some  diagnostic  value.  In  the  latter  situation  the  appear- 
ance is  first  as  a  tiny  vesicle,  and  later  as  a  superficial  ulcer  resembling 
that  of  herpetic  stomatitis.  Marfan  and  Halle  have  described  cases  of 
varicella  of  the  larynx.  Croupy  s)'mptoms  were  present,  and  in  one 
case  which  proved  fatal  from  pneumonia  a  tiny  ulcer  was  found  on  the 
vocal  cords. 

The  temperature  is  highest  when  the  eruption  is  most  rapidly  appear- 
ing, this  usually  being  the  second  or  third  day.  In  an  average  case  it 
reaches  only  101°  or  103°  F.,  and  lasts  but  two  days;  in  severe  cases  it 
may  rise  to  104°  or  105°  Y.,  and  lasts  for  four  or  five  days.  It  falls  grad- 
ually to  normal  as  the  rash  fades.  The  other  symptoms  are  mild  and 
not  characteristic. 

Complications. — The  most  important  complication  is  erysipelas, 
which  develops  about  the  pocks,  particularly  when  they  are  deep  and  at- 
tended with  some  ulceration.  I  have  known  of  three  fatal  cases  from  this 
cause.  Adenitis,  either  simple  or  suppurative,  and  abscesses  in  the  cel- 
lular tissue,  are  occasionally  seen.  ISTephritis  is  very  infrequent,  but  a 
number  of  cases  are  recorded.  It  may  occur  at  the  height  of  the  dis- 
ease, but  more  often  at  a  later  period,  like  the  nephritis  of  scarlet  fever. 
Varicella  is  quite  freciuently  complicated  by  other  infectious  diseases.  In 
the  Xew  York  Infant  Asylum  epidemics  of  varicella  and  scarlet  fever  at 
one  time  occurred  together,  and  in  at  least  a  dozen  children  both  diseases 
were  seen  at  the  same  time. 

Diagnosis. — The  diagnosis  of  varicella  is  usually  easy,  provided  the 
following  points  are  kept  in  mind :  first,  that  the  eruption  comes  out 
slowly  and  in  crops,  so  that  papules,  vesicles,  and  crusts  may  be  seen  upon 
the  skin  in  close  proximity;  secondly,  that  the  umbilication  is  due  only 
to  the  mode  of  drying  up  of  the  vesicle,  which  begins  at  the  centre; 
thirdly,  the  appearance  of  the  pocks  upon  the  mucous  membranes,  and 
the  history  of  exposure.  It  is  distinguished  from  urticaria  and  other 
forms  of  skin  disease  by  the  presence  of  fever. 


VACCINIA— VACCINATION.  979 

Treatment. — Although  it  is  usually  a  trivial  disease,  isolation  of  cases 
of  varicella  should  bo  enforced  in  schools  and  in  institutions  containing 
many  infants.  In  the  home,  unless  the  other  children  are  delicate  or  in 
poor  condition,  cjuarantine  is  unnecessary.  The  disease  may  probably  be 
conveyed  as  long  as  the  crusts  are  present,  hence  isolation  should  be 
maintained  until  they  have  fallen  off.  In  most  cases  constitutional  symp- 
toms of  the  disease  are  so  mild  as  to  require  no  treatment. 

Locally,  the  itching,  when  annoying,  may  be  allayed  by  sponging 
with  a  weak  solution  of  carbolic  acid  or  the  use  of  carbolized  vaseline. 
When  the  crusts  have  formed,  this  ointment  or  vaseline  containing  two 
per  cent  ichthyol  should  be  applied.  Care  is  necessary  to  keep  the  skin 
clean,  and,  in  the  case  of  infants,  to  prevent  scratching.  In  severe  cases 
the  urine  should  invariably  be  examined. 


CHAPTER  V. 
VACCINIA—  VACCINA  TION. 

Vaccinia  (cowpox)  is  a  febrile  disease  induced  in  man  by  inocula- 
tion with  the  virus  obtained  either  directly  from  the  cow  (bovine  virus) 
or  from  a  person  who  has  been  inoculated  (humanized  virus).  The  dis- 
ease is  not  contagious  in  the  ordinary  sense  of  the  term,  but  is  communi- 
cated by  inoculation  either  accidental  or  intentional. 

The  nature  of  the  protection  against  smallpox  which  vaccination 
affords  is  even  now  but  imperfectly  understood.  The  fact,  however,  re- 
mains one  of  the  best  attested  in  medical  history.  Its  effect  when  sys- 
tematically practised  is  graphically  shown  in  the  accompanying  chart 
(Fig.  183).  It  is  the  imperative  duty  of  the  physician  to  see  to  it  that 
every  young  infant  is  vaccinated. 

Re-vaccination. — Eegarding  the  duration  of  the  protective  power  of 
a  single  vaccination,  positive  statements  are  impossible.  Nearly  all 
writers  are  agreed  that  vaccination,  should  be  done  in  infancy,  again  at 
puberty,  and  a  third  time  at  about  the  age  of  twenty  or  twenty-five. 
Many  also  insist  upon  re-vaccination  at  about  the  seventh  year.  It  is  a 
safe  rule  when  siiiall])ox  is  prevalent  to  vaccinate  every  person  \vli(t  lias 
nr)t  been  siicccssriilly  vaccinated  within  five  years. 

Choice  of  Lymph. — The  substitution  of  bovine  for  huuianizcd  virus 
is  now  well-nigh  universal.  It  has  precluded  the  possibility  of  trans- 
mitting syphilis  and  greatly  lessened  the  chances  of  other  forms  of  in- 
fection. A  further  advance  has  lately  been  made  by  the  introduction  of 
"  glycerinated  "  lym])h.  As  now  prepared,  the  lymph  is  taken  from  the 
•calves  under  the  most  rigid  aseptic  precautions  and  emulsified  with 


980 


THE  SPECIFIC  INFECTIOUS  DISEASES. 


glycerin.     The  few  saprophytic  bacteria  present  soon  die,  so  that  when 
properly  prepared  the  glycerinated  virus  is  practically  sterile.*    It  should 


COMPULSORY  RE-VACCINATION 
AT  THE  AGE  OP  12. 


HOLLAITD. 


1868-1874 

Average 

yearly  Deaths 

from  small- 
pox in  every 

lOO.UOO 
inhabitants. 


After  the  Law  of  1874 


Liii 


Annual  Deaths 

from  small-poi 

in  every  100,000 

inhabitants. 


18G0-1872 

Average 

yearly  Deaths 

from  small- 

poi  in  every 

100,000 
inhabitants. 


ll 


L*xiil 


la 


aJ 


Atinxial  Deaths 

from  smalUpoz 

In  every  100,000 

Inhabitants. 


ATTSTRIA. 


1808-1874 


yearly  Deaths 
from  small- 
poi  in  every 

100,000 
inhabitants. 


Annual  Deaths 

from  amall-poi 

in  every  100,000 

Inhabitants, 


_  70  o 


i 

50  O 


Fig.  183. — Table  showing  the  protective  power  of  vaccination.     (Carsten.) 

not  be  distributed  until  it  has  been  carefully  tested  for  pathogenic  organ- 
isms of  all  kinds,  particularly  the  tetanus  bacillus.  It  is  preserved  and 
distributed  in  capillary  tubes  hermetically  sealed;  these  are  much  safer 


*  Reliable  glycerinated  lymph  is  prepared  by  the  New  York  Health  Department, 
Mulford  &  Co.,  and  Parke,  Davis  &  Co.  For  an  excellent  paper  on  Clinical  Aspects 
of  Vaccination,  see  Fielder,  Medical  News,  March  30,  1901.  On  Vaccination  Infec- 
tions, see  Kubin,  Medical  Record,  April  6,  1901. 


VACCINIA— VACCINATION.  981 

than  quills  or  ivory  points,  which  may  easily  become  contaminated  by 
handling.  After  the  lymph  has  been  taken,  the  calves  are  killed  in  order 
to  make  certain  that  they  are  free  from  disease.  The  practical  advan- 
tages of  glycerinated  lymph  are  so  great  that  it  has  been  officially 
adopted  by  the  Governments  of  the  United  States,  Great  Britain,  Ger- 
many, and  many  other  countries. 

Time  for  Vaccinating. — In  selecting  a  time  for  vaccination,  the  child's 
age  and  general  health  must  be  taken  into  consideration.  It  is  pretty 
well  established  that  the  constitutional  disturbance  is  much  less  in  in- 
fancy than  in  later  childhood,  and  less  in  very  young  infants  (under  one 
month)  than  in  those  of  five  or  six  months.  A  good  rule  for  general 
practice  is  to  vaccinate  every  healthy  infant  as  soon  as  its  nutrition  is 
established,  this  being  in  most  cases  during  the  first  three  months  of 
life.  In  delicate  infants  or  in  those  whose  nutrition  is  a  matter  of 
great  difficulty,  those  who  are  syphilitic,  those  suffering  from  eczema  or 
any  other  form  of  active  skin  disease,  vaccination  should  be  deferred 
until  the  child  is  in  good  condition,  unless  it  is  likely  to  be  exposed  to 
smallpox.    As  a  rule,  vaccination  should  be  avoided  during  dentition. 

Methods  of  Vaccinating. — In  my  experience  it  is  better  to  vaccinate  in 
one  place  rather  than  to  make  two  or  three  inoculations.  If  more  than 
one  is  made  they  should  be  at  least  an  inch  apart.  Either  the  leg  or  the 
arm  may  be  chosen;  in  young  infants  it  is  usually  easier  to  protect  the 
vaccine  sore  upon  the  leg  than  upon  the  arm;  in  children  old  enough 
to  run  about,  the  arm  is  to  be  preferred,  as  being  more  easily  kept  at  rest, 
.  The  point  selected  for  inoculation  should  be  either  the  outer  aspect  of  the 
left  calf,  about  the  junction  of  the  middle  with  the  upper  third  of  the  leg, 
or,  if  the  arm  is  chosen,  the  insertion  of  the  left  deltoid.  The  skin  should 
be  washed  with  soap  and  water,  dried,  and  then  washed  with  alcohol. 

The  ]Srew  York  Health  Department  supplies  with  each  tube  of  lymph 
a  needle,  a  bit  of  rubber  tubing,  and  a  tooth-pick  with  one  flat  end.  The 
needle  should  be  sterilized  in  an  alcohol  flame,  and  three  or  four  parallel 
scratches  made  a  quarter  of  an  inch  long,  crossed  by  as  many  more,  just 
deeply  enough  to  draw  blood.  The  ends  of  the  capillary  tubes  are  broken 
off,  one  end  inserted  in  the  rubber  tube,  and  the  lym])h  blown  out  of  the 
tube  upon  the  broad  end  of  the  tooth-pick,  then  applied  to  the  scratched 
surface  and  rubbed  in  for  a  full  minute.  The  wound  should  not  be 
covered  until  dry;  this  usually  requires  from  fifteen  to  twenty  minutes. 
It  may  then  be  covered  with  a  sterilized  bandage,  or  isinglass  plaster 
moistened  in  boiled  water.  If  thoroughly  dried  no  dressing  is  neces- 
sary.    The  limb  should  not  be  washed  for  twenty-four  hours. 

The  Normal  Course  of  Vaccinia. — The  course  of  a  proper  vaccination- 
pock  is  quite  uniform,  and  one  which  does  not  follow  this  course  should 
not  be  considered  protective.  The  wduiid  licals  and  nothing  is  noticed 
until  the  third  or  fourth  day,  when  a  red  jiajiulc  makes  its  appearance. 


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982 


VACCINIA— VACCINATION.  983 

Usually  in  twenty-four  hours  more  a  minute  vesicle  begins  to  form 
which  enlarges  until  the  sixth  or  seventh  day,  when  it  reaches  its  full 
development.  Its  shape  and  size  depend  much  upon  the  manner  of 
inoculation  (Figs.  184  and  185).  The  vesicle  is  usually  from  one-fourth 
to  one-half  inch  in  diameter;  it  is  of  a  pearly-gray  colour  and  has 
a  depressed  centre.  During  the  next  two  days  an  areola  forms  about  the 
vesicle  extending  from  it  a  variable  distance,  usually  one  or  two  inches 
into  the  healthy  skin.  It  is  often  much  less  than  is  shown  in  the  illustra- 
tion. This  areola  is  normally  of  a  bright-red  colour  and  accompanied  by 
some  induration.  It  is  generally  at  its  height  on  the  eighth  or  ninth 
day.  The  vesicle  usually  dries  down  to  a  firm,  dark  crust  which  remains 
from  one  to  three  weeks  and  falls  off,  leaving  a  bluish  scar  which  fades 
to  white,  becoming  somewhat  honey-combed.  Wlien  the  process  is  at  its 
height  some  constitutional  disturbance  is  usually  present;  there  may  be 
loss  of  appetite,  fretfulness,  and  general  indisposition,  and  the  tem- 
perature is  usually  elevated  from  one  to  three  degrees.  The  lymph 
nodes  in  the  groin  or  axilla  may  be  tender  and  swollen.  These  symp- 
toms generally  last  for  three  or  four  days. 

If  in  a  young  infant  the  first  inoculation  is  unsuccessful,  at  least 
three  trials  should  be  made  with  good  virus,  and  in  the  event  of  further 
failure,  after  a  year  vaccination  should  be  repeated.  A  failure  to  inocu- 
late does  not  mean  insusceptibility  to  smallpox,  as  is  often  popularly  be- 
lieved, but  most  frequently  arises  from  the  fact  that  the  virus  is  inert. 
I  have  known  one  case  in  which  the  seventh,  and  another  in  which  the  thir- 
teenth, inoculation  was  successful  after  previous  failures;  occasionally 
there  are  seen  children  who  can  not  be  inoculated  at  all. 

Constitutional  symptoms,  as  previously  stated,  may  be  absent  in  very 
3^oung  infants;  but  in  others  there  is  quite  constantly  present  a  fever 
which  runs  a  fairly  regular  course.  It  usually  begins  on  the  fourth  or 
fifth  day,  is  remittent  in  type,  and  rises  gradually,  reaching  its  high- 
est point  with  the  full  development  of  the  vesicle.  At  this  time  it  varies 
from  101°  to  101°  F.,  falling  gradually  to  normal.  The  duration  of  the 
fever  in  cases  running  the  usual  course  is  four  or  five  days.  Accompany- 
ing the  fever  there  may  be  anorexia,  restlessness,  loss  of  sleep,  slight  in- 
digestion, and  other  symptoms  of  a  general  indisposition. 

Both  the  local  and  the  general  symptoms  are  sometimes  more  severe. 
This  may  depend  upon  the  susceptibility  of  the  child,  the  lymph  being 
pure  and  the  vaccination  properly  done.  The  original  vesicle  may  be 
much  larger  than  usual,  and  small  secondary  vesicles  may  form  in  the 
neighbourhood  (Fig.  185).  In  very  rare  instances  a  generalized  erup- 
tion of  true  vaccine  vesicles  occurs  with  in.nked  fever  and  other  general 
symptoms  of  corresponding  severity.  Single  vesicles  may  be  produced 
on  distant  parts  of  the  body  as  a  result  of  auto-inoculation,  usually  by 
.scratching.    Where  eczema  of  the  face  is  present,  inoculation  is  not  infre- 


984  THE  SPECIFIC  INFECTIOUS  DISEASES. 

quently  carried  thither.  Most  of  the  very  sore  arms  and  legs,  however, 
are  due  to  infection  from  pyogenic  bacteria  contained  in  the  lymph,  or 
to  their  accidental  introduction  at  the  time  of  vaccination  or  subse- 
quently. In  the  milder  cases,  the  swelling  and  other  evidences  of  local  in- 
flammation are  more  marked  than  in  a  normal  vaccination;  a  drop  or 
two  of  pus  forms  beneath  the  scab,  and  when  the  latter  comes  away  an 
excavation  is  left  which  heals  in  two  or  three  weeks.  Or,  the  inflamma- 
tion may  extend  more  deeply  into  the  connective  tissue,  to  be  followed  by 
more  extensive  suppuration  or  sloughing,  leaving  an  ugly  ulcer  an  inch 
or  more  in  diameter  which  slowly  fllls  by  granulation  in  from  five  to  eight 
weeks.  Sometimes  the  period  of  incubation  is  unduly  prolonged,  so  that 
the  vesicle  does  not  form  until  the  twelfth  or  fourteenth  day,  although 
its  subsequent  course  may  be  normal.  In  other  cases,  the  incubation  is 
shorter  than  usual,  and  the  vesicle  may  appear  as  early  as  the  third  or 
fourth  day. 

Much  has  been  written  about  the  so-called  "  raspberry  excrescence  " 
which  not  very  infrequently  takes  the  place  of  a  proper  vesicle.  It  is  of 
a  dark-red  colour,  elevated,  smooth  or  slightly  granular,  not  sensitive, 
having  no  areola  and  no  constitutional  symptoms.  It  generally  per- 
sists for  two  or  three  weeks,  and  slowly  disappears,  leaving  no  scar.  It  is 
usually  the  result  of  virus  of  feeble  activity,  and  if  it  gives  any  protection 
it  is  very  slight.  Such  cases  should  always  be  re-vaccinated,  and  in  my 
experience  re-vaccination  is  usually  successful. 

Complications  and  Sequelse. — Post-vaccine  eruptions  are  many  and 
of  great  variety.  The  most  frequent  is  a  general  roseola,  sometimes 
resembling  scarlet  fever,  but  much  oftener  measles,  and  usually  occurring 
at  the  height  of  the  local  process.  Other  eruptions  seen  are  urticaria, 
various  forms  of  erythema,  and,  rarely,  purpura.  Other  complications 
are  chiefly  from  mixed  infection.  Syphilis  and  tuberculosis  are  practi- 
cally excluded  by  modern  methods  of  procuring  the  lymph.  Tetanus  can 
result  only  from  carelessness  or  neglect  of  suitable  precautions  in  pre- 
paring the  lymph;  proper  legal  restrictions  regarding  its  production 
should  in  the  future  make  this  impossible.  The  most  common  form  of 
local  infection  is  cellulitis,  which  may  terminate  in  suppuration  or 
sloughing  at  the  site  of  vaccination,  and  sometimes  may  cause  suppura- 
tion of  the  neighbouring  lymph  nodes.  In  rare  cases,  general  septicaemia 
or  pyaemia  may  follow.  Impetigo  contagiosa  sometimes  occurs.  Ery- 
sipelas may  develop  at  any  time  before  the  vaccine  sore  is  entirely  healed ; 
I  saw  it  once  as  late  as  the  sixth  week.  Pneumonia  and  nephritis  may  be 
associated  with  any  of  the  more  serious  complications.  Latent  tubercu- 
losis may  become  active  after  vaccinia,  and  a  child  who  is  subject  to 
eczema  is  liable  to  a  recurrence.  In  a  delicate  child  a  condition  of  mal- 
nutrition is  often  intensified  if  the  vaccinia  is  at  all  severe. 

The  mortality  of  vaccination  is  stated  by  Voigt,  from  careful  statis- 


PERTUSSIS.  985 

tics  drawn  from  German  sources,  to  have  been  35  in  2,275,000  cases,  in- 
cluding both  primary  and  secondary  vaccinations.  Of  the  deaths,  19 
were  due  to  erysipelas,  8  to  gangrene,  2  to  cellulitis,  3  to  "  blood  poison- 
ing," and  3  to  other  causes.  The  occurrence  of  tetanus  after  vaccinia  has 
already  been  mentioned.  With  proper  precautions  in  preparing  lymph  it 
will  not  occur.  In  fact,  nearly  all  the  deaths  are  from  causes  which  are 
preventable. 

Treatment. — The  whole  purpose  of  treatment  is  to  prevent  infection. 
The  first  essentials  are  a  clean  limb,  pure  virus,  and  a  clean  needle ;  the 
next,  to  allow  thorough  drying  of  the  wound  before  the  clothing  touches 
it.  After  this  nothing  is  necessary  until  the  vesicle  forms.  Then  the  im- 
portant thing  is  to  prevent  scratching  and  the  irritation  of  the  clothing. 
All  vaccine  shields  are  objectionable.  For  an  infant  nothing  is  better  than 
the  sterilized  bandage,  which  can  be  kept  in  place  by  sewing  to  the  stock- 
ing or  sleeve  of  the  shirt.  Any  constriction  of  the  limb  is  injurious. 
For  older  children  the  simplest  dressing  is  a  pad  of  sterile  gauze  fast- 
ened to  the  limb  by  two  pieces  of  adhesive  plaster.  Should  the  vesicle 
rupture  and  discharge  serum,  it  should  be  kept  clean  and  dry  by  dusting 
daily  with  boric  acid.  When  the  local  symptoms  are  at  all  severe  the 
limb  should  be  kept  at  rest.  An  infected  vaccination  wound,  like  any 
other  infected  wound,  requires  careful  surgical  treatment;  disastrous 
results  often  follow  the  use  of  poultices  and  other  applications  much  in 
vogue  in  domestic  practice. 


CHAPTEE    YI. 

PURTUSSIS. 

Synonym :  Whooping-cough. 

Pertussis  is  a  contagious  disease  which  prevails  epidemically  and  in 
most  large  cities  endemically.  Although  it  may  affect  persons  of  any 
age,  it  is  generally  seen  in  young  children,  and  as  a  rule  it  occurs  but  once 
in  the  same  individual.  While  in  later  childhood  pertussis  may  be  ranked 
as  one  of  the  milder  infectious  diseases,  in  infancy  it  is  one  of  the  most 
fatal.  Its  principal  complications  are  broncho-pneumonia  and  convul- 
sions. Pertussis  is  characterized  by  catarrhal  and  nervous  symptoms. 
The  catarrh  affects  the  mucous  membrane  of  the  respiratory  tract,  and  is 
probably  due  to  a  specific  form  of  infection.  It  is  accompanied  by  a  hy- 
pera?sthetic  condition  of  this  mucous  membrane.  The  most  prominent 
nervous  manifestation  is  a  peculiar  spasmodic  cough  which  occurs  in 
paroxysms,  and  from  which  the  disease  takes  its  name.  The  cough  is  no 
doubt  of  reflex  origin,  from  an  irritation  which  has  been  located  by  dif- 
ferent writers  in  various  parts  of  the  respiratory  tract.     In  addition  to 


986  THE  SPECIFIC  INFECTIOUS  DISEASES. 

these  conditions,  there  is  present  in  pertussis  a  very  marked  irritability 
of  the  nervous  system  generally,  which  in  infancy  frequently  shows  itself 
by  convulsions. 

Etiology. — Everything  that  is  known  of  pertussis  points  to  a  micro- 
organism as  its  cause;  the  nature  of  this,  however,  has  not  yet  been  fully- 
determined.*  Proximity  to  a  patient  is  all  that  is  required  to  communi- 
cate the  disease,  and,  as  in  the  case  of  measles,  even  close  proximity  is 
not  necessary.  There  seems  to  be  no  doubt,  from  clinical  experience,  that 
the  disease  may  be  contracted  in  the  open  air. 

Predisposition. — Fully  one  half  the  cases  of  pertussis  occur  during  the 
first  two  years  of  life.  This  statement,  which  is  in  accord  with  general 
experience,  is  borne  out  by  the  following  statistics  of  Szabo  (Buda- 
Pesth),  showing  the  ages  at  which  the  disease  was  met  with  in  4,591  cases, 
comprising  the  records  of  one  clinic  for  thirty-four  years : 


Under  one  year 1,028  cases. 

One  to  two  years 1,008     " 

Two  to  three  vears 659     " 


Three  to  four  years 904  cases. 

Four  to  seven  years 803     " 

Over  seven  vears.  .• 189     " 


Pertussis  thus  shows  a  stronger  tendency  to  affect  very  young  in- 
fants than  does  any  other  contagious  disease.  It  not  infrequently  occurs 
during  the  first  six  months  of  life,  a  number  of  cases  are  on  record  in 
which  it  has  occurred  during  the  first  month,  and  one  has  recently  come 
to  my  notice  where  a  child  twelve  days  old  was  attacked,  whose  mother 
was  suffering  from  the  disease  at  the  time  the  child  was  born.  Statistics 
taken  from  a  large  number  of  epidemics  show  that  the  disease  is  nearly 
twice  as  frecj[uent  in  the  winter  and  spring  as  in  the  summer  and  autumn. 
Epidemics  of  pertussis  often  occur  at  the  same  time  with  or  follow  those 
of  measles. 

The  susceptibility  to  pertussis  is  very  great,  and  is  equalled  only  by 
that  to  measles.  Biedert  reports  that  of  401  children  exposed  during  an 
epidemic  in  a  certain  village,  366,  or  ninety-one  per  cent,  took  the  disease. 

*  The  studies  of  Koplik  and  of  Czaplewski  and  Hensel  in  1897,  and  Walsh  in  1900, 
point  to  a  short  bacillus,  which  is  found  in  the  mucus  expelled  at  the  end  of  a  typical 
paroxysm,  better  in  the  earlier  part  of  the  disease  before  bronchitis  is  present.  It  is 
described  as  scarcely  half  the  length  of  the  diphtheria  bacillus.  It  stains  readily  with 
a  carbol-glycerin-fuchsine  solution  ;  appearing  sometimes  singly,  often  in  pairs  and 
sometimes  in  chains  of  three  or  four.  It  grows  readily  upon  Loeffier's  blood-serum, 
by  which  it  is  best  separated  from  the  other  bacteria  with  which  it  is  found.  In 
obtaining  the  sputum  for  examination  the  mouth  should  be  rinsed  with  a  permanga- 
nate solution,  and  then  with  sterile  water,  to  avoid  contamination.  Before  examina- 
tion the  sputum  also  should  be  washed  several  times  with  sterile  water.  It  should, 
however,  be  said  that  Behla.  Deichler,  and  others  believe  from  their  investigation  that 
the  organism  is  not  a  bacterium,  but  a  form  of  protozoon,  probably  an  amoeba.  See 
Koplik,  Archives  of  Pfediatrics,  1898,  63 :  Czaplewski  and  Hensel,  Deutsche  med. 
Woch.,  1897,586:  Walsh,  Studies  from  the  Pepper  Laboratory,  1900;  Behla,  Deutsche 
med.  Woch.,  1898,  299. 


PERTUSSIS.  987 

Infective  period. — Pertussis  may  be  conimiinicatecl  from  the  very  be- 
ginning of  the  catarrhal  stage ;  it  is  more  contagious  at  this  period  than 
later.  There  seems  little  doubt  that  it  is  contagious  throughout  the 
spasmodic  stage  and  possibly  longer.  Quarantine  is  generally  required 
for  two  months,  and  in  many  cases  for  a  longer  time.  The  usual  source 
of  the  contagion  is  the  patient,  rarely  the  room  or  the  clothing.  While 
pertussis  may  be  carried  by  a  third  person,  this  is  very  unlikely  unless 
one  has  been  in  very  close  contact  with  the  patient,  and  goes  at  once 
without  change  of  clothing  to  another  child. 

Incubation. — The  very  gradual  onset  of  pertussis  renders  it  impos- 
sible in  the  majority  of  cases  to  fix  the  exact  date,  and  hence  to  establish 
the  definite  duration  of  the  period  of  incubation.  In  cases  where  this 
could  best  be  determined  it  has  usually  been  from  seven  to  fourteen 
days,  or  about  the  same  as  in  measles.  If,  after  an  exposure,  sixteen 
days  pass  without  the  development  of  a  cough,  the  probabilities  are  very 
strong  that  the  disease  has  not  been  contracted. 

Lesions. — The  only  constant  lesion  of  pertussis  consists  in  a  catarrhal 
inflammation  of  varying  intensity,  which  affects  the  mucous  membrane 
of  the  lar}Tix,  trachea,  and  bronchi,  and  sometimes  that  of  the  nose  and 
pharynx.  If  the  child  dies  during  a  paroxysm,  either  with  or  without 
convulsions,  the  brain  is  found  intensely  congested  and  may  be  the  seat 
of  punctate  htemorrhages,  or  even  larger  extravasations.  The  lungs 
always  show  emphysema  if  the  attack  has  been  severe  or  protracted. 
The  other  pulmonary  lesions  are  due  to  complications,  the  most  fre- 
quent of  which  is  broncho-pneumonia.  Catarrhal  enteritis  and  colitis 
are  not  infrequent. 

Symptoms. — The  symptoms  of  pertussis  are  usually  divided  into  three 
stages — the  catarrhal,  the  spasmodic,  and  the  stage  of  decline. 

The  catarrlial  stage  continues  on  the  average  for  about  ten  days,  al- 
though cases  show  considerable  variation  on  this  point.  Some  children 
whoop  almost  from  the  very  beginning  of  the  disease,  while  others  may 
cough  for  three  or  four  weeks  before  a  typical  whoop  is  noticed.  The 
symptoms  in  the  beginning  are  indistinguishable  from  those  of  an  ordi- 
nary attack  of  subacute  tracheo-bronchitis,  and  unless  there  has  been  an 
exposure  to  pertussis  no  suspicion  is  excited.  After  five  or  six  days,  how- 
ever, the  cough,  instead  of  abating  as  in  an  ordinary  cold,  gradually  in- 
creases in  severity  and  occurs  in  paroxysms.  At  first  these  are  mild, 
and  there  are  only  two  or  three  a  day,  but  they  gradually  increase  in 
frequency  and  severity  until  the  typical  wlioop  is  heard  wliicli  marks 
the  beginning  of  the  s])asmodic  stage.  During  the  first  stage  there  may  be 
symptoms  of  a  mikl  grade  of  catarrhal  inflammation  of  the  nose,  pharynx, 
and  larynx,  and  often  there  is  a  slight  elevation  of  temperature. 

The  spasmodic  stage. — In  a  typical  paroxysm  of  average  severity  the 
child,  who  can  usually  foretell  it,  will  often  run  for  support  to  the  lap  of 


988  THE   SPECIFIC  INFECTIOUS   DISEASES. 

the  mother  or  the  nurse,  or  seize  a  chair  with  both  hands.  There  now 
occurs  a  series  of  exj)losive  coughs,  from  ten  to  twenty  in  number,  com- 
ing in  such  rapid  succession  that  the  child  can  not  get  its  breath  between 
them;  the  face  becomes  of  a  deep  red  or  purple  colour,  sometimes  almost 
black;  the  veins  of  the  face  and  scalp  stand  out  prominently;  the  eyes 
are  suffused,  and  seem  almost  to  start  from  their  sockets ;  there  follows 
a  long-drawn  inspiration  through  the  narrowed  glottis,  producing  the 
crowing  sound  known  as  the  whoop;  and  then  another  succession  of 
rapid  coughs  follows  and  another  whoop.  In  a  single  severe  paroxysm, 
which  lasts  two  or  three  minutes,  the  child  may  whoop  half  a  dozen 
times ;  with  the  final  paroxysm  a  mass  of  tenacious  mucus  is  usually 
brought  up.  In  a  young  child  vomiting  is  almost  certain  to  follow,  if 
food  has  been  recently  taken.  Epistaxis  sometimes  occurs  with  nearly 
every  severe  paroxysm,  but  in  most  cases  the  bleeding  is  slight.  After 
a  severe  attack  the  child  is  at  times  so  exhausted  as  to  be  hardly  able  to 
stand;  there  is  profuse  perspiration;  his  mind  is  confused,  and  he  may 
be  completely  dazed.  In  infants  the  attack  may  result  in  a  degree  of 
asphyxia  requiring  artificial  respiration.  Those  old  enough  to  describe 
their  sensations  tell  of  a  sense  of  impending  sufl'ocation,  the  suffering 
from  which  is  almost  indescribable. 

The  number  of  severe  paroxysms  or  "  kinks  ■'  in  twenty-four  hours 
varies,  according  to  the  severity  of  the  case,  from  half  a  dozen  to  forty 
or  fifty.  There  are  always  many  more  of  a  milder  form.  Paroxysms 
are  often  excited  by  eating  or  drinking  anything  cold,  by  a  draught  of  air, 
or  by  imitation;  they  are  usually  more  frequent  during  the  night  than 
the  day,  and  in  a  close  room  than  in  the  open  air. 

In  less  severe  cases  no  paroxysms  of  the  grade  above  described  may 
occur,  and  no  typical  whoop  may  be  heard  throughout  the  attack;  but 
the  paroxysmal  nature  of  the  cough  which  continues  until  the  plug  of 
mucus  is  expelled,  the  watery  eyes,  and  the  vomiting  which  follows  a 
paroxysm,  stamp  the  disease  as  pertussis.  In  young  infants  the  whoop 
is  frequently  not  marked.  The  child  sometimes  coughs  until  it  is  as- 
phyxiated, and  yet  no  whoop  occurs.  The  paroxysms  are  also  modified 
by  intercurrent  disease,  esijecially  by  attacks  of  pneumonia  or  severe 
bronchitis.  At  such  times  they  usually  become  less  frequent  and  less 
typical,  and  may  be  absent  for  several  days,  returning  as  the  complica- 
tion subsides. 

The  seat  of  the  irritation  which  produces  the  cough  has  been  various- 
ly located  by  different  observers:  some  have  thought  it  to  be  in  the  nose, 
others  in  the  trachea,  the  bronchi,  or  the  larynx.  It  is  very  probable  that 
it  may  not  always  be  in  the  same  place  and  that  the  infectious  catarrh, 
which  is  really  the  most  important  element  in  the  disease,  may  vary  in 
its  intensity  and  location  in  different  cases.  The  weight  of  evidence  seems 
to  be  that  in  the  great  majority  of  cases  the  source  of  irritation  is  in 


PERTUSSIS.  989 

the  larynx  or  trachea.  From  laryngoscopic  examinations  made  during 
the  disease,  Von  Herff  found  the  mucous  membrane  of  the  larynx  to  be 
swollen  and  congested,  and  occasionally  the  seat  of  small  haemorrhages 
or  superficial  ulcers.  He  states  that  the  frequency  and  severity  of  the 
paroxysms  corresponded  with  the  degree  of  laryngitis,  and  he  found  that 
a  paroxysm  could  always  be  excited  by  irritating  the  mucous  membrane 
between  the  arytenoid  cartilages.  During  a  paroxysm  he  observed  that 
there  was  a  collection  of  mucus  on  the  posterior  laryngeal  wall,  the  re- 
moval of  which  had  the  effect  of  shortening  the  paroxysm. 

Eossbach  made  laryngoscopic  examinations,  with  negative  results  so 
far  as  the  larynx  was  concerned,  but  he  states  that  a  plug  of  mucus  could 
■always  be  seen  in  the  lower  trachea  for  one  or  two  minutes  before  the 
paroxysm  occurred.  There  is  little  doubt  that  this  collection  of  mucus  is 
the  exciting  cause  of  the  paroxysm,  as  it  is  a  familiar  clinical  fact  that 
the  paroxysm  always  continues  until  this  is  dislodged. 

The  average  duration  of  the  spasmodic  stage  is  about  one  month.  It 
increases  in  intensity  for  the  first  two  weeks,  remains  stationary  for 
al)out  a  week,  and  then  gradually  diminishes  in  severity.  The  course  and 
duration  of  this  stage  are,  however,  subject  to  wide  variations.  In  mild 
cases  it  may  last  only  a  week;  in  severe  cases,  especially  in  the  winter 
season,  it  may  continue  for  three  months,  at  times  almost  subsiding,  but 
lighting  up  again  with  all  its  previous  severity  with  every  fresh  attack  of 
cold.  After  it  has  entirely  ceased  the  whoop  may  return  with  an  attack 
of  bronchitis,  and  continue  for  a  month  or  more.  This  is  not  to  be  re- 
garded as  a  true  relapse  of  pertussis.  The  habit  of  the  paroxysmal  cough 
once  established,  it  tends  to  recur  with  every  slight  bronchitis,  often  for 
months  afterward. 

The  stage  of  decline. — Gradually  the  severity  of  the  paroxysms  abates, 
the  whoop  ceases,  and  the  cough  resembles  more  and  more  that  of  ordi- 
nary bronchitis.  This  stage  usually  continues  about  three  weeks,  but 
may  be  prolonged  indefinitely  in  the  winter  months. 

Complications. — ITcemorrliages. — The  haemorrhages  of  pertussis  are 
mechanical,  and  depend  upon  the  intense  venous  congestion  which  accom- 
panies the  paroxysm.  Epistaxis  is  the  most  frequent  variet}^,  and  occurs 
in  a  considerable  proportion  of  the  severe  cases,  in  a  few  with  almost 
every  severe  paroxysm,  but  it  is  rarely  severe  enough  to  require  local 
treatment.  Haemorrhages  from  the  mouth  may  have  their  origin  either 
in  the  pharynx  or  the  bronchi,  the  blood  being  brought  up  by  the  cough; 
such  haemorrhages  are  usually  small.  Conjunctival  hasmorrhages  are  less 
frequent,  and  are  usually  slight,  although  I  have  seen  the  entire  con- 
junctiva covered.  In  a  case  under  my  observation  there  was  bleeding 
from  both  ears  with  every  severe  paroxysm,  for  more  than  a  week.  This 
child  had  previously  suffered  from  scarlatinal  otitis,  with  perforation  of 
the  drum  membrane.  Small  extravasations  into  the  cellular  tissue  be- 
G4 


990  THE  SPECIFIC  INFECTIOUS  DISEASES. 

neath  the  eyes  are  occasionally  seen,  giving  an  appearance  somewhat 
like  an  ordinary  "  black  eye/'  Intracranial  haemorrhages  are  not  fre- 
quent, but  many  examples  have  been  recorded,  and  they  may  be  severe 
enough  to  produce  death.  They  are  usually  meningeal,  very  rarely 
cerebral;  according  to  their  extent  and  location  they  may  produce 
hemiplegia,  monoplegia,  aphasia,  facial  paralysis,  or  disturbances  of 
sight,  hearing,  or  sensation;  in  addition,  there  may  be  convulsions  or 
rigidity,  but  rarely  complete  coma.  The  extravasations  are  usually 
small,  and  the  symptoms  which  they  produce  disappear  at  the  end  of  a 
few  weeks.  Fatal  cases  with  autopsies  have  been  reported  by  Cazin, 
Marshall,  and  others.  In  almost  every  instance  these  haemorrhages  have 
occurred  as  a  direct  result  of  the  severe  paroxysms.  Purpura  haemor- 
rhagica  as  a  sequel  of  pertussis  was  twice  seen  at  the  New  York  Infant 
Asylum. 

Respiratory  system. — The  most  serious  complications  of  pertussis  are 
connected  with  the  lungs.  By  far  the  largest  proportion  of  deaths  is  due 
to  pulmonary  complications,  usually  broncho-pneumonia.  This  is  more 
frequent  in  winter  and  spring  than  in  the  summer  months,  and  is  espe- 
cially to  be  dreaded  during  infancy.  In  later  childhood  lobar  pneumonia 
is  occasionally  seen.  Pneumonia  rarely  begins  before  the  second  week 
of  the  disease,  and  most  frequently  develops  at  the  height  or  toward  the 
close  of  the  spasmodic  stage.  The  physical  signs  present  no  peculiarities ; 
the  cough  changes  somewhat  in  character  during  the  pneumonia,  and 
the  whoop  may  not  be  heard.  The  prognosis  of  the  pneumonia  is  bad, 
because  of  the  debilitated  condition  of  the  children  at  the  time  of  its  oc- 
currence. A  great  danger  is  from  the  supervention  of  conviilsions,  this 
being  a  frequent  mode  of  termination.  As  there  is  always  considerable 
emphysema  the  rapidity  of  breathing  is  frequently  out  of  proportion  to 
the  temperature,  which  often  is  only  moderately  elevated.  -If  the  child 
escapes  the  dangers  of  the  acute  stage,  death  may  still  occur  from  ex- 
haustion, owing  to  the  protracted  course  which  the  disease  frequently 
runs  (see  page  547). 

Bronchitis  of  the  large  tubes  is  present  in  almost  all  the  severe 
cases,  and  is  not  of  itself  serious.  Bronchitis  of  the  small  tubes  has 
the  same  dangers  and  the  same  complications  as  broncho-pneumonia. 

Vesicular  emphysema  has  been  present,  I  think,  in  every  case  which 
I  have  seen  upon  the  post-mortem  table ;  a  certain  amount  of  it,  no  doubt, 
occurs  in  every  severe  case.  It  is  produced  by  the  forcible  cough  of  the 
paroxysm.  In  very  severe  cases  interstitial  emphysema  is  also  found. 
jSTorthrup  has  reported  a  remarkable  instance  of  this  complication.  Eup- 
ture  of  the  air-blebs  which  form  on  the  surface  of  the  lung  may  lead  to 
emphysema  of  the  cellular  tissue  of  the  mediastinum,  and  the  air  may 
find  its  way  along  the  great  vessels  into  the  neck,  and  finally  into  the 
subcutaneous  cellular  tissue  of  the  entire  body.     Cases  of  general  sub- 


PERTUSSIS.  991 

cutaneous  emphysema  have  been  reported  by  Croker  and  by  Hodge, 
both  of  which  ended  fatally,  one  in  three  and  one  in  eight  days  from 
the  beginning  of  the  emphysema.  In  the  great  majority  of  the  cases 
vesicular  emphysema  is  not  permanent. 

Digestive  system. — During  the  summer,  infants  with  pertussis  are 
almost  certain  to  suffer  from  diarrhoea;  it  may  be  only  an  occasional 
symptom,  or  the  attack  may  be  severe  and  prolonged,  resulting  in  the  de- 
velopment of  ileo-colitis.  The  intestinal  complications  may  be  almost 
as  serious  in  summer  as  are  those  of  the  respiratory  tract  in  winter. 
Vomiting  is  even  more  frequent  than  diarrhoea,  and  while  it  may  be  dis- 
tressing at  any  age,  it  is  especially  so  in  infancy.  So  frequently  does  the 
taking  of  food  excite  vomiting,  that  the  nutrition  of  these  patients  often 
becomes  a  matter  of  the  greatest  difficulty,  and  in  fact  the  most  serious 
problem  in  the  management  of  a  case.  Malnutrition  and  even  marasmus 
may  follow,  or  the  general  resistance  of  the  child  may  become  so  reduced 
by  lack  of  food  that  it  falls  a  ready  prey  to  pneumonia. 

Nervous  system. — There  may  be  convulsions,  coma,  paralysis,  aphasia, 
disturbances  of  sight  or  hearing,  and  in  rare  cases  even  of  the  mental  con- 
dition. The  most  serious  of  these  complications  are  convulsions.  They 
are  much  more  frequent  in  infancy  than  later,  and  particularly  in  those 
who  are  rachitic,  in  whom  they  are  often  fatal.  Convulsions  are  of 
course  more  common  in  severe  attacks,  but  they  may  occur  suddenly  where 
there  has  previously  been  no  cause  for  anxiety.  They  are  especially  to  be 
dreaded  if  pneumonia  is  present.  The  attack  of  convulsions  may  be  the 
culmination  of  the  extreme  degree  of  nervous  irritability  which  accom- 
panies the  paroxysm,  it  may  be  due  to  asphyxia,  or  to  an  intracranial 
lesion ;  if  the  latter,  there  is  usually  meningeal  haemorrhage.  This  is  to 
be  suspected  if  there  are  continued  convulsions  for  several  hours,  with 
general  rigidity  or  hemiplegia. 

Disturbances  of  sight  are  not  infrequent  in  severe  cases;  usually 
these  are  transient,  but  there  may  be  blindness  lasting  two  or  three 
days  or  even  weeks.  The  transient  symptoms  depend  most  likely  upon 
circulatory  changes  that  occur  in  the  brain  during  the  paroxysm, 
while  those  which  last  for  two  or  three  weeks  are  probably  due  to 
meningeal  haemorrhage.  Disturbances  of  hearing  are  rare.  The  dif- 
ferent forms  of  paralysis  occurring  with  pertussis  may  likewise  be 
transient  or  permanent.  They  are  to  be  explained  in  the  same  way 
as  the  disturbances  of  the  special  senses.  The  most  common  form  is 
hemiplegia. 

Albuminuria  is  not  infrequent,  being  found  in  fiO  of  86  examinations 
by  Knight.  The  quantity  of  albumin  is  rarely  large,  and  it  may  be  ac- 
companied by  a  few  hyaline  casts.  Both  are  probably  the  result  of  circu- 
latory disturbances  in  the  kidney.  Other  complications  of  pertussis  are 
hernia,  prolapsus  ani,  and  ulcer  of  the  frenum  linguae. 


992  THE  SPECIFIC  INFECTIOUS  DISEASES. 

Diagnosis. — The  only  constant  features  of  pertussis  are  the  course  of 
the  disease  and  its  communicability.  In  many  cases  the  typical  whoop  is 
never  heard.  There  are  no  symptoms  by  which  a  positive  diagnosis  can 
be  made  in  the  catarrhal  stage;  but  a  cough  not  accompanied  by  fever  or 
physical  signS;,  which  steadily  increases  in  severity  for  two  weeks,  in  spite 
of  treatment,  and  which  occurs  chiefly  at  night,  is  always  suspicious. 
Wlien,  in  addition,  the  cough  begins  to  come  in  paroxysms,  accompanied 
by  suffusion  of  the  face  and  occasionally  by  vomiting,  there  can  be  little 
doubt  even  though  no  whoop  is  heard.  If  the  disease  is  prevalent  the 
diagnosis  is  practically  certain.  Mild  cases  which  do  not  go  even  as  far 
as  the  symptoms  mentioned  are  most  puzzling.  But  if  there  is  a  history 
of  exposure,  if  the  cough  continues  from  four  to  six  weeks,  little  influ- 
enced by  treatment,  and  if  other  cases  follow,  the  disease  must  be  per- 
tussis. Without  evidence  of  communicability,  however,  one  may  be  in 
doubt  even  after  the  disease  is  over.  In  early  infancy  any  cough  may 
have  more  or  less  of  a  spasmodic  character,  and  a  fairly  typical  whoop  is 
often  heard  in  the  course  of  an  ordinary  bronchitis.  I  have  several 
times  seen  abortive  or  very  short  attacks  in  one  member  of  a  family  of 
children,  the  others  having  the  disease  in  a  typical  form.  Occurring  by 
themselves  such  cases  cannot  be  recognised. 

Irritation  of  the  pneumogastric  or  recurrent  laryngeal  nerve  from  en- 
larged tracheal  or  bronchial  lymph  nodes,  whether  of  a  simple  or  tuber- 
culous character,  may  give  rise  to  a  spasmodic  cough,  which  in  certain 
cases  may  be  indistinguishable  from  pertussis.  The  prolonged  duration 
of  these  cases  is  sometimes  the  only  diagnostic  point ;  but  the  paroxysms 
are  usually  not  so  severe  as  in  true  pertussis,  and  the  course  is  generally 
less  typical. 

The  presence  of  leucocytosis  may  be  an  aid  to  diagnosis  in  some 
doubtful  cases.* 

Prognosis. — The  most  important  factor  in  the  prognosis  of  the  dis- 
ease is  the  age  of  the  patient.  After  the  fourth  year  it  is  indeed  rare 
that  either  a  fatal  result  or  serious  complications  are  seen;  but  during  in- 
fancy, and  particularly  during  the  first  year,  there  are  few  diseases  more 
to  be  dreaded.  This  is  especially  true  on  account  of  the  connection  of 
whooping-cough  with  the  three  most  fatal  conditions  of  infantile  life — 
broncho-pneumonia,  diarrhceal  diseases,  and  convulsions.  Fully  two 
thirds  of  the  deaths  from  whooping-cough  occur  during  the  first  year  of 

*  According  to  the  observations  of  Frohlich  and  Meunier.  leueocvtosis  is  nearly 
constant  in  the  early  stage  of  pertussis,  being  most  marked  in  infants  and  veiy  young 
children,  in  whom  the  leucocyte  count  is  often  as  high  as  25,000.  It  usually  reaches 
its  height  in  the  early  part  of  the  convulsive  stage.  The  value  of  this  symptom  for 
diagnosis,  if  further  experience  shall  confirm  these  observations,  is  increased  by  the 
fact  that  leucocytosis  is  not  present  in  those  conditions  with  which  pertussis  is  most 
likelv  to  be  confounded. 


PERTUSSIS.  993 

life.  TTie  prognosis  is  very  much  worse  in  infants  nnder  three  months 
than  in  those  who  are  older  and  consequently  have  more  resistance.  It  is 
better  in  the  summer  than  in  the  winter,  because  broncho-pneumonia  is 
then  less  frequent.  It  is  particularly  bad  in  delicate  infants,  in  those 
who  are  rachitic,  in  those  who  are  prone  to  attacks  of  bronchitis,  in 
those  who  have  suffered  previously  from  pneumonia,  and  in  those  with 
a  strong  tendency  to  tuberculosis. 

The  exact  mortality  of  whooping-cough  it  is  difficult  to  state  in  fig- 
ures. During  the  first  year  of  life  it  is  probably  not  far  from  twenty-five 
per  cent,  although  it  diminishes  rapidly  after  this  time.  In  foundling 
asylums  and  hospitals  for  infants  it  is  to  be  ranked  among  the  most  fatal 
diseases,  and  in  some  epidemics  the  mortality  in  such  institutions  is  as 
high  as  fifty  per  cent. 

Fully  two  thirds  of  the  deaths  during  whooping-cough  are  from 
broncho-pneumonia ;  the  next  most  frequent  cause  is  diarrhoeal  diseases. 
Convulsions  may  be  the  mode  of  death  in  either  of  the  above  conditions, 
or  may  occur  apart  from  them.  During  the  first  year,  death  often  results 
from  marasmus,  the  child  having  been  reduced  by  the  prolonged  disease. 
Occasionally  death  is  due  to  asphyxia  following  a  severe  paroxysm,  to 
intracranial  haemorrhage,  or  to  general  emphysema. 

As  a  predisposing  cause  of  tuberculosis,  pertussis  is  second  only  to 
measles.  In  both  diseases  tuberculosis  develops  in  much  the  same  way 
and  from  practically  the  same  causes. 

Prophylaxis. — Pertussis  is  a  contagious  disease,  and  a  child  suffering 
from  it  should  be  isolated  from  other  children  whenever  this  is  possible. 
Children  with  pertussis  should  never  be  allowed  to  attend  school,  and 
needless  exposure  should  always  be  avoided. 

Young  infants,  delicate  children,  and  those  with  a  predisposition  to 
tuberculosis,  should  be  most  carefully  protected  against  exposure,  since  it 
is  in  them  chiefly  that  the  disease  is  likely  to  be  serious.  As  it  is  from 
the  patient  that  the  disease  is  nearly  always  contracted,  there  does  not 
exist  the  same  necessity  for  the  fumigation  and  disinfection  of  apart- 
ments as  after  other  contagious  diseases.  In  institutions,  however,  this 
should  always  be  practised,  and  in  private  houses  if  the  room  is  subse- 
quently to  be  occupied  by  an  infant. 

It  is  as  undesirable  as  it  is  impossible  to  confine  a  child  with  pertus- 
sis to  a  single  room  during  the  attack;  all  those  persons  for  whom  expo- 
sure would  be  dangerous  should  therefore  be  sent  away  from  the  house. 
Quarantine  should  continue  for  at  least  six  weeks,  or  until  the  spas- 
modic stage  is  over. 

Treatment. — We  have  as  yet  no  specific  remedy  for  pertussis.  The 
important  thing  in  most  cases  is  the  hygiene  or  general  management  of 
the  case;  fully  half  of  the  cases  seen  in  practice  require  nothing  more. 
Much  harm  is  done  by  indiscriminate  drugging. 


994  THE  SPECIFIC  INFECTIOUS  DISEASES. 

General  measures. — Fresh  air  is  important  throughout  the  attack.  It 
is  almost  invariable  that  the  paroxysms  are  fewer  while  patients  are  out 
of  doors,  and  more  frequent  when  they  are  in  close  rooms.  Older  chil- 
dren with  pertussis  may  go  out  even  in  winter  except  on  stormy,  raw,  or 
windy  days.  With  infants  and  delicate  children,  the  outdoor  treat- 
ment in  cold  weather  so  enthusiastically  advocated  by  some  writers 
should  be  used  with  the  greatest  caution.  It  should  certainly  not  be  per- 
mitted if  the  patient  has  even  the  slightest  amount  of  bronchitis.  My 
own  experience  is  that  during  the  winter  in  a  climate  like  that  of  New 
York  or  N'ew  England,  the  class  of  patients  just  referred  to  are  better 
off  indoors,  taking  their  airing,  if  at  all,  in  their  rooms.  In  warm 
weather  or  in  a  mild  climate  all  children  should  be  kept  in  the  open  air 
as  much  as  possible. 

A  change  of  climate  is  desirable  when  the  cough  is  unduly  prolonged, 
also  for  delicate  children  in  winter.  A  warm  place  at  the  seashore  is 
one  which  is  most  likely  to  be  beneficial.  The  improvement  following  a 
sea  voyage  is  often  very  marked,  surpassing  even  a  residence  at  the  sea- 
shore. 

The  rooms  occupied  by  children  suffering  from  pertussis  should  be 
frequently  changed,  thoroughly  aired,  and  occasionally  fumigated.  The 
daily  use  in  the  room  of  one  of  the  small  formalin  lamps  is  of  decided 
benefit.  A  change  of  rooms,  clothing,  bedding,  etc.,  sometimes  exerts  a 
marked  influence  on  the  course  of  very  prolonged  attacks,  the  inference 
being  that  continued  re-infection  takes  place.  Such  a  change  should  be 
made  twice  a  week,  and  it  is  of  special  importance  in  hospitals,  where 
many  children  quarantined  in  a  ward  seem  to  cough  interminably. 

Careful  feeding  and  attention  to  the  bowels  are  matters  of  the  great- 
est importance;  with  infants  particularly,  chronic  indigestion  and  ab- 
dominal distention  have  a  very  marked  effect  in  increasing  the  frequency 
of  the  paroxysms.  Feeding  is  difficult  since  vomiting  occurs  so  easily. 
In  most  cases  it  is  necessary  to  repeat  the  meal  in  a  short  time,  if 
the  first  one  has  been  vomited.  Children  over  two  years  old  should  in 
all  such  cases  be  kept  upon  a  fluid  diet,  chiefly  of  milk.  For  infants,  milk 
should  be  diluted,  and  in  many  instances  it  should  also  be  partially  pep- 
tonized. Any  medication  which  causes  disturbance  of  the  stomach 
should  be  omitted.  In  severe  cases  the  child's  strength  should  be  kept 
up  by  the  judicious  use  of  alcoholic  stimulants. 

Local  treatment. — This  may  be  effected  by  insufflations  of  powder  into 
the  nose,  by  local  applications  to  the  larynx,  or  by  inhalations. 

The  first  two  methods  have  been  advocated,  in  the  belief  that  the 
cough  is  due  to  an  infectious  catarrh  having  its  seat  in  the  nose  or 
larynx.  For  insufflation,  quinine  or  benzoic  acid  is  preferred,  mixed 
with  some  finely  divided,  inert  powder,  such  as  bicarbonate  of  sodium, 
talcum,  or  coffee;  these  are  used  with  the  powder  insufflator  once  or 


PERTUSSIS.  995 

twice  daily.  Local  applications  to  the  larynx  may  be  made  by  means 
of  a  spray  or  swab.  Kesorcin  and  carbolic  acid,  each  in  a  one-per-cent 
solution,  are  most  used.  These  applications  are  made  once  or  twice 
daily.  I  have  never  seen  from  any  of  the  above  methods  the  beneficial 
results  claimed,  and  I  belieye  them  to  have  been  exaggerated.  The 
application  of  cocaine  to  the  larynx  should  never  be  em])loyed  in  young 
children  on  account  of  the  danger  of  poisoning. 

Inhalations  are  of  much  more  value.  They  arc  useful  to  modify  the 
catarrh  by  allaying  irritation,  facilitating  the  expulsion  of  the  mucus,  and 
possibly  as  antiseptics.  Those  most  emploj^ed  are  carbolic  acid,  creosote, 
and  cresolene.  In  my  experience  creosote  is  the  best.  These  sub- 
stances may  be  used  upon  cotton  in  a  respirator,  or  vapourized  over  an 
alcohol  lamp  (page  58).  The  possibility  of  absorption  should  not  be 
forgotten,  and  the  urine  should  be  watched.  Where  the  paroxysms  are 
frequent  and  of  great  severit}^,  chloroform  may  be  used  to  ward  off  con- 
vulsions or  prevent  dangerous  asphyxia.  In  such  conditions  O'Dwyer 
used  intubation  with  striking  benefit.  The  tube  entirely  overcomes  the 
glottic  spasm  which  is  the  chief  cause  of  suffering  and  danger.  O'Dwyer's 
plan  was  to  have  the  tube  worn  constantly  until  the  severity  of  the  dis- 
ease had  passed.  With  the  rubber  tubes  now  in  use  the  difficulty  in  get- 
ting rid  of  the  tube  subsequently  is  not  great. 

Internal  medication. — Of  the  innumerable  drugs  which  have  been  rec- 
ommended for  this  disease,  four  possess  undoubted  advantages  over  all 
others — viz.,  quinine,  belladonna,  bromoform,  and  antipyrine.  Quinine 
should  not  be  used  for  infants  and  seldom  for  young  children  on  ac- 
count of  its  tendency  to  upset  the  stomach.  For  older  children  full 
doses  are  required  to  be  of  much  benefit — i.  e.,  twelve  to  fifteen  grains 
daily  to  a  child  of  five  years.  In  giving  belladonna  it  is  important  to 
begin  with  a  small  dose  and  gradually  increase  both  its  frequency  and 
size  until  the  physiological  effects  of  the  drug  are  produced.  To  an 
infant  two  years  old,  half  a  minim  of  the  fluid  extract  may  be  given 
every  four  hours  as  an  initial  dose,  gradually  increasing  to  every  two 
hours ;  if  atropine  is  used,  gr.  -^-^  may  be  given  in  the  same  way.  Al- 
though belladonna  usually  has  a  decided  influence  in  reducing  both  the 
frequency  and  the  severity  of  the  paroxysms,  it  causes  many  unpleasant 
.symptoms,  and  its  effects  must  be  closely  watched. 

Bromoform  has  considerable  value,  but  it  is  by  no  means  a  specific. 
A  convenient  method  of  administration  is  to  drop  it  upon  sugar.  When 
prescribed  in  emulsions  or  mixtures  these  should  be  carefully  shaken 
before  each  dose,  or  the  patient  may  be  poisoped  by  getting  the  greater 
part  of  the  drug  in  the  last  few  doses.  The  dose  at  two  3'ears  is  from 
one  to  three  drops,  at  five  years  two  to  four  drops  from  three  to  five 
times  a  day.    In  full  doses  it  must  be  used  with  caution. 

Anti])yrine  has  been  in  my  experience  more  generally  useful  than 


996  THE  SPECIFIC  INFECTIOUS  DISEASES. 

any  other  single  drug.  It  may  be  given  with  safety,  even  to  young  in- 
fants, in  considerably  larger  doses  than  are  ordinarily  employed.  For  a 
child  six  months  old  the  initial  dose  may  be  one  grain  every  three  hours ;. 
later  this  may  be  given  every  two  hours.  For  a  child  two  years  old  the 
initial  dose  may  be  two  grains  repeated  every  four  to  six  hours,  gradually 
increasing  up  to  two  grains  every  two  hours.  Should  pneumonia  de- 
velop, the  antipyrine  should  be  discontinued. 

Nearly  all  drugs  which  allay  nervous  irritability  have  a  certain  amount 
of  effect  in  controlling  the  paroxysms  of  pertussis;  codeine,  chloral,  and' 
trional  are  useful  where  the  night  attacks  are  so  severe  as  to  prevent 
sleep.  A  combination  of  the  bromide  of  sodium  with  antipyrine  is  often 
better  than  the  latter  given  alone.  Heroin,  although  in  use  but  a  short 
time,  promises  to  be  a  valuable  addition  to  our  therapeutics.  I  do  not 
believe  that  any  form  of  internal  medication  or  local  treatment  shortens 
pertussis;  but,  inasmuch  as  the  disease  is  self-limited,  great  benefit  to 
the  patient  results  from  the  reduction  of  the  number  and  the  diminu- 
tion of  the  severity  of  the  paroxysms. 

In  establishing  the  value  of  any  method  of  treatment,  it  should  be 
remembered  that  the  number  of  cases  in  which  the  disease  is  considerably 
shorter  than  the  average  is  large,  and  also  that  almost  any  method  of 
treatment  if  employed  after  the  attack  has  reached  its  height  will  be 
thought  beneficial,  as  the  natural  tendency  is  then  to  improve.  The  value 
of  any  particular  line  of  treatment  is  to  be  judged  in  a  given  case  only 
by  its  effect  in  reducing  the  number  and  severity  of  the  paroxysms.  This 
ought  to  be  evident  in  the  case  of  drugs  witbin  two  or  three  days,  and  can 
only  be  determined  by  keeping  a  careful  record  of  the  number  of  severe 
paroxysms  day  and  night.    ISTo  drug  succeeds  equally  well  in  all  cases. 

In  a  mild  case,  where  the  number  of  paroxysms  does  not  exceed 
eight  or  ten  during  the  day,  where  there  is  no  vomiting  and  the  gen- 
eral health  is  not  affected,  it  is  not  usually  advisable  to  continue  the 
administration  of  any  drugs  throughout  the  disease.  A  single  dose  of 
antipyrine  or  codeine  at  night  may  be  all  that  is  necessary.  All  cases 
in  infants  must  be  watched  with  great  care  and  the  parents  warned  of 
the  possible  dangers  which  may  supervene  suddenly,  even  in  the  course 
of  mild  attacks.  For  severe  cases  antipyrine  should  be  given  to  diminish 
the  frequency  and  the  severity  of  the  paroxysms,  and  inhalations  of 
creosote  used  if  much  catarrh  is  present.  All  the  fresh  air  possible 
should  be  allowed.  For  older  children  the  same  plan  of  treatment  may  be 
followed,  or  quinine  or  belladonna  may  be  substituted  for  the  antipyrine. 
As  these  drugs  are  given  solely  for  the  purpose  of  diminishing  the 
frequency  and  severity  of  the  paroxysms,  their  continuous  use  should  be 
deferred  until  the  symptoms  are  sufficiently  severe  to  greatly  disturb  the 
child,  the  benefit  at  this  period  being  more  striking  than  if  they  are 
begun  early  and  used  continuously. 


MUMPS.  997 


CHAPTER   VII. 

MUMPS. 

Synonym :  Epidemic  parotitis. 

Mumps  is  a  contagions  disease  characterized  by  swelling  of  the  par- 
otid, and  sometimes  of  the  other  salivary  glands,  with  constitutional 
symptoms  which  are  usiially  mild.  Both  severe  complications  and  a 
fatal  termination  are  extremely  infrequent.  The  disease  is  not  a  very 
common  one,  and  general  epidemics  are  rare. 

Pathology  and  Lesions. — The  contagious  character,  definite  incuba- 
tion, and  typical  course,  stamp  the  disease  as  a  general  one  due  to  a  spe- 
cific poison,  probably  a  micro-organism,  whose  nature  is  as  yet  unknown. 
It  is  probable  that  infection  takes  place  through  the  salivary  ducts. 

The  precise  nature  of  the  changes  in  the  gland  is  still  a  matter  of 
dispute,  as  opportunities  for  pathological  examination  are  very  rare. 
From  existing  evidence  it  would  appear  that  the  gland  substance  is  first 
involved,  and  afterward  the  surrounding  connective  tissue.  The  gland 
is  the  seat  of  an  intense  hyperaemia  and  oedema ;  the  walls  of  the  salivary 
ducts  are  swollen,  and  the  ducts  are  obstructed.  While  the  primary  dis- 
ease does  not  tend  to  excite  suppuration,  pyogenic  germs  may  occasionally 
gain  entrance  and  an  abscess  form;  but  this  is  to  be  regarded  as  a  rare 
accidental  infection. 

In  the  great  proportion  of  cases  the  parotids  alone  are  affected,  al- 
though the  same  changes  are  occasionally  found  in  the  other  salivary 
glands.  There  are  no  other  essential  lesions  of  the  disease,  those  which 
are  found  depending  upon  complications. 

Etiology. — Mumps  is  spread  by  contagion,  close  contact  being  usually 
required  to  communicate  the  disease,  although  it  is  known  to  have  been 
carried  by  a  third  person  and  even  by  clothing.  The  susceptibility  of 
children  to  the  poison  of  mumps  is  much  less  than  is  the  case  with  the 
other  contagious  diseases,  so  that  only  a  small  number  of  those  who  are 
exposed  take  the  disease.  The  greatest  predisposition  is  between  the 
fourth  and  fourteenth  years.  Infants  are  rarely  affected,  although  a 
case  in  a  child  three  weeks  old  is  vouched  for  by  so  good  an  observer  as 
Demme. 

Mumps  is  contagious  from  the  beginning  of  the  symptoms.  Two  cases 
have  come  under  my  notice  in  which  the  disease  was  communicated 
before  any  swelling  was  seen.  It  is  impossible  to  fix  with  certainty  the 
duration  of  the  infective  period.  The  disease  is  undoubtedly  communi- 
cable for  several  days  after  the  swelling  has  subsided ;  and  for  safety  a 
case  should  be  isolated  for  three  weeks  from  the  beginning  of  symptoms^ 
or  at  least  ten  days  after  the  swelling  has  disappeared. 


998  THE  SPECIFIC  INFECTIOUS  DISEASES. 

Incubation. — In  forty-eight  collected  cases  in  which  the  incubation 
was  definitely  determined,  it  varied  between  three  and  twenty-five  days. 
It  was  less  than  fourteen  days  in  only  four  cases,  and  in  twenty-six  of 
the  forty-eight  cases  it  was  between  seventeen  and  twenty  days.  In  three 
cases  of  my  own  in  which  it  could  be  definitely  fixed,  the  incubation  was 
nineteen  days  in  one  case  and  twenty  days  in  two  cases.  The  average 
jDeriod  of  incubation,  then,  may  be  stated  to  be  from  seventeen  to 
twenty  days. 

Symptoms. — In  the  milder  cases  the  local  symptoms  are  the  first  to 
attract  attention;  in  those  which  are  more  severe  there  are  frequently 
prodromal  symptoms  of  from  twelve  to  forty-eight  hours'  duration — 
anorexia,  headache,  vomiting,  pains  in  the  back  and  limbs,  and  fever. 
Soltmann  has  reported  a  case  ushered  in  by  convulsions.  Tbe  initial 
temperature  in  a  mild  attack  is  100°  to  101°  F. ;  in  a  severe  one,  from 
102°  to  104°  F. 

Of  the  local  symptoms,  the  pain  usually  precedes  the  swelling;  it  is 
increased  by  movement  of  the  jaws,  by  pressure,  and  sometimes  by  the 
presence  of  acid  substances  in  the  mouth.  It  is  usually  referred  to  the 
posterior  part  of  the  jaw  just  below  the  ear.  The  swelling  may  begin 
simultaneously  in  both  parotids,  but  more  frequently  one  side  is  involved 
a  day  or  two  in  advance  of  the  other.  It  usually  reaches  its  maximum  on 
the  third  day,  often  on  the  second,  remains  stationary  for  two  or  three 
days,  and  then  subsides  gradually.  The  degree  of  swelling  varies  with 
the  severity  of  the  attack.  Wlien  it  is  marked,  the  patient  may  be  so 
changed  in  appearance  as  scarcely  to  be  recognisable;  it  fills  the  lateral 
region  of  the  neck  between  the  jaw  and  the  sterno-mastoid  muscle  and 
extends  forward  upon  the  face  to  the  zygomatic  arch,  so  that  the  centre 
of  the  tumour  is  usually  the  lobe  of  the  ear.  The  other  salivary  glands 
may  swell  simultaneously  with  the  parotids,  or  several  days  later,  even 
after  the  parotid  tumour  has  disappeared.  Occasionally  swelling  of  the 
submaxillary  or  the  sublingual  glands  occurs  before  that  of  the  parotid, 
and  in  rare  instances  these  may  be  the  only  glands  affected. 

As  a  rule,  the  parotid  of  both  sides  is  involved.  Of  282  cases  both 
sides  were  affected  in  215.  When  one  side  alone  is  involved,  it  is  the 
left  a  little  more  frequently  than  the  right.  The  interval  between  the 
swelling  of  the  two  sides  may  be  a  week,  or  even  five  or  six  weeks,  but 
usually  it  is  only  two  or  three  days. 

The  salivary  secretion  is  usually  very  much  diminished,  and  the  dry 
mouth  causes  great  discomfort.  An  exceptional  instance  has  been  re- 
ported by  Simon,  in  which  a  distressing  salivation  occurred,  the  secre- 
tion amounting  to  six  or  eight  ounces  daily. 

Although  as  a  rule  the  patient  is  not  seriously  ill,  mumps  may  in  rare 
cases  produce  most  alarming  and  even  dangerous  symptoms.  The  tem- 
perature may  for  several  days  reach  104°  F.  or  more,  deglutition  may  be 


MUMPS.  999 

extremely  difficult,  pressure  on  the  jugular  veins  may  lead  to  venous 
liyperaemia  of  the  brain,  causing  headache  and  sometimes  delirium ;  there 
is  sometimes  great  prostration  and  the  symptoms  of  the  typhoid  condi- 
tion. These  severe  attacks  are  nearly  always  in  children  over  twelve 
years  old. 

The  constitutional  symptoms  of  mumps  usually  last  from  three  to 
five  days;  the  swelling  continues  on  an  average  a  little  less  than  a 
week.  If  the  case  has  been  a  severe  one,  slight  swelling  may  continue 
for  two  weeks  or  even  longer.  Eelapses,  in  which  the  opposite  side  from 
the  one  first  affected  is  involved,  are  quite  frequent,  occurring  in  about 
ten  per  cent  of  the  cases. 

Complications  and  Sequelae. — In  childhood  the  complications  are  few 
and  usually  unimportant;  but  in  adolescence  they  are  occasionally  seri- 
ous. Orchitis  is  exceedingly  rare  in  childhood;  of  230  cases  observed  by 
Eilliet  and  Barthez,  this  was  seen  in  but  10,  and  only  3  of  these  cases 
were  under  fifteen  years,  and  no  case  under  twelve  years  old.  When  or- 
chitis occurs  it  is  generally  toward  the  end  of  the  second  or  the  beginning 
of  the  third  week;  it  is  usually  marked  by  an  accession  of  fever,  sometimes 
by  a  chill;  if  severe,  nervous  symptoms  may  be  present.  The  body  of 
the  testicle  and  not  the  epididymis  is  generally  affected.  The  acute 
symptoms  continue  for  three  or  four  days,  and  the  entire  duration  of  the 
attack  is  about  a  week ;  although  the  testicle  is  often  enlarged  for  some 
time  afterward,  and  atrophy  of  the  organ  may  follow. 

In  females,  congestion  and  swelling  of  the  breasts,  ovaries,  or  labia 
majora  may  occur;  and,  although  these  complications  are  all  very  rare, 
most  of  them  have  been  observed  even  in  young  children. 

Nephritis  has  in  a  few  instances  followed  mumps,  sometimes  coming 
on  as  late  as  four  or  five  weeks  after  the  attack.  Single  eases  have  been 
reported  by  Croner,  Isham,  Henoch,  and  others.  Kervous  sequelae  are 
more  frequent,  but  even  these  are  rare.  Jaffrey  has  reported  a  case  of 
multiple  neuritis  with  typical  symptoms,  occurring  three  weeks  after  an 
attack.  Facial  paralysis  three  weeks  after  mumps  has  been  reported  by 
HillieT,  apparently  due  to  an  extension  of  inflammation  from  the  gland 
to  the  seventh  nerve. 

Pearce  *  has  collected  an  interesting  series  of  forty  cases  of  deafness 
following  mumps,  in  w^iich  there  was  no  sign  of  otitis,  the  symptoms 
coming  on  suddenly  with  vertigo,  a  staggering  gait,  and  often  with  vomit- 
ing. In  most  of  the  cases  the  deafness  was  unilateral  and  the  loss  of 
hearing  was  permanent.  The  cause  assigned  was  disease  of  the  auditory 
nerve,  the  seat  of  the  trouble  being  in  the  labyrinth.  Toynbee  has  re- 
ported an  instance  of  hasmorrhage  into  the  labyrinth.  Otitis  media  is 
rarely  seen. 

*  Manchester  Chronicle,  1885. 


1000  THE  SPECIFIC  INFECTIOUS  DISEASES. 

Suppuration  of  the  parotid  gland  occurs  in  about  one  per  cent  of 
the  cases,  and  is  probably  due  to  accidental  infection.  Gangrene  and 
sloughing  of  the  parotid  were  observed  twice  by  Denime  in  117  cases; 
both  of  these  proved  fatal.  Pneumonia,  meningitis,  endocarditis,  and 
pericarditis  have  been  observed  as  complications  of  mumps,  although 
all  are  extremely  rare. 

Prognosis. — In  the  great  proportion  of  cases  mumps  is  a  mild  dis- 
ease, and  terminates  in  complete  recovery  in  a  few  days.  In  young  chil- 
dren complications  are  infrequent,  and  those  which  occur  are  rarely 
severe. 

Diagnosis. — Mumps  is  most  likely  to  be  confounded  with  acute  swell- 
ing of  the  cervical  lymph  nodes.  In  a  parotid  swelling,  the  lobe  of  the  ear 
is  near  the  centre  of  the  tumour,  which  extends  backward  to  the  sterno- 
mastoid  muscle  and  forward  upon  the  face  as  far  as  the  zygomatic  arch, 
embracing  the  angle  and  ramus  of  the  jaw. 

A  swollen  lymph  node  is  usually  entirely  below  the  ear  and  behind 
the  jaw,  not  extending  upon  the  face.  The  tumour  is  generally  smaller 
and  more  circumscribed  if  only  a  single  node  is  involved,  and  it  comes  on 
much  more  slowly  than  does  mumps.  When  only  the  submaxillary  or  sub- 
lingual glands  are  affected,  the  diagnosis  from  swollen  lymph  nodes  is 
sometimes  impossible  except  by  the  course  of  the  disease.  Mumps  is 
characterized  by  the  rapidity  with  which  the  swelling  occurs,  and  by  its 
relatively  short  duration. 

Treatment. — The  disease  is  self-limited  and  the  individual  symptoms 
rarely  distressing,  so  that  in  most  cases  very  little  treatment  is  required. 
If  constitutional  symptoms  are  present  the  patient  should  be  kept  in 
bed,  and  if  there  are  none  he  should  be  confined  to  the  house.  The  gland 
should  be  protected  by  cotton  or  spongio-piline,  and  if  the  pain  is  severe 
heat  should  be  applied  or  the  gland  painted  with  belladonna.  The  diet 
should  be  liquid,  on  account  of  the  pain  produced  by  mastication.  The 
mouth  should  be  kept  clean  by  the  use  of  some  antiseptic  mouth-wash. 
The  general  symptoms  and  complications  are  to  be  treated  according  to 
the  indications  presented.  Cases  of  mumps  occurring  in  schools  or  insti- 
tutions should  be  quarantined  for  three  weeks,  and  in  private  practice 
where  there  are  susceptible  persons.  Fumigation  and  disinfection  after 
an  attack  are  unnecessary. 


CHAPTEE    VIII. 
DIPHTHERIA. 

UxTiL  within  the  last  few  years  it  has  been  customary  to  class  as 
diphtheria  all  diseases  characterized  by  the  production  of  a  false  mem- 
brane upon  the  mucous  membranes  of  the  throat  or  air  passages.    Bacte- 


DIPHTHERIA.  1001 

riological  study  of  these  cases  has  yielded  results  so  uniform  that  we  are 
now  able  to  separate  them  into  two  groups  :  In  one,  there  has  been  demon- 
strated the  constant  presence  of  the  Klebs-Loeffler  bacillus — the  Bacillus 
diphtherice;  this  group  includes  cases  formerly  classed  as  primary  diph- 
theria, and  also  certain  others,  such  as  primary  membranous  laryngitis 
and  rhinitis,  the  pathology  of  which  has  been  the  subject  of  much  dis- 
pute. In  the  other  group  the  Klebs-Loeffler  bacillus  is  absent ;  this  group 
includes  most  of  the  membranous  inflammations  of  the  throat  which 
occur  as  complications  of  measles  and  scarlet  feyer,  and  many  primary 
■cases  of  such  inflammations  affecting  only  the  tonsils  or  the  tonsils  and 
pharynx,  and  formerly  regarded  by  some  as  croupous  tonsillitis,  by  others 
as  mild  or  doubtful  diphtheria.  The  form  of  bacterium  which  has  usually 
been  found  in  these  inflammations  which  simulate  diphtheria,  is  the 
streptococcus  pyogenes,  occasionally  the  staphylococcus.  In  the  follow- 
ing pages  the  term  diphtheria  will  be  limited  to  those  cases  in  which  the 
Klebs-Loeffler  bacillus  is  present,  the  others  being  grouped  under  the 
head  of  false  or  pseudo-diphtheria. 

Diphtheria  may  then  be  defined  as  an  acute,  specific,  communicable 
■disease  due  to  the  bacillus  of  Klebs  and  Loeffler.  It  is  usually  charac- 
terized by  the  formation  of  a  false  membrane  upon  certain  mucous  mem- 
hranes,  especially  those  of  the  tonsils,  pharynx,  nose,  or  larynx.  Like 
other  pathogenic  organisms,  however,  this  germ  acts  with  varying  in- 
tensity, and  may  cause  inflammation  of  all  degrees  of  severity,  from 
a  mild  catarrhal  angina  to  the  most  serious  membranous  inflammation; 
but  to  all  alike  the  term  diphtheria  should  be  applied.  In  its  mild  form 
it  may  be  almost  without  constitutional  s5anptoms  ;  but  in  its  severe  form 
it  is  attended  by  great  general  prostration,  cardiac  depression,  and 
anaemia,  it  is  frequently  complicated  by  pneumonia  and  nephritis,  and 
it  may  be  followed  by  localized  or  general  paralysis;  it  then  constitutes 
one  of  the  diseases  most  to  be  dreaded  in  childhood.  "\^Qiile,  therefore, 
there  are  now  included  under  the  term  diphtheria  many  cases  formerly 
not  recognised  as  such,  there  are  excluded  many  others  which  some- 
what resemble  it  clinicall}',  but  in  which  the  bacillus  of  diphtheria  is 
absent. 

Etiology. — The  Bacillus  Diphtherice. — This  was  first  described  by 
Klel)s  in  1883,  and  during  the  following  year  it  was  isolated  by  Loeffler 
and  shown  to  be  pathogenic.  Little  was  added  to  this  discovery  until 
1888,  but  from  that  time  until  1891  very  extensive  observations  were 
made  in  France,  Germany,  and  America,*  all  confirming  the  early  conclu- 
sions of  Loeffler.  By  1891  all  the  conditions,  says  Welch,  had  been  ful- 
filled to  demonstrate  that  this  bacillus  was  the  cause  of  diphtheria — viz., 

*  For  a  summary  of  the  literature  upon  this  subject,  see  Welch  and  Abbott,  Johns 
Hopkins  Hospital  Bulletin.  February  and  IMarch,  1891 ;  Prudden,  New  York  Medical 
Record,  April,  1891 ;  Park.  New  York  Medical  Record.  July  and  August,  1892. 


1002  THE  SPECIFIC  INFECTIOUS  DISEASES. 

(1)  its  constant  presence;  (2)  its  isolation  in  puie  culture;  (3)  the 
reproduction  of  the  disease  in  animals  by  inoculation  with  pure  cultures; 
(4)  the  finding  of  a  similar  distribution  of  the  bacilli  both  in  the  original 
and  in  the  experimental  disease. 

The  bacillus  of  diphtheria  varies  considerably  in  size  and  shape  even 
in  the  same  culture.  Its  length  is  from  1-5  to  6-5  micro-millimetres;  its 
diameter,  from  0-3  to  0*8  micro-millimetres.  In  a  specimen  it  occurs 
singly  or  in  pairs,  sometimes  in  chains  of  three  or  four;  the  bacilli  may 
lie  parallel,  but  frequently  two  form  an  acute  or  an  obtuse  angle  (Plate 
XX,  3,  4,  and  5).  They  are  straight  or  slightly  curved,  and  sometimes 
branching;  they  may  be  swollen  or  club-shaped  at  their  ends.  The  bacilli 
have  no  spores,  but  contain  highly  refractile  bodies,  which  cause  them 
to  stain  peculiarly.  With  alkaline  methylene  blue  (Loeffler's  stain)  they 
stain  in  a  very  characteristic  way;  not  uniformly,  but  the  oval  bodies  in 
the  central  parts  or  in  the  extremities  of  the  bacillus,  stain  more  deeply 
than  the  rest  of  the  protoplasm. 

The  best  culture  medium  is  Loeffler's  blood-serum.  After  ten  or 
twelve  hours,  at  a  temperature  of  about  100°  F.,  the  colonies  (Plate 
XX,  1  and  2)  appear  slightly  elevated,  of  a  white  or  grayish  colour,  with 
rounded  but  generally  irregular  borders.  They  may  increase  to  one 
fourth  of  an  inch  in  size;  and  although  the  early  colonies  are  about  the 
same  size  as  those  of  the  streptococcus,  the  later  ones  are  larger. 

Distribution  and  mode  of  communication. — Diphtheria  prevails  epi- 
demically, endemically,  and  sporadically.  In  most  large  cities  it  is  en- 
demic, occasional  cases  occurring  throughout  the  year,  with  periods  in 
which  outbreaks  of  considerable  severity  are  observed.  In  the  country 
it  prevails  chiefly  as  an  epidemic.  The  disease  is  often  introduced  into 
remote  districts  in  some  inexplicable  manner,  and  before  its  nature  is 
recognised  a  large  number  of  persons  may  be  exposed,  and  an  epidemic 
results.* 

Diphtheria  does  not  arise  de  novo.  Every  case  has  its  origin  in  a 
previous  case  either  directly  or  remotely.  The  bacilli  may  enter  the 
body  through  the  inspired  air;  they  may  be  taken  into  the  mouth  with 
toys  or  other  articles  upon  which  they  have  lodged,  or  by  kissing,  and 

*  The  following  is  an  example  of  the  way  in  which  diphtheria  may  be  introduced : 
In  the  country  branch  of  the  New  York  Infant  Asylum,  consisting  of  a  somewhat  iso- 
lated community  of  about  five  hundred  persons,  chiefly  children,  there  had  been  no 
case  of  diphtheria  for  several  years  until  1887.  The  first  case  was  one  of  membranous 
laryngitis,  proving  rapidly  fatal  in  two  days.  At  autopsy,  membrane  was  found  only 
in  the  larynx.  The  case  was  regarded  at  that  time  as  evidence  of  the  existence  of  a 
primary  non-diphtheritic  membranous  croup.  In  the  course  of  the  next  few  weeks 
there  developed  a  number  of  cases  of  typical  diphtheria.  On  investigation,  it  was  dis- 
covered that  the  nurse  who  had  charge  of  the  child  first  affected  had  been  a  few  weeks 
before  in  attendance  upon  a  case  of  diphtheria.  During  the  five  years  following,  cases 
of  diphtheria  occurred  in  the  institution  every  year. 


DIPHTHERIA.  1003 

sometimes  by  accidental  inoculation.  As  a  rule,  the  iDacilli  first  gain  a 
foothold  upon  the  mucous  membrane  of  the  tonsils,  nose,  or  larynx. 

Direct  infection  is  the  cause  in  the  great  majority  of  the  cases. 
There  is  no  proof  that  the  bacilli  are  contained  in  the  breath  of  a  person 
suffering  from  the  disease.  They  are  discharged  in  great  numbers  in 
the  saliva  and  mucus  from  the  mouth  and  nose,  and  in  pieces  of  mem- 
brane which  are  coughed  up;  they  are  not  present  in  the  urine  or  faeces. 
The  most  contagious  cases  are  those  of  pharyngeal  diphtheria  of  severe 
type  and  long  duration,  chiefly  on  account  of  the  amount  of  discharge 
which  accompanies  them.  The  cases  that  are  least  contagious  are  those 
in  which  the  membrane  is  limited  to  the  larynx  and  lower  air  passages. 

Direct  infection  may  occur  from  persons  convalescent  from  diph- 
theria, whose  throats  still  contain  virulent  bacilli,  or  from  persons  suf- 
fering from  a  mild  form  of  the  disease,  w^hich  is  not  recognised  as  diph- 
theria. In  the  latter  way  it  is  often  spread  in  schools.  It  has  been 
shown  that  a  person  may  harbour  virulent  bacilli  in  his  nose  or  throat, 
and  may  even  communicate  the  disease  to  others,  without  himself  suf- 
fering from  diphtheria  at  any  time. 

The  length  of  time  during  which  a  patient  with  diphtheria  may  con- 
vey the  disease  to  others  is  somewhat  uncertain.  Transmission  is  possi- 
ble so  long  as  virulent  bacilli  remain  in  the  throat;  these  are  frequently 
found  two  weeks  after  the  membrane  has  disappeared  and  the  patient  is 
regarded  as  entirely  well,  and  in  a  few  cases  they  are  found  five  or  six 
weeks  or  longer  after  recovery. 

Indirect  infection  is  not  uncommon,  and  may  occur  from  the  bed  or 
clothing  of  the  patient,  from  the  carpet,  furniture,  wall-paper  or  hang- 
ings of  the  room,  from  toys  or  picture-books,  from  dishes,  feeding-bot- 
tles, or  drinking-cups,  from  swabs  and  brushes  used  for  local  applica- 
tions to  the  throat,  from  spoons  and  tongue-depressors,  and  from  surgi- 
cal instruments  with  which  tracheotomy  or  intubation  has  been  done. 
Diphtheria  may  be  carried  by  a  third  person,  but  rarely  except  by  one 
who  has  been  in  close  contact  with  the  patient — either  the  physician  or 
nurse.  The  frequency  of  diphtheria  in  physicians'  families  bears  wit- 
ness to  the  great  danger  of  infection  in  this  manner. 

Bacilli  may  retain  their  virulence  for  an  indefinite  period.  Both 
Park  and  Locffler  found  cultures  in  blood-serum  to  be  virulent  after 
seven  months;  Roux  and  Yersin,  bacilli  in  dried  membrane  to  be  viru- 
lent after  twenty  weeks;  and  Abel,  upon  a  child's  toy  after  five  months. 

Domestic  animals  may  in  rare  instances  be  carriers  of  infection,  and 
in  the  case  of  pigeons,  at  least,  they  may  themselves  suffer  from  the  dis- 
ease. Diphtheria  has  been  repeatedly  spread  by  milk,  but  very  rarely 
through  the  contamination  of  a  water  supply. 

Predisposing  causes. — Local  conditions  in  the  throat  influence  very 
largely  the  occurrence  of  diphtheria.    An  important  predisposing  cause 


1004  THE  SPECIFIC  INFECTIOUS  DISEASES. 

is  the  existence  of  a  chronic  catarrhal  inflammation  of  the  mucous  mem- 
branes of  the  nose  and  throat,  so  frequently  found  in  children  sufEering 
from  adenoid  growths  of  the  pharynx  or  from  enlarged  tonsils.  These 
adenoid  growths,  the  tonsillar  crypts,  and  the  cavities  of  carious  teeth, 
may  harbour  the  bacilli  for  a  considerable  time  both  before  and  after  an 
attack.  The  condition  of  the  mucous  membranes  of  the  nose  and  phar- 
ynx in  other  acute  infectious  diseases  furnishes  a  marked  predisposition 
to  diphtheria.  This  is  most  striking  in  the  case  of  measles  and  scarlet 
fever;  it  is  seen  less  frequently  in  typhoid  fever  and  influenza. 

The  two  sexes  are  about  equally  liable  to  the  disease.  Children 
under  ten  are  much  more  often  affected  than  those  who  are  older,  the 
greatest  susceptibility  as  regards  age  being  between  the  second  and  fifth 
years.  Of  14,688  deaths  occurring  in  ISTew  York  from  diphtheria  during 
ten  years,  the  ages  were  as  follows  (Billington) : 

Under  one  year 1,214 

One  to  five  years 9,622 

Five  to  ten  years 3,213 

Ten  to  fifteen  years 311 

Over  fifteen  years 329 

14,688 

While  diphtheria  is  seen  throughout  the  year,  it  is  rather  more  fre- 
quent during  the  cold  than  the  warm  months.  Of  16,688  deaths  occur- 
ring in  New  York  from  diphtheria  during  thirteen  years,  there  were 
10,769  from  October  to  March,  inclusive,  and  7,919  from  April  to  Sep- 
tember, inclusive  (Bosworth). 

The  incubation  of  diphtheria  is  short.  In  most  of  the  cases  in  which 
it  could  be  definitely  traced  it  has  been  between  two  and  five  days.  The 
virulence  of  the  bacillus  varies  much  in  different  cases  and  in  different 
seasons,  and  while  it  is  frequently  true  that  persons  infected  from  a 
mild  type  of  the  disease,  and  those  infected  from  a  malignant  one  a 
severe  type,  there  is  no  certainty  that  such  will  be  the  sequence.  Dr. 
W.  H.  Park  informs  me  that,  out  of  many  hundreds  tested  in  the  labora- 
tory of  the  New  York  Health  Department,  by  far  the  most  virulent  ba- 
cillus "was  obtained  from  the  throat  of  a  boy  who  had  what  was  clinically 
regarded  as  a  very  mild  form  of  tonsillar  diphtheria. 

Second  attacks  of  diphtheria,  while  more  frequent  than  those  of 
measles  or  scarlet  fever,  are  relatively  rare.  It  seems  to  be  established 
by  recent  observations  that  the  immunity  conferred  by  one  attack  of 
diphtheria  is  of  comparatively  short  duration,  amounting  probably  to  a 
few  months  only.  Instances  have  recently  been  reported  where  a  second 
attack  occurred  within  two  months  of  the  first,  although  antitoxin 
was  used. 

Lesions. — The  essential  lesions  of  diphtheria  consist  not  in  the  pro- 
duction of  a  membrane,  but,  as  long  ago  pointed  out  by  Oertel,  and  more 


DIPHTHERIA. 


1005 


recently  by  Babes,  Sidney  Martin,  and  others,  in  certain  acute  degenera- 
tive changes  in  the  cells  of  the  body  caused  by  the  diphtheria  toxins. 
These  changes  are  seen  particularly  in  the  epithelial  cells  of  the  affected 
mucous  membranes,  the  heart  muscle;,  the  kidney,  the  liver,  the  central 
and  peripheral  nervous  system,  the  spleen,  and  the  lymph  glands;  the 
most  characteristic  being  those  of  the  nerves  and  the  liver.  There  are 
other  lesions  which  are  the  result  of  the  action  of  other  organisms,  espe- 
cially the  streptococcus  pyogenes  and  the  pneumococcus,  either  alone, 
together,  or  in  conjunction  with  the  diphtheria  bacillus.  The  most  im- 
portant lesions  due  to  these  organisms  are  broncho-pneumonia  and  ne- 
phritis; but  there  may  be  found  in  the  blood,  and  in  many  of  the  organs 
of  the  body,  the  evidences  of  the  invasion  of  these  bacteria — i.  e.,  a 
streptococcus  septicaemia,  less  frequently  a  general  pneumococcus  in- 
fection. 

Distribution  of  the  diphtheria  hacillus  in  the  body. — Unlike  many 
other  pathogenic  organisms,  the  diphtheria  bacillus  is  not  in  most  cases 
widely  distributed  throughout  the  body.  It  is  found  in  great  numbers 
on  the  surface  of  the  affected  mucous  membranes  and  in  the  false  mem- 
brane itself,  particularly  in  its  superficial  portion,  but  it  does  not  invade 
deeply  the  subjacent  structures. 

The  frequency  with  which  the  diphtheria  bacillus  and  other  organ- 
isms are  found  in  the  blood  and  viscera  is  shown  in  a  series  of  209  cases 
studied  by  Councilman,  Mallory,  and  Pearce,  of  Boston,  in  1901.  The 
following  table  shows  the  percentage  of  cases  in  which  the  different  bac- 
teria were  found  by  culture: 


Diphtheria  bacillus . . . 

Streptococcus 

Staphylococcus  aureus 
Pneumococcus 


Heart's  blood. 


6  per  cent. 
20 

2-5  " 
1-5   •' 


Liver. 


20  per  cent. 
30       " 

4       " 

2-5   " 


Spleen. 


12  per  cent. 
27       " 

3       " 

1-5   " 


Kidneys. 


19  per  cent. 

28       " 


In  this  series,  153  cases  were  pure  diphtheria;  56  were  complicated 
by  measles  or  scarlet  fever  or  both.  The  streptococcus  was  much  oftener 
found  in  the  viscera  in  the  complicated  cases;  otherwise  there  was  little 
difference  in  the  two  groups  of  cases. 

The  diphtheria  toxins. — The  wide-sjjroad  effects  seen  in  diphtheria 
are  due  to  the  action  of  certain  substances  called  toxins  which  the  di])h- 
theria  bacillus  produces  during  its  growth  on  mucous  membranes.  The 
toxins  have  been  studied  especially  l)y  Koux  and  Yersin,  Brieger,  Ehr- 
lich,  and  Madsen.  They  are  very  diffusible,  readily  entering  the  lym- 
phatic circulation  and  the  blood,  and  through  tliese  channels  may 
affect  the  entire  body.  It  has  been  shown  by  Welch  and  Fk^xner  and 
others  that  in  susceptible  animals  there  may  be  ])roduced  by  the  injec- 
tion of  these  toxins  all  the  characteristic  lesions  of  di])htheria  except 
65 


1006  THE  SPECIFIC  INFECTIOUS   DISEASES. 

the  membrane,  as  well  as  the  essential  symptoms  of  the  disease,  even 
including  paral3'sis.  For  the  production  of  the  membrane  living  bacilli 
are  required. 

"  Catarrhal "  diphtJieria. — The  routine  practice  of  making  cultures 
from  diseased  throats  has  established  the  fact  that  catarrhal  inflamma- 
tion may  often  be  the  only  result  of  diphtheritic  infection.  Although 
to  the  naked  eye  there  were  only  the  ordinary  changes  of  a  simple  in- 
flammation, Oertel  found  the  characteristic  degenerative  changes  in  the 
epithelial  cells,  varying  in  degree  with  the  severity  of  the  process. 

The  diphtheritic  membrane. — The  membrane  in  diphtheria  is  most 
frequently  seen  upon  the  mucous  membrane  of  the  tonsils,  soft  palate, 
uvula,  pharynx,  nose,  larynx,  trachea,  and  bronchi;  less  frequently  upon 
the  mouth,  lips,  oesophagus,  conjunctivEe,  middle  ear,  stomach,  and  geni- 
tal organs.  It  may  also  affect  fresh  wounds,  notably  a  tracheotomy 
wound,  or  any  abraded  cutaneous  surface.  The  gross  appearance  of  the 
membrane  varies  greatly  (Plate  XIX).  It  is  most  frequently  of  a  gray  or 
mouse-colour,  but  it  may  be  pearly  white,  yellow,  green,  and  sometimes 
almost  black.  It  is  composed  of  fibrin,  cells,  granular  matter,  and  bac- 
teria. Its  consistency  varies  with  the  relative  proportions  of  the  differ- 
ent elements.  When  made  up  chiefly  of  fibrin  it  is  firm  and  retains  its 
form,  often  being  discharged  as  a  complete  cast  of  the  nose,  larynx,  or 
trachea.  When  the  amount  of  fibrin  is  small  the  membrane  is  soft, 
friable,  and  sometimes  granular.  It  is  more  closely  adherent  upon  the 
mucous  membranes  covered  with  squamous  epithelium,  as  in  the  phar- 
ynx and  upper  air  passages,  than  upon  those  covered  with  columnar  and 
ciliated  epithelium,  as  in  the  lower  air  passages. 

The  microscopical  examination  shows  the  fibrin  to  be  sometimes 
granular,  but  usually  in  the  form  of  a  network,  inclosing  in  its  meshes 
small  round  cells  and  epithelial  cells  in  various  stages  of  degeneration. 
On  the  surface  and  in  the  superficial  layer  there  is  usually  found  quite  a 
variety  of  bacteria  including  diphtheria  bacilli.  Beneath  this  is  a  cellu- 
lar layer  containing  little  or  no  fibrin,  in  which  also  the  diphtheria  ba- 
cilli are  usually  found.  In  the  deepest  parts  of  the  false  membrane  and 
in  the  mucous  membrane  itself  they  are  few  in  number  or  absent. 

Characteristic  changes,  which  are  similar  in  all  the  affected  mucous 
membranes,  are  found  in  the  epithelial  cells,  which  undergo  marked 
degeneration  with  fragmentation  of  their  nuclei;  the  mucosa  is  infil- 
trated with  leucocytes.  The  infiltration  with  small  round  cells  is  vari- 
able in  degree  in  the  different  mucous  membranes;  in  some  it  extends 
deeply  into  the  submucous  and  even  the  muscular  layers,  while  in  others 
it  is  very  superficial.  Marked  evidences  of  degeneration  are  seen  also 
in  the  cells  infiltrating  the  deeper  layers.  In  places  the  epithelium  is 
detached,  in  others  the  line  between  the  false  membrane  and  the  gran- 
ular mucous  membrane  is  scarcely  distinguishable. 


DIPHTHERIA.  1007 

The  seat  and  the  distribution  of  the  memhrane. — This  varies  somewhat 
with  the  age  of  the  patient,  the  season,  and  the  peculiarity  of  the  epi- 
demic. In  the  following  table  are  given  some  figures  from  the  records 
of  the  New  York  Infant  Asylum.  These  cases  were  taken  consecutive- 
ly, and  did  not  belong  to  a  single  epidemic: 

. ,         ^,     ,  r  Tonsils  only 27  cases. 

Above  the  larynx   I      ,                '   ,                 a  <^       ■^  10     < 

„„  .  "^        -|   Pharynx  or  pharynx  and  tonsils 18     '• 

''I  Pharynx  and  nose  or  rhino-pharynx 18     " 


Not  above  the 
larynx 


Both  above  and 

below  the  larynx 

(36  cases). 


r  Larynx  only. 

Larynx  and  trachea 1  case. 

Larynx,  trachea,  and  large  bronchi 1     " 

^  I  Larynx,  trachea,  large  and  to  smallest  bronchi 2  cases. 

f  Pharynx  and  larynx 12    " 

Pharynx,  larynx,  and  trachea 6     " 

Pharynx,  larynx,  trachea,  and  large  bronchi 4    " 

Pharynx,  larynx,  trachea,  large  and  to  smallest  bronchi.     10    " 

Nose,  pharynx,  larynx,  and  trachea 1  case. 

Nose,  larynx,  and  trachea 1     " 

Pharynx  and  trachea  (none  in  larynx) 1     " 

I   Pharynx,  trachea,  and  bronchi  (none  in  larynx) 1     " 

109  cases. 
All  these  cases  were  in  young  children,  80  per  cent  of  them  being 
under  two  years  old.  In  the  first  group  the  mortality  was  30  per  cent; 
in  the  second  group,  90  per  cent;  in  the  third  group,  92  per  cent.  The 
larynx  was  involved  in  42-2  per  cent  of  the  eases.  The  location  of  the 
membrane  was  determined  by  autopsies  in  all  the  sixty-one  fatal  cases. 
The  strong  tendency  of  the  disease  in  young  children  to  invade  the 
lower  air  passages,  and  to  extend  far  into  the  bronchi  when  once  the 
larynx  is  involved,  is  also  shown  in  a  report  upon  eighty-seven  autopsies 
in  laryngeal  cases  made  by  Northrup.  In  only  three  was  the  larynx 
alone  the  seat  of  membrane;  in  57  per  cent  the  membrane  descended 
into  the  bronchi,  and  in  37  per  cent,  to  the  finest  bronchi.  All  these 
records  are  of  pre-antitoxin  days. 

An  interesting  comparison  with  the  figures  above  given  may  be  made 
with  those  of  Lennox  Browne  of  1,000  clinical  cases,  including  persons 
of  all  ages,  but  mainly,  doubtless,  children: 

f  Fauces  (including  tonsils)  alone 672  cases. 

Above  the  larynx   I    Nose  alone 2    " 

(841,  or  84-1       -J   Fauces  and  nose 165     " 

per  cent).  1   Mouth  or  lips  alone 1  case. 

[  Hard  palate  alone 1     " 

Involving  the      f  Larynx  alone 4  cases. 

larynx  (159,  or     -;   Larynx  and  fauces 109     " 

15-9  per  cent).      I  Larynx,  fauces,  and  nose 46    " 

The  tonsils  are  the  most  frequent  and  usually  the  earliest  seat  of  the 
diphtheritic  membrane;  it  may  form  here  a  tough,  leathery  patch,  par- 


1008  THE   SPECIFIC  INFECTIOUS  DISEASES. 

tially  or  completely  covering  and  very  adherent  to  them;  or  the  disease 
may  affect  only  the  tonsillar  crypts,  so  that  the  gross  lesion  may  resem- 
ble that  of  ordinary  follicular  tonsillitis.  There  is  in  most  cases  only 
moderate  swelling,  but  it  may  be  so  great  that  the  tonsils  are  in  contact. 
The  surrounding  cellular  tissue  is  infiltrated  with  inflammatory  products. 
The  membrane  covering  the  pharynx  and  uvula  is  also  usually  very 
adherent  and  intimately  blended  -with  the  mucous  membrane.  The 
uvula  is  swollen  and  oedematous.  Membrane  may  be  seen  only  upon  the 
fauces  and  uvula,  or  tlie  posterior  and  lateral  pharyngeal  walls  may  be 
covered  down  to  the  level  of  the  cricoid  cartilage,  but  generally  not 
below  this  point.  If  the  posterior  pharyngeal  wall  is  covered,  the  mem- 
brane is  apt  to  extend  into  the  rhino-pharjTix,  and  may  fill  the  entire 
pharyngeal  vault,  covering  the  posterior  portion  of  the  velum  and  ex- 
tending into  the  posterior  nares.  The  adenoid  tissue  of  the  vault  is  fre- 
quently the  part  most  affected. 

The  nose  may  be  involved  secondarily  to  the  rhino-pharynx,  or  infec- 
tion may  be  through  the  anterior  nares:  if  the  latter,  it  is  not  infre- 
quently the  only  part  involved.  Many  cases  classed  as  nasal  are  really 
rhino-pharyngeal.  The  membrane  in  the  pure  nasal  cases  is  usually 
thick  and  tough  and  often  separates  en  masse.  Both  sides  are  generally 
involved,  but  it  may  be  unilateral. 

The  observationo  of  Councilman,  Mallory,  and  Pearce  have  shown 
that  it  is  very  common  for  the  accessory  sinuses  of  the  nose,  especially 
the  antrum  of  Highmore,  to  be  involved  in  fatal  cases.  It  seems  highly 
probable  that  infection  of  these  parts  explains  the  remarkable  persist- 
ence of  diphtheria  bacilli  in  the  nose  which  is  occasionally  seen. 

The  epiglottis  is  swollen  to  three  or  four  times  its  normal  thickness, 
and  the  aryteno-epiglottic  folds  are  cedematous.  The  anterior  surface 
of  the  epiglottis  is  rarely  covered  by  membrane;  but  its  lateral  borders 
and  posterior  surface,  and  the  arj'teno-epigiottic  folds  are  involved  in 
most  of  the  severe  pharyngeal  cases  (Plate  XIX,  C).  This  lesion  is  asso- 
ciated with  pharyngeal  rather  than  with  laryngeal  diphtheria. 

The  lesions  which  extend  most  deeply  are  thus  seen  in  the  tonsils, 
uvula,  pharynx,  and  epiglottis.  But  even  here  there  is  very  rarely  deep 
or  extensive  sloughing. 

The  lesions  of  the  larynx,  trachea,  and  bronchi  are  similar  to  the 
above,  although  much  more  superficial.  The  interior  of  the  lar}Tix  may 
be  completely  covered,  the  membrane  coating  the  true  and  false  vocal 
cords  and  lining  the  ventricles  of  the  larynx.  The  membrane  in  the 
larjmx  is  not  usually  ver)'  adherent,  and  it  frequently  separates  and  is 
coughed  up  in  large  pieces  or  even  as  a  cast.  That  covering  the  epiglot- 
tis and  the  aryteno-epiglottic  folds  is  very  adlierent,  like  that  in  the 
pharynx.  Catarrhal  laryngitis  is  not  an  uncommon  complication  of 
pharyngeal  diphtheria. 


DIPHTHERIA.  1009 

In  a  considerable  number  of  cases  the  membrane  stops  abruptly  at 
the  lower  border  of  the  larynx.  In  the  trachea  it  is  generally  loosely 
attached,  and  often  it  is  found  at  autopsy  entirely  separated  from  the 
mucous  membrane.  It  is  almost  invariably  associated  with  membrane  in 
the  larynx.  Usually  the  membrane  in  the  bronchi  is  continuous  with 
that  in  the  trachea.  Occasionally  I  have  seen  the  trachea  and  larger 
bronchi  passed  over  and  found  membrane  only  in  the  larynx  and  smaller 
bronchi.  As  a  rule,  the  bronchi  of  both  sides  are  affected,  and  to  the 
same  degree.  I  once  saw  a  case  of  laryngeal  diphtheria  in  which  mem- 
brane was  found  only  in  the  bronchi  of  one  lung.  The  above  exceptions 
are  to  be  explained  as  accidents  in  the  mechanical  transportation  of 
bacilli. 

The  extent  of  the  membrane  varies  greatly  in  difEerent  cases.  It 
may  stop  at  the  bifurcation  of  the  trachea  or  at  the  bifurcation  of  the 
primary  bronchi;  but  if  it  goes  beyond  this  point  it  is  likely  to  extend 
to  the  minutest  subdivisions.  Exceptionally  a  very  tough  fibrinous 
membrane  forms  in  the  trachea  and  bronchi,  of  sufficient  thickness  and 
consistency  to  be  expelled  as  a  cast,  reproducing  almost  the  entire  bron- 
chial tree. 

The  inflammation  of  the  mucous  membrane  of  the  larynx,  trachea, 
and  bronchi  is  very  much  less  severe  and  more  superficial  in  character 
than  that  of  the  pharynx,  tonsils,  and  upper  air  passages. 

The  buccal  cavity  is  very  seldom  covered  by  the  membrane;  but 
in  the  worst  cases  of  pharyngeal  disease  it  may  line  the  cheeks,  cover 
the  lips,  gums,  and  more  or  less  of  the  hard  palate,  but  rarely  the 
tongue.  It  usually  occurs  in  patches  rather  than  as  a  continuous  mem- 
brane. In  a  recent  case  I  saw  the  membrane  on  the  lower  lip,  extend- 
ing on  to  the  face,  though  the  buccal  cavity  was  free.  It  is  not  com- 
mon for  the  diphtheritic  membrane  to  spread  down  the  digestive  tract. 
In  127  autopsies  studied  by  Councilman,  Mallory,  and  Pearce,  in  which 
the  extent  of  the  membrane  was  carefully  noted,  it  was  found  twelve 
times  in  the  oesophagus,  five  times  in  the  stomach,  and  once  in  the 
duodenum.  The  amount  of  membrane  varied  from  small  striations  on 
the  folds  of  the  stomach  or  oesophagus  to  a  complete  covering.  The 
accompanying  changes  consist  in  infiltration,  hjemorrhage,  and  cell 
degeneration.  In  the  intestines  there  is  often  found  a  hyperplasia  of 
the  lymphoid  elements — solitary  follicles  and  Peyer's  patches — with 
changes  similar  to  those  in  the  lymph  nodes  elsewhere  in  the  body,  but 
nothing  else  that  is  characteristic.  The  writers  just  referred  to  found 
otitis,  usually  double,  in  60  per  cent  of  144  autopsies;  although  in  less 
than  one  third  of  the  number  was  the  complication  recognised  during 
life.  Mastoid  disease  is  infrequent.  Otitis  is  usually  the  result  of  direct 
extension  from  the  pharynx.  It  may  be  due  to  the  diphtheria  bacillus 
alone,  to  the  streptococcus  alone,  or  more  frequently  to  both  combined; 


2010  THE   SPECIFIC   IXFECTlOrS  DISEASES. 

occasionally  the  pneumococcus  is  found.  Conjunctival  diphtheria  is 
rare  and  probably  due  to  accidental  infection  rather  than  extension 
through  the  lachrymal  duct.  Before  the  advent  of  antitoxin,  it  almost 
invariably  resulted  in  destruction  of  the  eye;  but  a  number  of  cases  suc- 
cessfully treated  have  now  been  reported,  and  one  has  recently  come 
under  my  own  observation.  Diphtheria  may  attack  any  muco-cutaneous 
surface,  especially  the  anus,  prepuce,  or  female  genitals;  any  abraded 
cutaneous  surface,  or  recent  wound,  most  frequently  the  tracheotomy 
wound  of  the  neck.  The  diphtheria  bacilli  have  been  found  in  pure 
culture  in  superficial  abscesses. 

Visceral  lesions. — The  visceral  lesions  *  of  diphtheria  are  due  partly 
to  the  action  of  the  diphtheria  toxins  and  partly  to  the  invasion  of  the 
body  with  other  organisms,  especially  the  streptococcus.  It  is  to  experi- 
mental diphtheria  that  we  owe  our  most  accurate  knowledge  of  the  for- 
mer changes,  for  in  human  diphtheria  the  large  proportion  of  all  the 
fatal  cases  show  infection  with  other  organisms,  particularly  the  strepto- 
coccus, to  a  less  degree  the  pneumococcus  or  staphylococcus.  The  fre- 
quency with  which  these  bacteria  are  found  at  autopsy  in  different 
organs  is  indicated  on  page  1005. 

The  visceral  lesions  of  diphtheria  consist  in  wide-spread  areas  of  cell 
degeneration  similar  to  those  which  have  already  been  described  as  oc- 
curring in  the  epithelial  cells  of  the  affected  mucous  membranes,  to- 
gether with  haemorrhages  due  to  changes  in  the  blood-vessels  and  pos- 
sibly in  the  blood  itself. 

The  lymph  nodes  of  the  cervical  region  are  the  most  constantly  and 
the  most  seriously  affected.  Similar  but  less  marked  changes  are  seen 
in  the  traeheo-bronchial  and  the  mesenteric  groups,  and  in  the  lymph 
nodules  of  the  mucous  membrane  of  the  stomach  and  intestine.  There 
are  degenerative  charges  in  the  cells  of  the  nodes  most  affected,  with 
marked  infiltration  with  leucocytes  and  frequently  small  hsemorrhages. 
The  cellular  tissue  in  the  neighbourhood  of  the  cervical  nodes  is  often 
extensively  infiltrated  with  cells.  The  process  in  the  lymph  nodes  usu- 
allv  terminates  in  resolution,  rarely  in  suppuration. 

The  changes  in  the  spleen  are  quite  constant.  The  organ  is  swollen, 
sometimes  very  much  so,  and  deeply  congested.  Hsemorrhages  are  often 
seen  beneath  the  capsule;  the  spleen  pulp  is  soft,  the  follicles  are  large, 
and  cell  degeneration  is  quite  constantly  observed  similar  to  that  which 
takes  place  in  the  lymph  nodes. 

There  are  frequently  small  hsemorrhages  beneath  the  capsule  of  the 
liver,  and  sometimes  these  are  seen  throughout  the  organ.     There  are 


*  For  an  exhaustive  study  of  the  pathological  anatomy  of  diphtheria,  see  mono- 
graph of  Councilman,  Mallory,  and  Pearce  (Boston,  1901) ;  being  a  study  of  220  fatal 
cases. 


DIPHTHERIA.  1011 

found  scattered  through  the  liver,  areas  of  necrotic  hepatic  cells  which 
are  peculiar  to  this  disease;  some  of  these  areas  are  infiltrated  with 
leucocytes. 

The  kidneys  are  involved  in  almost  all  fatal  cases  except  where  death 
occurs  early  from  laryngeal  stenosis,  also  in  nearly  every  severe  case 
which  terminates  in  recovery.  Acute  degeneration  of  the  epithelium 
of  the  tubes  and  the  tufts  is  seen  in  less  severe  cases  and  those  of 
shorter  duration,  and  is  the  direct  result  of  the  action  of  the  toxins  in 
the  blood.  In  the  more  severe  and  protracted  cases  there  is  acute  dif- 
fuse nephritis  of  variable  type  and  intensity.  There  is  no  form  of  in- 
flammation which  is  peculiar  to  diphtheria;  in  some  cases  the  intersti- 
tial changes  predominate,  in  others  the  glomerular  changes.  Welch 
mentions  hyaline  changes  in  the  glomerular  capillaries  and  small  arter- 
ies as  the  characteristic  feature  of  the  nephritis  of  diphtheria. 

In  cases  dying  suddenly  in  the  early  stage  of  the  disease,  cardiac 
thrombi  are  occasionally  found.  They  may  form  rapidly  only  a  short 
time  before  death,  or  slowly  during  several  days  when  the  circulation 
is  very  feeble.  Portions  of  these  thrombi  may  be  carried  into  the  pul- 
monary or  systemic  circulation,  causing  embolism  in  any  of  the  arter- 
ies of  the  extremities,  the  lungs,  or  other  viscera.  Even  in  the  early 
fatal  cases  the  heart  muscle  may  be  seriously  affected;  in  the  later  ones 
this  is  almost  constant.  The  changes  consist  in  a  toxic  myocarditis,  the 
left  ventricle  being  most  involved. 

Degeneration  of  the  arteries,  especially  of  the  endothelial  layer,  is 
occasionally  seen,  and  there  may  be  infiltration  of  the  adventitia.  The 
arteries  of  any  of  the  viscera  may  be  the  seat  of  hyaline  degeneration. 

Lesions  of  the  brain  are  rare;  both  haemorrhage  and  embolism  may 
be  met  with.  In  the  cord  and  spinal  membranes  multiple  hasmorrhages 
occasionally  occur.  The  characteristic  lesion,  however,  consists  in  de- 
generative changes  which  are  found  to  some  degree  in  nearly  all  the 
more  severe  cases  which  have  been  examined.  These  affect  the  ganglion 
cells  of  the  anterior  horns,  the  anterior  and  posterior  nerve-roots,  and 
sometimes  the  pyramidal  tracts  and  columns  of  Goll.  In  some  cases  of 
paralysis  induced  in  animals,  lesions  practically  identical  with  those  of 
ordinary  poliomyelitis  have  been  seen.  Some  recent  writers  (Katz  and 
Crosz)  are  of  the  opinion  that  the  cord  lesions  are  primary  and  the  de- 
generations of  the  spinal  nerves  secondary.  However,  the  general  opin- 
ion still  prevails  that  certainly  the  less  severe  cases  of  diphtheritic  pa- 
ralysis are  due  to  peripheral  rather  than  to  central  lesions.  Degenera- 
tive changes  have  been  found  also  in  the  pneumogastric,  spinal  acces- 
sory, hypoglossal,  motor-oculi,  and  in  the  cardiac  nerves.  These  nerve 
degenerations  produced  by  the  diphtheria  toxin  constitute  one  of  the 
most  striking  lesions  of  diphtheria.     (See  Multiple  Neuritis.) 

In  infants  and  young  children  broncho-pneumonia  is  found  at  au- 


1012  THE  SPECIFIC   INFECTIOUS  DISEASES. 

topsy  in  fully  three  fourths  of  the  cases,  and  in  a  large  proportion  of 
these  it  is  the  cause  of  death.  It  is  well-nigh  constant  in  cases  of  diph- 
theritic hronchitis  of  the  finer  tubes,  and  is  usually  present  where  the 
membrane  has  extended  to  the  bifurcation  of  the  trachea.  The  largest 
factor  in  the  production  of  pneumonia  is  the  aspiration  of  diphtheria 
bacilli  and  streptococci  from  the  upper  air  passages;  an  important  part 
is  also  played  by  the  pneumococcus  and  the  influenza  bacillus.  These 
organisms  may  be  present  in  many  combinations. 

With  laryngeal  stenosis,  some  emphysema  is  invariably  present,  and 
usually  it  is  of  the  vesicular  variety.  In  extreme  or  protracted  cases  of 
stenosis  there  may  be  interstitial  emphysema.  Eupture  of  some  of 
these  blebs  may  lead  to  the  escape  of  air  into  the  cellular  tissue  of  the 
mediastintmi  or  of  the  neck,  which  may  result  in  the  production  of  a 
general  emphysema  of  the  subcutaneous  cellular  tissue. 

Blood. — According  to  the  studies  of  Ewing,  Morse,  Billings,  and 
others,  there  is  found  in  all  severe  cases  of  diphtheria  a  reduction  in  the 
number  of  red  cells  to  the  extent  of  500,000  to  2,000,000.  There  is  a 
nearly  proportionate  reduction  in  the  hEemoglobin,  this  amounting  to 
from  12  to  28  per  cent.  While  the  hgemoglobin  falls  coincidently  with 
the  number  of  red  cells,  it  is  regained  much  more  slowly.  Leucocy- 
tosis  is  generally  present,  and  usually  proportionate  to  the  severity  of 
the  attack,  but  is  occasionally  wanting  in  the  most  severe  as  well  as  in 
some  of  the  very  mildest  eases.  The  increase  in  the  leucocytes  is  in  the 
polynuclear  forms.  Engel  has  noted  the  frequent  presence  of  myelo- 
cytes, especially  in  fatal  eases,  the  proportion  of  these  in  some  instances 
reaching  16  per  cent  of  the  white  cells.  In  his  observations,  every  case 
in  which  the  myelocytes  exceeded  2  per  cent,  proved  fatal. 

Symptoms. — The  clinical  picture  of  diphtheria  is  one  which  presents 
wide  variations,  depending  upon  the  principal  location  of  the  disease,  its 
severity,  and  its  complications.  For  practical  purposes  the  following 
seems  the  simplest  grouping  that  can  be  made: 

1.  The  mild  cases,  in  which  there  is  either  no  membrane,  or  the 
amount  of  membrane  is  small  and  limited  to  the  tonsils  or  to  the  nose, 
with  few  or  none  of  the  constitutional  symptoms  which  follow  absorp- 
tion of  the  diphtheria  poison.  These  cases  partake  essentially  of  the 
character  of  a  local  disease. 

2.  The  severe  cases,  which  are  of  two  kinds:  first,  those  in  which 
there  are  marked  evidences  of  constitutional  poisoning  from  diphtheria 
toxins;  and,  secondly,  those  with  laryngeal  stenosis.  The  first  form 
is  usually  accompanied  by  an  extensive  formation  of  membrane  in  the 
pharynx  and  sometimes  in  the  nose.  The  larynx  may  be  involved 
secondarily  to  disease  in  the  pharynx  or  nose,  or  it  may  be  primarily 
affected. 

3.  The  cases  of  mixed  infection  or  the  septic  eases.     In  very  many 


DIPHTHERIA.  1013 

of  the  cases  of  the  two  preceding  groups  streptococci  are  found  in  the 
throat,  but  they  are  not  in  sufficient  numbers  or  of  sufficient  virulence 
to  modify  the  course  of  the  disease.  In  the  eases  to  which  the  term 
mixed  infection  is  applied,  in  addition  to  the  constitutional  symptoms  of 
diphtheritic  toxaemia  and  the  local  conditions  which  usually  attend  it, 
there  are  marked  evidences  of  a  general  septicaemia,  usually  due  to  the 
streptococcus.  In  these  cas€S  the  symptoms  of  inflammation  are  espe- 
cially prominent,  not  only  in  the  pharynx  but  sometimes  in  the  lymph 
glands  and  cellular  tissue  of  the  neck,  which  may  be  followed  by  sup- 
puration or  sloughing.  This  form  is  frequently  complicated  by  bron- 
cho-pneumonia even  without  laryngeal  disease,  and  sometimes  by  severe 
nephritis. 

Cases  witliout  membrane. — During  an  epidemic  of  diphtheria  in  a 
family  or  an  institution,  cases  are  frequently  seen  which  present  the 
clinical  evidences  of  only  a  catarrhal  inflammation  of  the  nose  or  phar- 
ynx, and  yet  cultures  show  the  presence  of  the  diphtheria  bacillus. 
Such  cases  may  be  examples  of  simple  catarrhal  inflammation  with  the 
accidental  presence  of  the  diphtheria  bacillus;  or  the  inflammation  may 
be  caused  by  infection  with  the  diphtheria  bacillus,  but  not  of  sufficient 
intensity  to  lead  to  the  production  of  a  membrane.  The  latter  is  the 
view  of  pathologists,  and  the  one  to  which  clinicians  must,  it  seems, 
inevitably  come.  However,  a  membrane  has  so  long  been  regarded  as  a 
sine  qua  non  of  this  disease  that  the  existence  of  diphtheria  without  it, 
is  something  which  the  clinician  finds  it  hard  to  grasp. 

Catarrhal  diphtheria  may  be  either  pharyngeal  or  nasal.  In  the 
pharyngeal  cases  there  are  present  the  usual  appearances  belonging  to 
a  catarrhal  inflammation  of  moderate  severity,  often  accompanied  by 
swelling  and  tenderness  of  the  cervical  lymph  glands. 

The  nasal  cases,  in  my  experience,  have  been  most  frequent  in  in- 
fants or  very  young  children.  Constitutional  symptoms  may  be  want- 
ing or  so  slight  as  to  be  overlooked.  The  only  striking  thing  is  a  per- 
sistent nasal  discharge  which  may  be  serous  and  frothy,  purulent  or 
bloody.  It  is  usually  copious,  often  excoriating  the  upper  lip  and 
sometimes  continuing  for  three  or  four  weeks  before  any  other  symp- 
toms are  observed.  I  have  known  it  to  be  mistaken  for  a  sypliilitic 
coryza.  Such  cases  can  be  recognised  with  certainty  only  by  cultures. 
Clinical  evidence  of  their  true  character  is  sometimes  afforded  by  the 
appearance  of  visible  membrane  in  the  nose  or  pharynx,  by  the  develop- 
ment of  croup,  or  by  the  fact  that  they  cause  diphtheria  in  other  chil- 
dren. 

Catarrhal  diphtheria  is  not  in  itself  serious,  but  it  may  be  followed, 
particularly  in  young  children,  by  laryngeal  diphtheria,  or,  after  it  has 
existed  for  a  time,  pharyngeal  diphtheria  may  develop  in  its  usual  form. 
Cases  like  those  just  described  are  to  be  distinguished  from  others  in 


1014  THE  SPECIFIC  INFECTIOUS  DISEASES. 

which  bacilli,  either  of  the  virulent  or  the  non-virulent  variety,  are 
found  without  any  evidence  of  inflammation. 

Cases  with  a  small  amount  of  membrane. — Tonsillar  diphtheria. — The 
exudation  is  usually  limited  to  the  tonsils  (Plate  XIX,  A),  and  may  par- 
take of  the  character  of  either  follicular  or  croupous  tonsillitis;  some- 
times there  is  a  slight  extension  to  the  faucial  pillars  or  to  the  pharynx. 
These  cases  are  quite  common,  and  in  some  epidemics  most  of  those  seen 
are  of  this  variety.  They  are  more  frequent  in  older  children  and  adults 
than  in  infants  and  young  children. 

The 'onset  is  accompanied  by  a  little  soreness  of  the  throat;  the  ini- 
tial temperature  is  from  100°  to  103°  F.;  but  the  symptoms  are  often  not 
severe  enough  to  keep  the  patient  in  bed.  If  seen  early,  the  throat 
shows  slight  redness,  followed  by  a  gray  film,  and  later  by  a  gray  or 
white  deposit  upon  the  tonsils.  It  may  start  as  a  small  patch  which  en- 
larges, or  as  small,  isolated  spots  which  coalesce  or  remain  separate. 
Until  it  disappears  the  membrane  generally  remains  of  its  original 
colour.  It  is  generally  quite  adherent,  and  can  not  easily  be  removed 
with  a  swab;  usually  it  is  sharply  defined,  but  with  a  somewhat  irregular 
outline.  In  many  cases  the  patch  is  not  larger  than  the  finger  nail. 
The  inflammatory  changes  in  the  pharynx  are  slight;  a  faint  red  areola 
is  frequently  present  at  the  border  of  the  patch.  The  lymph  glands 
behind  the  jaw  may  be  slightly  swollen.  There  is  no  nasal  discharge 
and  very  little  increase  in  the  saliva  or  mucus  from  the  pharynx.  The 
constitutional  symptoms  are  slight,  sometimes  almost  absent.  The  tem- 
perature commonly  continues  above  the  normal  while  the  membrane 
lasts,  its  usual  range  being  from  100°  to  102°  F.  The  membrane  re- 
mains from  three  to  ten  days — a  shorter  time  if  antitoxin  is  used.  It  is 
very  often  a  matter  of  surprise  that  so  small  an  exudate  is  so  persistent. 
The  urine  is  generally  normal.  The  parents  are  loath  to  believe  that 
strict  quarantine  is  necessary  in  so  mild  an  illness;  and  where  the  mem- 
brane is  only  upon  the  tonsils,  even  after  the  disease  has  run  its  course, 
the  physician  may  be  led  to  doubt  the  diagnosis  of  diphtheria. 

In  most  cases  one  with  experience  can  usually  make  an  accurate  diag- 
nosis from  the  clinical  symptoms;  but  there  are  others  in  which  the  diag- 
nosis from  ordinary  tonsillitis  is  impossible,  even  by  the  most  practised 
observers,  except  by  bacteriological  examination.  When  diphtheria  bacilli 
are  found  in  these  mild  cases  the  question  often  arises  whether  they  may 
not  be  the  non-virulent  form.  Park  tested  forty  such  cases,  and  found 
the  bacilli  to  be  virulent  in  thirty-five  and  non-virulent  in  five.  In 
twenty  of  the  forty  cases  the  clinical  diagnosis  was  follicular  tonsillitis.* 

*  From  one  of  these  mild  cases  was  obtained  a  bacillus  whose  virulence  so  greatly 
exceeded  that  obtained  from  any  other  case  of  diphtheria,  that  its  cultures  were  used 
for  the  preparation  of  toxins  for  injecting  horses.  It  was  by  means  of  these  powerful 
toxins  that  the  strongest  antitoxin  was  produced. 


PLATE   XIX. 


J  ( 


The  Diphtheritic  Membrane. 

A.  Typical  tonsillar  diphtheria. 

B.  Severe  pharyngeal  diphtheria  (fatal  case). 

C.  Pseudo-diphtheria.  The  specimen  is  seen  from  behind,  the  larynx  and  trachea 
having  been  laid  open,  and  shows  an  extensive  membrane  involving  the  epiglottis  and 
the  entire  lower  pharynx,  but  extending  into  the  larynx  only  a  short  distance.  It  is 
also  seen  upon  the  posterior  surface  of  the  uvula  and  soft  palate,  the  tonsils  being  only 
partially  covered.  The  colour  of  the  membrane  is  not  cliaracteristic  of  pseudo-diph- 
theria, as  the  same  appeai-ance  is  often  seen  in  true  diphtheria,  particularly  of  the 
septic  type. 


DIPHTHERIA.  1015 

Severe  cases. — The  onset  may  be  gradual,  even  insidious.  There  is 
then  a  slight  indisposition  for  a  day  or  two,  and  perhaps  some  soreness 
of  the  throat;  the  temperature,  however,  is  hut  little  elevated,  often 
less  than  100°  F.  The  symptoms  may  steadily  increase  in  intensity  for 
four  or  five  days,  until  the  maximum  is  reached.  At  other  times  the 
disease  begins  abruptly  with  vomiting,  headache,  chilly  sensations,  and  a 
temperature  of  103°  or  104°  F.  Occasionally,  the  first  thing  to  attract 
attention  is  the  swelling  of  the  cervical  lymph  glands,  which  may  be  so 
great  that  mumps  is  suspected.  The  abrupt  onset  is  more  often  seen  in 
young  children  than  in  those  who  are  older. 

The  membrane  upon  the  tonsils  resembles  that  of  the  mild  form  pre- 
viously described,  but,  instead  of  remaining  limited  to  them,  it  gradually 
spreads  to  the  fauces,  the  lateral  wall  of  the  pharynx,  the  uvula,  the 
rhino-pharynx,  and  the  posterior  nares.  The  rapidity  with  which  the 
membrane  extends  is  in  direct  proportion  to  the  severity  of  the  attack. 
In  some  cases  it  may  cover  all  the  parts  mentioned  in  twenty-four  hours 
from  its  first  appearance;  in  others  this  may  require  four  or  five  days. 
AVhen  the  nose  is  first  affected  there  is  an  abundant  discharge  of  serum 
and  mucus,  occasionally  tinged  with  blood,  which  may  continue  several 
days  before  any  membrane  is  visible. 

Wlien  a  severe  case  is  fully  developed  there  is  a  very  abundant  dis- 
charge of  mucus  from  the  mouth  and  nose.  The  tonsils,  the  entire  fau- 
cial  ring,  and  the  pharynx  are  covered  with  membrane  (Plate  XIX,  B) 
which  is  at  first  gray  and  gradually  becomes  darker,  often  being  of  a 
dirty  olive-green  colour.  Membrane  is  sometimes  seen  upon  the  lips,  or 
in  patches  in  the  mouth.  There  is  obstruction  to  nasal  respiration  from 
the  swelling  of  the  palate,  the  tonsils,  and  the  tissues  of  the  rhino-phar- 
ynx; the  mouth  is  half  open,  the  breathing  noisy,  the  tongue  dry,  and 
the  lips  are  fissured  and  bleed  readily.  Occasionally  large  nasal  hem- 
orrhages occur  which  may  necessitate  plugging  the  nares  Both  nostrils 
are  generally  blocked  by  the  swelling  and  the  false  membrane;  the  dis- 
charge excoriates  the  upper  lip,  and  frequently  has  a  fetid  odour.  Dur- 
ing the  second  week  there  is  often  regurgitation  of  iluids  through  the 
nose,  owing  to  paralysis  of  the  palate.  The  lym])h  glands  at  the  angle 
of  the  Jaw  swell  rapidly;  in  severe  cases  they  are  very  prominent,  and 
there  may  also  be  extensive  infiltration  of  the  cellular  tissue  about 
them,  although  this  is  uKire  characteristic  of  the  cases  of  mixed  in- 
fection. 

The  constitutional  symjitoms  usually  increase  steadily  with  the  ex- 
tension of  the  membrane.  In  the  most  severe  cases  the  system  is  over- 
whelmed with  the  poison,  and  all  the  evidences  of  intense  toxaemia  are 
present  by  the  second  or  third  day  of  the  disease.  This  is  shown  by 
great  muscular  weakness  and  prostration,  by  a  feeble,  rapid  pulse,  and  a 
mental  state  of  com])loto  ajiathy  or  stupor,  sometimes  alternating  with 


1016  THE  SPECIFIC  INFECTIOUS  DISEASES. 

great  restlessness.  It  is  more  frequent  for  the  constitutional  symptoms 
to  develop  gradually,  and  not  to  reach  their  height  before  the  fifth  or 
sixth  day.  The  pulse  becomes  rapid,  weak,  and  compressible,  sometimes 
irregular;  and  there  is  a  great  and  steadily  increasing  angemia.  The 
course  of  the  temperature  is  irregular,  and  bears  no  constant  relation  to 
the  severity  of  the  other  symptoms.  Its  usual  range  is  from  101°  to 
103°,  but  in  some  of  the  worst  cases  it  may  never  go  above  101°  F.  It 
fluctuates  irregularly  with  the  development  of  complications,  and  some- 
times without  apparent  cause.  By  the  second  or  third  day  the  urine 
regularly  shows  the  presence  of  albumin,  and  by  the  end  of  the  first 
week  the  quantity  is  often  large.  Granular  and  hyaline  casts,  and  occa- 
sionally blood  in  small  quantities,  are  also  found.  The  amount  of  urine 
secreted  is  not  noticeably  diminished,  and  dropsy  is  rare.  There  is  com- 
plete anorexia,  and  often  vomiting  and  diarrhoea  are  present;  in  some 
of  the  cases  they  are  prominent.  Xervous  symptoms  are  seen  in  all  the 
very  severe  cases.  There  may  be  dulness  and  apathy,  but  more  fre- 
quently, owing  to  the  discomfort  arising  from  local  symptoms,  there  is 
extreme  restlessness  and  excitement,  sometimes  followed  by  delirium. 

At  any  time  during  the  first  week,  but  not  often  after  that  time, 
symptoms  may  arise  indicating  that  the  disease  has  extended  to  the 
larynx.  The  first  signs  of  laryngeal  invasion  usually  appear  from  the 
second  to  the  fifth  day  of  the  disease.  These  are  at  first  hoarseness,  a 
croupy  cough,  and  slight  dyspnoea.  In  the  severe  cases  these  symptoms 
steadily  increase  until  all  the  signs  of  laryngeal  stenosis  are  present. 
The  symptoms  of  diphtheria  of  the  larynx,  whether  it  begins  there  or 
follows  disease  of  the  pharynx,  have  already  been  described  in  the  chap- 
ter on  Diseases  of  the  Larynx  (page  492). 

The  local  process  in  the  phar}Tix  seems  to  be  a  self -limited  one. 
When  contracted  it  has  usually  reached  its  height  by  the  fifth  or  sixth 
day,  and  after  that  the  appearances  do  not  change  materially  for  two 
or  three  days.  From  the  seventh  to  the  tenth  day,  in  favourable  cases, 
the  diphtheritic  membrane  begins  to  loosen  and  separate  from  its  at- 
tachment. It  hangs  loosely  from  the  palate  or  uvula,  and  can  often  be 
pulled  away  in  large  masses.  The  detachment  is  frequently  rapid,  and 
in  two  or  three  days  from  the  time  when  the  first  improvement  is  seen, 
the  tonsils  and  pharynx  may  be  almost  free  from  membrane.  The  mu- 
cous surface  left  behind  is  of  a  bright-red  colour  and  bleeds  easily.  The 
separation  of  the  membrane  in  the  nose  and  rhino-phar}Tix  takes  place 
more  slowly.  From  the  former  it  may  disintegrate  gradually  or  come 
away  en  masse.  With  the  disappearance  of  the  membrane  the  local  symp- 
toms abate  rapidly — the  discharge  ceases,  the  swelling  of  the  lymph 
glands  subsides,  deglutition  becomes  easy  and  natural,  and  nasal  breath- 
ing is  re-established.  Simultaneously  with  these  changes  in  the  throat 
the  constitutional  symptoms  improve,  but  much  more  slowly.    Convales- 


DIPHTHERIA.  1017 

cence  is  often  protracted.  The  anaemia  and  muscular  weakness,  and, 
most  of  all,  the  feeble  heart  action,  may  persist  for  weeks. 

Instead  of  the  usual  course  just  described,  the  diphtheritic  mem- 
brane may  persist  for  three  weeks  or  even  longer.  In  rare  cases  relapses 
occur,  the  membrane  forming  again  after  it  has  entirely  or  partially 
disappeared. 

The  early  course  of  the  disease  in  the  fatal  cases  often  does  not  dif- 
fer from  that  of  the  severe  cases  which  end  in  recovery,  except  in  the 
malignant  form,  which  kills  in  twenty-four  or  forty-eight  hours,  and 
which,  after  all,  is  rare.  Death  may  be  due  to  progressive  asthenia  the 
result  of  diphtheritic  toxaemia.  It  frequently  occurs  from  sudden  heart 
failure,  which  may  come  early  or  late.  Other  causes  of  death  are  in- 
vasion of  the  larynx  and  complications,  particularly  broncho-pneumo- 
nia, rarely  nephritis  or  hemorrhages. 

Even  after  the  throat  has  cleared  off  completely  the  disease  may  end 
fatally  from  the  occurrence  of  late  pneumonia  or  nephritis  or  from 
heart  paralysis.  It  often  happens  that  the  patient  is  regarded  as  con- 
valescent, and  the  great  vigilance  of  the  previous  days  or  weeks  has 
been  relaxed.  The  physician  has  ceased  his  frequent  visits  and  looks  in 
only  once  a  day  to  satisfy  himself  that  the  patient  is  doing  well,  and  all 
congratulate  themselves  that  the  danger  is  over.  If  the  pulse  is  care- 
fully watched,  it  is  one  day  discovered  that  it  is  weaker  than  formerly, 
and  in  most  cases  somewhat  irregular.  It  is  usually  slower,  but  may 
be  more  rapid  than  normal.  On  inquiry,  it  is  generally  found  that  the 
patient  has  vomited  once  or  twice  and  often  has  complained  of  epigas- 
tric pain  or  distress.  Slight  dyspnoea  is  noticed,  and  the  face  is  paler 
than  usual.  Sometimes,  within  twenty-four  hours  from  the  beginning 
of  such  symptoms,  the  patient  is  dead.  The  changes  for  the  worse  may 
occur  very  rapidly.  The  pulse  becomes  weaker,  more  irregular,  often 
abnormally  slow,  but  very  rapid  on  slight  exertion,  and  there  may  be  a 
sense  of  precordial  weakness  or  distress.  There  is  dyspnoea  without 
cyanosis,  anxiety,  and  great  restlessness,  but  the  mind  is  clear.  There 
is  vomiting  if  food  or  stimulants  are  taken.  The  extremities  are  cold. 
Auscultation  shows  feeble  and  confused  heart  sounds,  but  no  murmur. 
Death  results  from  syncope,  which  may  be  gradual  or  rapid  in  its  devel- 
opment; sometimes  it  occurs  during  an  attempt  to  administer  food,  or 
from  such  slight  exertion  as  turning  in  the  crib. 

Instead  of  such  a  rapid  course,  the  same  symptoms  may  develop 
more  gradually  during  three  or  four  days,  the  significance  of  the  earlier 
symptoms  not  being  appreciated. 

Although  such  symptoms  are  more  often  seen  after  severe  cases, 
they  may  occur  after  those  of  only  moderate  intensity,  and  even  when 
the  patient  has  been  considered  well  enough  to  be  up  and  about  or  out  of 
doors.    Sometimes  no  premonitory  symptoms  are  present,  and  the  child 


1018  THE  SPECIFIC  INFECTIOUS  DISEASES. 

falls  dead  after  walking  across  the  room,  or  suddenly  sitting  up  in  ted, 
or  after  some  other  muscular  effort,  or  possibly  as  a  consequence  of 
passion  or  excitement.  One  little  girl  was  considered  well  enough  to 
go  coasting,  and  died  suddenly  after  the  exertion. 

The  explanation  of  heart  failure  during  or  after  diphtheria  is  not 
always  the  same.  When  it  occurs  at  the  height  of  the  disease  it  is 
sometimes  due  to  cardiac  thrombosis,  probably  always  associated  with 
changes  in  the  muscular  walls.  When  it  occurs  late  and  follows  some 
sudden  muscular  effort  or  excitement  without  premonitory  symptoms  of 
any  sort,  it  is  probably  the  result  of  changes  in  the  muscular  walls — a 
toxic  myocarditis.  When  prodromal  symptoms  are  present,  and  particu- 
larly when  accompanied  by  vomiting,  abdominal  pain,  and  disturbed  res- 
piration, it  is  probably  the  result  of  a  toxic  neuritis  affecting  either  the 
pneumogastric  or  the  cardiac  nerves,  and  is  to  be  regarded  as  a  form  of 
post-diphtheritic  paralysis.  In  many  cases,  no  doubt,  changes  are  pres- 
ent both  in  the  nerves  and  in  the  myocardium.  The  other  forms  of 
diphtheritic  paralysis  which  may  result  fatally,  are  discussed  in  the 
chapter  on  Diseases  of  the  Peripheral  Xerves. 

Cases  of  mixed  infection  or  septic  cUplitlieria. — The  sjTnptoms  are 
usually  severe  from  the  outset.  The  exudation  in  these  cases  may  be 
of  a  yellow  or  dirty-gray  or  olive  colour,  sometimes  being  almost  black 
from  the  presence  of  blood.  The  membrane  is  usually  extensive,  cover- 
ing the  entire  pharynx,  often  extending  to  the  nose  and  the  middle  ear, 
and  occasionally  spreading  to  the  buccal  cavity.  There  is  great  swelling 
of  the  tonsils  and  uvula,  and  it  is  often  impossible  to  obtain  a  view  of 
the  pharynx;  all  the  evidences  of  inflammation  are  usually  more  marked 
than  in  the  severe  uncomplicated  cases.  Sometimes  the  inflammation  is 
of  a  necrotic  character,  and  there  may  be  extensive  sloughing  of  the 
tonsils,  the  uvula,  or  the  soft  palate.  The  nasal  discharge  is  generally 
abundant,  and  often  very  offensive.  There  is  marked  swelling  of  the 
cervical  lymph  glands,  and  frequently  extensive  infiltration  of  the  cellu- 
lar tissue  of  the  neck,  so  that  the  head  is  thrown  back  to  relieve  the 
pressure  upon  the  larynx  and  trachea.  The  swelling  sometimes  forms  a 
distinct  collar,  reaching  from  ear  to  ear  and  filling  out  the  whole  space 
beneath  the  jaw.  The  pressure  upon  the  jugular  veins  leads  to  conges- 
tion and  swelling  of  the  face  and  congestion  of  the  brain. 

The  general  symptoms  are  those  of  a  severe  septicaemia.  The  tem- 
perature is  usually  higher  than  in  simple  diphtheria:  it  follows  no  regular 
course,  but  is  generally  high  and  sometimes  fluctuates  widely  from  102° 
to  106°  F.  In  the  cases  characterized  by  such  high  temperatures  there  is 
frequently  found  a  general  streptococcus  or  pneumococcus  infection,  usu- 
ally the  former.  The  pulse  is  weak,  rapid,  and  compressible.  The  periph- 
eral circulation  is  poor,  the  extremities  are  often  cold,  there  is  extreme 
muscular  prostration,  and  both  vomiting  and  diarrhoea  are  frequent. 


DIPHTHERIA.  1019 

There  may  be  excitement,  restlessness,  and  active  delirium,  or  dulness, 
apathy,  and  stupor.  Nephritis  is  very  frequent  and  is  often  severe;  the 
urine  contains  a  large  amount  of  albumin  and  easts  of  all  varieties,  but 
rarely  blood.  In  a  large  proportion  of  the  children  under  three  years 
old  broncho-pneumonia  develops.  Severe  symptoms  continue  for  from 
two  days  to  a  week;  the  patient  may  die  from  the  sudden  invasion  of  the 
larynx,  or  there  may  be  suppression  of  urine  and  uraemic  convulsions; 
but  more  frequently  the  cause  of  death  is  asthenia  or  broncho-pneu- 
monia. Death  usually  occurs  while  the  local  disease  is  at  its  height. 
Occasionally  it  comes  later  from  heart  failure,  after  the  signs  of  local 
improvement  have  begun. 

Those  who  manage  to  escape  the  dangers  of  the  acute  period  have 
still  others  to  encounter.  Among  the  latter  may  be  mentioned:  ex- 
tensive sloughing  in  the  throat  or  of  the  cellular  tissue  of  the  neck, 
which  may  be  followed  by  severe  or  even  fatal  hgemorrhage,  diffuse  sup- 
puration of  the  same  region,  late  nephritis,  pneumonia,  or  pleurisy,  and 
finally  paralysis  of  the  heart  or  respiration. 

Complications  and  Sequelae. — Most  of  the  complications  of  diph- 
theria have  already  been  mentioned  either  under  the  head  of  Lesions  or 
Symptoms.    It  only  remains  to  consider  their  clinical  association. 

Otitis  occurs  particularly  in  the  rhino-pharyngeal  cases,  and  is  some- 
times due  to  the  diphtheria  bacillus  alone,  but  more  often  to  mixed  in- 
fection. The  type  of  inflammation  is  often  a  severe  one,  and  it  may  be 
accompanied  by  necrotic  changes  in  the  drum  membrane  which  resem- 
ble those  of  scarlet  fever. 

Broncho-pneumonia  is  the  most  frequent  complication  in  young  chil- 
dren. It  occurs  especially  in  laryngeal  cases,  and  in  those  of  a  septic 
type  whether  the  larynx  is  involved  or  not.  Other  pulmonary  complica- 
tions are  infrequent.  Pleurisy  with  a  serous  effusion  may  occur  in  con- 
nection with  severe  nephritis,  and  empyema  in  septic  cases.  Emphy- 
sema is  a  complication  of  laryngeal  diphtheria;  it  is  nearly  always  vesic- 
ular, sometimes  interstitial,  and  may  become  general,  extending  into 
the  cellular  tissue  of  the  neck  and  afterward  that  of  the  entire  body. 
Pericarditis,  endocarditis,  and  meningitis  are  all  very  rare  and  are  seen 
chiefly  in  septic  cases  of  the  most  severe  type.  Myocarditis  is  much 
more  frequent,  and  is  present  to  a  greater  or  less  degree  in  nearly  all 
severe  cases,  although  in  but  a  small  proportion  of  these  does  it  give 
rise  to  distinct  symptoms.  It  is  closely  connected  pathologically  with 
degeneration  of  the  cardiac  nerves,  and  it  may  be  a  cause  of  sudden 
death  at  any  time  during  the  acute  period  of  the  disease  or  during  con- 
valescence. 

Thrombosis  and  embolism  are  among  the  less  frequent  complica- 
tions. If  cerebral,  they  may  cause  hemiplegia,  aphasia,  and  sometimes 
convulsions;  if  peripheral,  they  usually  affect  one  of  the  lower  extrem- 


1020  THE  SPECIFIC  INFECTIOUS  DISEASES. 

ities,  where  they  may  cause  sudden  pain,  numbness,  and  coldness  of  the 
limb,  followed  by  partial  paralysis,  oedema,  and  sometimes  even  by  gan- 
grene. Thrombosis  of  the  pulmonary  artery  or  of  the  heart  may  be  a 
cause  of  sudden  death,  the  symptoms  being  dyspnoea  and  prascordial  dis- 
tress, with  pallor  or  cyanosis.  Both  thrombosis  and  embolism  are  asso- 
ciated with  a  very  feeble  action  of  the  heart,  and  generally  they  are  pre- 
ceded by  degenerative  changes  in  its  muscular  walls. 

Haemorrhages  are  usually  nasal,  and  while  in  most  cases  they  are  not 
serious,  they  may  necessitate  plugging  of  the  posterior  nares.  Bleeding 
from  any  other  mucous  membrane  may  occur,  but  it  is  rare  except  from 
the  mouth.  Subcutaneous  hgemorrhages  are  infrequent,  and  are  evi- 
dence of  a  very  high  degree  of  diphtheritic  toxgemia.  They  usually 
occur  as  small  petechial  spots,  but  are  sometimes  extensive.  They  may 
be  seen  upon  almost  any  part  of  the  body,  most  frequently  upon  the 
abdomen  and  lower  extremities;  but  the  most  extensive  extravasation 
I  have  ever  seen  was  in  the  neck,  reaching  from  the  clavicle  almost 
to  the  ear  and  covering  nearly  one  lateral  half  of  the  neck. 

Albumin  is  present  m  the  urine  of  almost  every  case  of  moderate 
severity,  usually  depending  upon  acute  degeneration  of  the  kidney. 
Acute  nephritis  is  most  frequently  seen  in  septic  cases.  It  then  usually 
develops  at  the  height  of  the  local  disease,  but  may  come  during  con- 
valescence. Albumin  and  casts  are  found  in  the  urine,  but  rarely  is 
there  dropsy  or  signs  of  ursemia.  Less  frequently  a  more  severe  form 
of  inflammation  occurs,  with  dropsy,  scanty  urine  or  even  suppression, 
vomiting,  and  all  the  usual  symptoms  of  acute  urgemia.  This  complica- 
tion may  be  a  cause  of  death. 

Functional  disturbances  of  the  stomach  are  present  in  most  of  the 
severe  cases,  but  lesions  of  the  mucous  membrane  are  rare.  While  diar- 
rhoea is  often  seen  without  intestinal  lesions,  the  latter  are  of  frequent 
occurrence.  The  most  characteristic  form  of  inflammation  is  a  follicu- 
lar ileo-colitis,  which  seldom  goes  on  to  ulceration.  It  is  extremely  rare 
that  the  membranous  form  is  seen,  and  then  it  is  generally  associated 
with  the  presence  of  streptococci,  not  with  diphtheria  bacilli. 

Diphtheria  is  usually  followed  by  a  severe  and  often  persistent  ana?- 
mia  which  may  continue  for  weeks.  Pneumonia,  nephritis,  and  cardiac 
disease  may  first  show  themselves  during  convalescence,  and  so  be 
ranked  as  sequelse.  The  most  important  sequel  of  diphtheria,  however, 
is  multiple  neuritis  or  post-diphtheritic  paralysis  (page  836). 

Diagnosis. — The  diagnosis  of  diphtheria  rests  upon  two  kinds  of  evi- 
dence— clinical  and  bacteriological.  While  the  bacteriological  diagnosis 
is,  on  the  whole,  more  exact,  it  should  not  be  depended  upon  to  the  ex- 
clusion of  the  clinical  diagnosis.  The  prevailing  tendency  to  disregard 
the  clinical  evidences  of  the  disease  and  rely  wholly  upon  bacteriology, 
is  greatly  to  be  deprecated.     Bacteriology  applied  to  the  diagnosis  of 


DIPHTHERIA  1021 

diphtheria  has  rendered  incalculable  service,  but  it  has  its  limitations. 
As  has  well  been  said  by  Welch,  the  mere  presence  of  the  diphtheria 
bacilli  in  the  throat  of  a  patient  no  more  proves  that  he  has  diphtheria, 
than  the  presence  of  the  pneumococcus  in  his  saliva  establishes  the  fact 
that  he  has  pneumonia,  xlgain,  the  case  may  be  one  of  undoubted  diph- 
theria and  yet  the  bacilli  may  not  be  found  at  the  first  examination, 
although  found  subsequently.  While  in  no  way  detracting  from  the 
immense  advantage  of  having  bacteriological  assistance  in  the  diagno- 
sis, the  clinical  manifestations  of  diphtheria  should  be  observed  with  the 
same  care  as  heretofore,  particularly  since  the  great  body  of  the  pro- 
fession are  as  yet  compelled  to  rely  solely  upon  clinical  diagnosis. 
Every  one  who  has  seen  much  of  the  two  methods  of  diagnosis  studied 
side  by  side  will,  I  think,  admit  that  in  fully  four  fifths  of  the  cases  an 
accurate  clinical  diagnosis  can  be  made  after  twenty-four  hours'  obser- 
vation, and  in  a  considerable  proportion  of  these  in  a  shorter  time;  the 
remainder  require  either  a  longer  period  of  observation  or  continue 
doubtful  to  the  end.  The  great  majority  of  such  cases  are  of  the  mild- 
est variety  and  terminate  in  recovery.  In  them  an  accurate  diagnosis 
is  of  importance  more  for  the  sake  of  others  than  for  the  patient 
himself. 

1.  The  Clinical  Diagnosis. — In  arriving  at  this,  there  must  be  con- 
sidered the  patient  and  his  surroundings,  the  constitutional  or  general 
symptoms,  and  the  local  evidences  of  disease.  The  chances  of  diph- 
theria are  greatly  increased  if  the  patient  is  a  young  child,  if  his  home 
is  in  a  tenement  house  or  an  institution,  if  he  mingles  in  school  with 
children  coming  from  all  sorts  of  homes,  and  if  there  are  other  cases  in 
the  family  or  in  the  neighbourhood.  If  the  throat  symptoms  occur  with 
measles  or  scarlet  fever,  the  time  of  their  development  is  of  some  im- 
portance; when  they  precede  the  eruption  or  appear  while  the  fever  is 
at  its  height,  the  disease  is  usually  not  true  diphtheria;  while,  if  they 
develop  at  a  later  period  or  after  defervescence,  diphtheria  is  highly 
probable. 

Not  much  importance  can  be  attached  to  the  mode  of  onset,  for 
diphtheria  develops  in  such  a  variety  of  ways.  The  onset  is  more  fre- 
quently gradual,  and  the  initial  temperature  is  more  often  low,  than  is 
the  case  with  other  throat  inflammations.  The  presence  of  a  nasal  dis- 
charge, especially  if  abundant,  ichorous  and  tinged  witli  blood,  the  early 
development  of  the  symptoms  of  croup,  the  rapid  enlargement  of  the 
cervical  lymph  glands,  and  the  early  appearance  of  albumin  in  the  urine 
— all  point  strongly  to  diphtheria.  Later  symptoms  which  are  espe- 
cially diagnostic  are  marked  anaemia,  progressive  a.'^thenia,  intense 
toxaemia  often  with  a  low  temperature,  very  feeble  pulse  which  is 
sometimes  slow,  sometimes  rapid,  sudden  attacks  of  syncope,  nasal 
haemorrhages,  nasal  regurgitation  from  paralysis  of  the  soft  palate, 
66 


1022  THE  SPECIFIC  INFECTIOUS  DISEASES. 

contagion,  and,  finall}',  the  development  of  paralysis  of  the  muscles 
of  the  throat,  eye,  or  extremities,  with  paralysis  of  the  heart  or  respi- 
ration. 

The  characteristic  membrane  of  diphtheria  generally  appears  first 
upon  the  tonsils,  usually  as  a  gray  film  which  gradually  becomes  more 
dense  and  white,  and  often  has  the  look  of  being  plastered  on.  The 
colour  of  older  membrane  is  gray,  greenish-yellow,  brown,  sometimes 
black.  Beginning  as  a  small  patch,  it  soon  covers  the  tonsils.  It  fre- 
quently affects  one  tonsil  twenty-four  or  thirty-six  hours  before  the 
other,  and  occasionally  it  is  confined  to  one  side.  In  exceptional  cases 
it  begins  in  the  crypts  of  the  tonsil  and  appears  as  isolated  dots,  which 
may  coalesce  to  form  a  continuous  patch  like  that  already  described,  or 
it  may  remain  isolated  like  the  exudate  of  an  ordinary  follicular  ton- 
sillitis. When  the  membrane  is  forcibly  removed  it  reforms  in  most 
cases  within  twenty-four  hours.  More  important  still  for  diagnosis  is 
the  fact  that  the  membrane  spreads  from  the  original  seat,  and  also  the 
manner  of  its  spreading.  If  it  extends  beyond  the  tonsils  to  the  walls  of 
the  pharynx,  the  faucial  pillars,  and  the  uvula,  it  is  almost  surely  diph- 
theria. The  same  is  true  of  doubtful  patches  on  the  tonsils  or  fauces 
followed  by  symptoms  of  croup.  The  rapidity  of  the  spreading  varies 
much  in  the  difilerent  cases,  depending  upon  the  intensity  of  the  infec- 
tion; but  the  gradual  extension,  as  shown  by  observations  made  at  in- 
tervals of  six  or  eight  hours,  usually  settles  the  diagnosis  in  the  primary 
cases.  However,  if  the  throat  symptoms  complicate  measles  or  scarlet 
fever  the  above  rules  do  not  apply. 

In  pure  diphtheria  there  is  a  notable  absence  of  oedema  of  the  fau- 
cial pillars  and  uvula,  so  common  in  throat  inflammations  due  to  cocci. 
In  fact,  whenever  there  are  seen  in  the  throat  evidences  of  a  very  high 
degree  of  inflammation,  it  usually  points  either  to  mixed  infection  or  to 
false  diphtheria. 

Primary  membranous  inflammation  of  the  larynx  may  always  be 
safely  regarded  as  diphtheria;  but  if  there  is  no  visible  membrane,  the 
diagnosis  is  rendered  positive  only  by  a  bacteriological  examination. 
This  may  be  true  of  many  nasal  cases  where  the  only  s3'mptoms  are  a 
discharge  of  the  character  previously  described.  Such  cases  may  con- 
tinue for  weeks  with  no  symptoms  other  than  the  discharge.  Some  of 
them  are  examples  of  catarrhal  diphtheria;  in  others,  membrane  is 
present  in  the  post-nasal  space  or  in  the  nose  itself. 

The  most  characteristic  clinical  differences  between  diphtheria 
and  other  inflammations  accompanied  by  an  exudation  upon  the  throat 
or  in  the  nose — i.  e.,  pseudo-diphtheria — are  shown  in  the  following 
table: 


DIPHTHERIA. 


1023 


DIPHTHERIA. 

1.  Often  a  history  of  exposure,  or  preva- 
lence of  an  epidemic. 

2.  Onset  often  gradual,  with  low  tem- 
perature and  slight  constitutional  symp- 
toms. 

3.  Previous  attacks  rare. 

4.  Often  begins  in  the  larynx. 

5.  H  pharyngeal,  shows  a  strong  tend- 
ency to  extend  to  the  larynx. 

6.  Primary  cases  frequently  severe. 

7.  When  it  complicates  measles  or  scar- 
let fever  it  often  develops  late — after 
primary  fever  has  subsided. 

8.  Occasionally  limited  to  the  nose 
(croupous  rhinitis). 

9.  Albuminuria  the  rule,  except  in  the 
mildest  eases. 

10.  Nasal  regurgitation  from  paralysis 
of  the  palate  in  the  second  week  or  later. 

11.  Toxic  symptoms  common  ;  asthenia, 
great  anaemia  after  the  fourth  or  fifth 
day ;  later,  sudden  heart  paralysis,  respira- 
tory paralysis,  or  post-diphtheritic  paraly- 
sis of  throat,  eyes,  or  extremities. 

12.  Usually  less  evidence  of  inflamma- 
tion of  mucous  membrane  and  in  sur- 
rounding parts. 

13.  A  membrane  on  the  tonsils  with 
patches  on  the  uvula  or  elsewhere  in  the 
pharynx  is  usually  diphtheria ;  doubtful 
patches  on  the  tonsils  followed  by  croup 
almost  invariably  diphtheria. 


PSEUDO-DIPHTHERIA. 

1.  Usually  none. 

2.  Onset  usually  abrupt,  with  high  tem- 
perature and  quite  marked  constitutional 
symptoms. 

3.  Often  a  history  of  repeated  attacks. 

4.  Seldom  if  ever  does  so  when  primary. 

5.  This  tendency  is  much  less  marked. 

6.  Rarely  severe  unless  secondary,  par- 
ticularly to  measles  or  scarlet  fevei-. 

7.  Usually  occurs  at  the  height  of  the 
primary  disease. 

8.  Doubtful  if  ever  so. 

9.  Rarely  seen  m  primary  cases,  and 
sometimes  not  in  secondary  form,  even 
though  the  symptoms  are  severe. 

10.  Never  seen. 

11.  Septic  symptoms  frequent,  espe- 
cially when  secondary,  but  the  peculiar 
toxic  symptoms  are  never  seen. 


12.  Often  evidence  of  intense  inflamma- 
tion. 

13.  It  is  never  possible  to  say  by  the 
appearance  of  the  membrane  alone  that 
the  case  is  not  true  diphtheria. 


The  difficulties  of  diagnosis  are  greatest  in  the  mild  cases  and  in  the 
early  stage.  There  are  very  few  cases,  except  those  of  the  mildest  type, 
in  which  a  diagnosis  is  not  possible  by  the  course  of  the  disease;  but 
there  are  very  many  in  which  an  early  diagnosis  is  impossible  without 
cultures. 

It  is  not  often  difficult  to  distinguish  diphtheria  from  any  other  dis- 
ease; but  the  exudation  upon  the  pharynx  or  tonsils  may  be  confounded 
with  thrush  or  herpes.  This  mistake  can  scarcely  be  made  by  one  who 
examines  a  case  with  any  degree  of  care.  The  appearance  of  the  tonsils 
on  the  second  or  third  day  after  tonsillotomy  has  been  performed,  may 
easily  be  mistaken  for  diphtheria  by  one  wlio  is  unfamiliar  with  the  ap- 
pearance of  the  wound. 

Diphtheria  of  the  mouth  may  be  mistaken  for  herpetic  or  ulcerative 


1024  THE  SPECIFIC  INFECTIOUS  DISEASES. 

stomatitis;  but,  as  a  rule,  it  is  seen  only  in  the  worst  cases  of  pharyngeal 
diphtheria.  Diphtheria  of  the  mouth  alone  is  so  rare  that  it  may  be 
ignored. 

It  is  sometimes  difficult  to  distinguish  cases  of  scarlet  fever  in  which 
the  throat  symptoms  are  severe  and  appear  early,  from  cases  of  primary 
diphtheria.  In  many  of  these  cases  the  eruption  appears  late,  and  is 
not  characteristic.  Much  importance  is  to  be  attached,  as  pointing 
toward  scarlet  fever,  to  a  prevailing  epidemic,  a  history  of  exposure,  a 
sudden  onset  with  severe  symptoms,  vomiting,  prostration,  very  high 
temperature,  and  to  a  very  active  inflammation  in  the  pharynx.  In  all 
cases  with  a  sudden  onset,  in  which  from  the  throat  symptoms  one  is 
inclined  to  make  a  diagnosis  of  diphtheria,  the  possibility  of  scarlet 
fever  should  not  be  forgotten;  and  one  should  never  omit  to  examine 
the  patient  thoroughly  for  an  eruption.  The  diagnosis  of  primary  diph- 
theria of  the  larynx  has  already  been  considered  (page  493). 

2.  The  Bacteriological  Diagnosis.* — The  technique. — In  many  cases 
an  immediate  diagnosis  may  be  reached  by  smearing  a  cover-glass  with 
a  swab  which  has  been  drawn  over  the  diphtheritic  membrane;  the 
cover-glass  is  then  dried  and  stained.  Although  in  the  hands  of  an  ex- 
pert this  method  is  fairly  exact,  it  is  not  adapted  to  general  use,  as 
bacilli  directly  from  the  throat  are  much  less  typical  than  those  from 
cultures,  and  the  chances  of  contamination  are  much  increased.  Fur- 
thermore, the  mouth  often  contains  bacilli  which  somewhat  resemble 
the  diphtheria  bacillus. 

In  making  cultures  there  is  required  a  sterilized  swab  and  a  tube  or 
plate  of  Loeffler's  blood-serum.  In  taking  a  culture  from  the  throat, 
the  tongue  should  be  depressed  and  the  tonsils,  pharynx,  or  other  seat 
of  visible  membrane  rubbed  firmly  with  a  swab,  which  is  then  rubbed 
over  the  surface  of  the  culture-medium  in  the  tube  or  on  the  plate. 
In  laryngeal  cases  the, culture  should  be  taken  from  the  posterior  wall 
of  the  pharynx,  and  in  nasal  cases  from  the  nostril.  The  tube  or  plate 
is  then  placed  in  an  incubator  for  twelve  or  fourteen  hours  f  and  kept 
at  a  temperature  of  about  100°  F.  (37°  C),  at  the  end  of  which  time 
the  colonies  (Plate  XX,  1  and  2)  may  be  examined.  A  sterilized  plati- 
num needle  is  dipped  into  a  colony  and  washed  off  in  a  drop  of  steril- 

*  I  am  greatly  indebted  for  many  facts  in  these  pages  to  the  Scientific  Bulletin 
No.  1,  of  the  New  York  Health  Department,  in  whose  bacteriological  laboratory,  under 
the  supervision  of  Drs.  H.  M.  Biggs  and  W.  H.  Park,  some  of  the  best  work  in  the 
bacteriological  diagnosis  of  diphtheria  has  been  done. 

•|-  In  the  laboratory  of  the  Babies'  Hospital  we  have  found  that  the  rapid  method 
of  staining  cultures  at  the  end  of  five  or  six  hours  can  usually  be  depended  upon,  but 
that  it  is  not  always  reliable  where  the  result  is  negative.  In  every  case  it  is  wise  for 
control  to  make  an  examination  of  individual  colonies  at  the  expiration  of  the  usual 
time.  However,  the  rapid  method  is  of  great  advantage,  as  the  saving  of  time  is  of  so 
much  importance  in  the  administration  of  antitoxin. 


PLATE    XX. 


^r- 


ujim 


♦3 


>4 


##1^ 

4*^'' 


Ml    . 


/^ 


Diphtheria  Bacilli  and  their  Associates. 

1  and  2,  colonics  of  diplitlicria  l)acilli  under  a  low  and  a  hifjli  jiowci';  :i,  4.  H.  diar- 
acteristic  diphtheria  haeiili  x  1,000;  5,  showinf,'  the  short  evcii-.stained  dij>h(iicria 
bacilli;  6,  pseudo-diphtheria  bacilli;  7.  streptococci  from  a  soriini  culture;  8.  strep- 
tococci from  a  smear  directly  frmu  the  throat.  (After  I'ark.) 


DIPHTHERIA.  1025 

ized  water  upon  the  cover-glass,  dried  in  the  air,  and  then  heated  by 
passing  several  times  over  an  alcohol  flame  and  stained  for  five  minutes 
with  Loeffler's  solution  of  alkaline  m.ethylene  blue,  without  heating; 
after  which  it  is  rinsed,  dried,  and  mounted  in  balsam.  Examination 
with  an  oil-immersion  lens,  in  the  great  majority  of  cases,  shows  either 
a  great  number  of  diphtheria  bacilli  (Plate  XX,  3,  4,  and  5)  and  a  few 
cocci,  or  only  cocci  in  pairs  or  short  chains  (7  and  8);  exceptionally,  the 
cocci  and  bacilli  may  be  present  in  nearly  equal  numbers'. 

A  definite  opinion  should  not  be  given  without  examining  several 
colonies  from  different  parts  of  the  specimen.  The  diagnosis  is  com- 
pleted by  testing  the  virulence  of  the  bacilli  found.  This  is  usually 
done -by  injecting  a  guinea-pig  with  a  pure  broth-culture;  if  it  dies 
within  seventy-two  hours,  the  bacilli  are  said  to  be  fully  virulent. 

Tlie  reliance  to  he  placed  upon  bacteriological  diagnosis. — In  fully 
ninety-five  per  cent  of  the  cases  in  which  one  would  unhesitatingly  make 
the  diagnosis  of  diphtheria  by  clinical  symptoms,  the  Klebs-Loeffler 
bacillus  is  found,  provided  proper  precautions  are  observed.  It  will 
almost  invariably  be  found:  (1)  if  there  is  visible  membrane  in  the 
pharynx;  (2)  if  the  culture  is  made  during  the  period  in  which  the 
membrane  is  forming;  (3)  if  no  antiseptics  have  been  applied  shortly 
before  using  the  swab;  (4)  if  the  culture  has  been  made  with  sufficient 
care  to  avoid  contamination. 

The  diphtheria  bacillus  sometimes  disappears  early;  hence  cultures 
made  while  the  membrane  is  loosening  may  be  negative.  If  the  mem- 
brane has  disappeared,  or  if  none  has  been  present,  it  is  not  infrequently 
necessary  to  go  into  the  tonsillar  crypts  with  probe  or  spoon  to  discover 
bacilli.  It  is  therefore  important  in  all  cases  to  consider  the  duration 
of  the  disease  before  drawing  a  conclusion  from  a  negative  culture.  If 
the  case  is  one  of  laryngeal  disease  without  pharyngeal  exudation,  a 
negative  culture  from  the  pharynx  in  the  early  stage  is  not  uncommon, 
although  a  little  later  bacilli  may  be  coughed  up  and  found  in  the  phar- 
ynx in  abundance.  A  single  negative  culture  is  never  to  be  taken  as 
conclusive. 

The  consensus  of  opinion  among  bacteriologists  is  that,  for  diag- 
nostic purposes,  all  bacilli  present  in  suspicious  throats,  having  the 
morphological  and  cultural  characteristics  of  diphtheria  bacilli,  are  to 
be  regarded  as  virulent.  This  is  equally  true  of  bacilli  from  both  mild 
and  severe  cases. 

Non-virulent  bacilli  resembling  the  diphtheria  bacillus. — There  may  be 
found  in  throats  two  forms  of  bacilli  which  resemble  the  diphtheria  ba- 
cillus and  which  may  occasionally  be  a  source  of  error.  The  first  is  the 
non-virulent  diphtheria  bacillus,  a  form  which  corresponds  in  every 
other  characteristic  with  the  diphtheria  bacillus,  but  which  lacks  viru- 
lence as  shown  by  animal  tests.     The  exact  status  of  this  form  is  not 


1026  THE  SPECIFIC  INFECTIOUS  DISEASES. 

yet  fully  determined.  The  view  most  widely  accepted  is  that  of  Eoux 
and  Yersin — viz.,  that  they  are  simply  diphtheria  bacilli  which  have  lost 
their  virulence.  The  other  form,  though  in  many  particulars  resem- 
bling the  diphtheria  bacillus,  differs  from  it  in  being  shorter,  plumper, 
and  more  uniform  in  size,  and  in  producing  an  alkali  in  broth  cultures; 
to  this  the  term  pseudo-diphtheria  iacillus  *  (Plate  XX,  6)  has  been 
given.  It  is  more  frequently  seen  than  the  form  Just  described  and  like 
it  is  non-virulent.  Both  these  forms  of  bacteria  are  rare  in  throats 
where  a  suspicion  of  diphtheria  exists. 

The  presence  of  virulent  hacilli  in  the  throats  of  healthy  persons. — That 
virulent  bacilli  may  be  harboured  for  an  indefinite  period  in  the  throat 
or  nose  of  a  healthy  person  is  proved  by  many  observations.  In  Esche- 
rich's  well-known  case,  the  throat  of  an  apparently  healthy  nurse,  under 
whose  care  a  number  of  cases  of  diphtheria  had  developed,  was  found  to 
contain  numerous  virulent  bacilli  which  remained  for  weeks.  In  a  case 
observed  by  Park,  virulent  bacilli  were  found  for  months  in  the  nose  of 
an  apparently  healthy  infant,  and  this  child  communicated  diphtheria, 
it  was  believed,  to  two  other  members  of  the  family,  without  itself  ever 
suffering  from  the  disease.  These  cases  are  to  be  regarded  as  very  ex- 
ceptional. However,  the  presence  of  bacilli  in  the  nose  or  throat  of  a 
child  who  has  recently  been  exposed  to  diphtheria  is  very  common.  The 
New  York  Health  Department  made  observations  upon  forty-eight  chil- 
dren in  fourteen  families  in  which  one  or  more  cases  of  diphtheria  had 
occurred,  and  where  no  attempt  at  isolation  had  been  made.  In  one 
half  these  cases  bacilli  were  found,  and  animal  tests  showed  them  to  be 
virulent  in  every  one  of  six  cases  tested,  although  four  of  the  children 
did  not  develop  diphtheria.  Of  the  entire  number,  forty  per  cent  subse- 
quently developed  diphtheria.  My  own  experience  in  two  institutions 
where  diphtheria  has  been  endemic,  fully  confirms  the  observation  that 
bacilli  of  all  degrees  of  virulence  are  very  frequently  found  in  the  noses 
or  throats  of  such  exposed  children,  although  a  large  proportion  of  them 
never  develop  the  disease.  Outside  of  institutions  and  infected  tene- 
ment houses,  however,  such  a  condition  is  extremely  rare. 

Summary.— 1.  For  ordinary  diagnostic  purposes  the  discovery  in  the 
throat  of  a  case  of  suspected  diphtheria,  of  bacilli  having  the  appear- 
ance of  the  Klebs-Loeffler  bacillus,  may  be  regarded  as  conclusive  evi- 
dence of  diphtheria. 

2.  Cultures  may  yield  negative  results  late  in  pharyngeal  cases,  or 
early  in  laryngeal  cases;  but  in  no  instance  is  a  single  negative. culture 
to  be  regarded  as  conclusive. 

3.  Both  the  local  appearance  of  the  throat  and  the  stage  of  the  dis- 

*  An  unfortunate  term,  as  this  bacillus  has  nothing  to  do  with  the  form  of  angina 
classed  as  pseudo-diphtheria,  which  is  generally  due  to  the  streptococcus. 


DIPHTHERIA.  1027 

ease  are  always  to  be  considered  in  connection  with  the  bacteriological 
report. 

4.  Virulent  bacilli  are  frequently  found  in  the  noses  or  throats  of 
children  exposed  to  diphtheria,  apart  from  all  throat  lesions.  Such  a 
finding  is  not  in  itself  evidence  that  these  persons  have  diphtheria, 
but,  inasmuch  as  they  may  infect  others  and  as  a  considerable  proportion 
of  them  subsequently  develop  diphtheria  themselves,  they  should  be 
regarded  with  suspicion  and  if  possible  kept  under  observation. 

5.  N^on-virulent  bacilli  are  occasionally,  and  virulent  bacilli  are  very 
rarely,  found  in  the  throats  of  healthy  persons  when  there  is  no  history 
of  exposure  to  diphtheria. 

6.  The  existence  of  a  membranous  inflammation  in  the  nose  or  phar- 
ynx, associated  with  the  presence  of  diphtheria  bacilli,  is  conclusive  evi- 
dence of  the  existence  of  diphtheria. 

7.  The  presence  of  such  bacilli,  associated  with  marked  evidences  of 
catarrhal  inflammation  of  the  mucous  membrane,  is  likewise  evidence  of 
diphtheritic  infection. 

Prognosis. — Many  possiblities  exist,  and  even  the  mildest  case  must 
be  regarded  as  serious  and  carefully  watched,  since  we  can  never  know 
when  unfavourable  symptoms  may  develop. 

The  factors  to  be  considered  in  the  prognosis  of  any  given  case  are: 
the  age  and  previous  condition  of  the  patient;  the  extent  of  the  mem- 
brane and  the  rapidity  with  which  it  is  spreading;  the  degree  of  diph- 
theritic toxemia  as  shown  by  the  condition  of  the  pulse  and  the  nervous 
symptoms;  whether  or  not  the  membrane  has  invaded  the  larynx;  and 
the  presence  or  absence  of  complications,  especially  nephritis  and  bron- 
cho-pneumonia; but  of  more  importance  than  any  or  all  these  things  is 
whether  antitoxin  is  used  and  when  it  is  administered.  Statistics  upon 
the  latter  point  might  be  multiplied  indefinitely,  but  two  groups  of 
cases  will  suffice.  The  first  are  from  the  American  Pa^diatric  Society's 
Report  in  1896  upon  results  with  antitoxin  in  private  practice: 

Died.  Blortality. 

Injected  1st  day 764 38 4-9  per  cent. 

"        2d  day 1.065  89 8-3       " 

"       3dday 630 79 12-7       " 

"       4th  day 336 77 22-9       " 

later 390......   152 38-9       « 

Totals 3^ 435  13-7       " 

This  collective  investigation  was  made  after  antitoxin  had  been  in 
use  in  this  country  only  a  little  over  one  year;  much  of  the  serum  used 
■was  either  inert  or  of  very  low  potency,  and  in  a  majority  of  the  cases 
the  doses  given  would  now  be  considered  entirely  inadequate.  The 
patients  were  treated  by  over  six  hundred  din'(M'ont  physicians;  the  re- 
sults embody  their  earliest  experience,  and  include  many  moribund  cases. 


1028  THE  SPECIFIC  INFECTIOUS  DISEASES. 

The  following  figures  are  from  the  Report  of  the  Health  Depart- 
ment of  Chicago  of  cases  treated  from  October  5,  1895,  to  February  28, 
1899: 

Died.  Mortality. 

Injected  1st  day 355 1 0*27  per  cent. 

2dday 1,018 17 1-67       " 

3dday 1,509 57 3-77       " 

4th  day 720  82 11-39       " 

later 469  119 25-37       " 


Totals 4,071   276 6-77       " 

These  cases  were  all  treated  by  the  inspectors  of  the  Health  Depart- 
ment, and  the  results  embody  the  later  and  riper  experience  with  the 
serum.  In  all  these  cases  the  diagnosis  of  diphtheria  was  confirmed  by 
cultures;  in  the  Psediatric  Society's  Report  73  per  cent  were  confirmed 
by  cultures. 

Diphtheria  mortality  is  highest  during  the  first  two  years  of  life, 
from  its  strong  tendency  to  invade  the  larynx  and  lower  air  passages, 
and  from  the  frequency  with  which  broncho-pneumonia  occurs  as  a  com- 
plication. Those  whose  experience  with  this  disease  does  not  antedate 
the  introduction  of  antitoxin  can  scarcely  appreciate  the  results  previ- 
ously obtained.  Of  eighty-five  consecutive  cases  under  twenty-six 
months  of  age  observed  in  the  iSTew  York  Infant  Asylum,  in  a  period 
extending  over  two  years,  the  mortality  was  68  per  cent;  in  over  two 
thirds  of  the  fatal  cases  the  disease  involved  the  larynx.  In  diphtheria 
hospitals,  where  most  of  the  mild  cases  included  in  the  above  statistics 
would  probably  not  have  been  admitted,  the  mortality  in  children  under 
two  years  formerly  varied  from  60  to  80  per  cent;  in  private  practice  it 
ranged  for  this  age  from  30  to  60  per  cent. 

After  the  second  year  there  is  a  steady  fall  in  the  mortality  up  to 
puberty. 

General  mortality  statistics  will  be  considered  later.  There  has  been 
considerable  discussion  as  to  what  influence  the  general  introduction  of 
bacteriological  diagnosis  has  had  upon  diphtheria  statistics.  While 
many  cases  of  pseudo-diphtheria,  most  of  which  recover,  have  been  ex- 
cluded, there  have  been  included  many  cases  formerly  regarded  as  exam- 
ples of  simple  tonsillitis.  In  a  single  month  there  were  reported  to  the 
New  York  Health  Department  as  diphtheria  (without  a  bacteriological 
examination)  107  cases  which  were  proven  by  cultures  to  be  pseudo- 
diphtheria;  while  during  the  same  month  there  were  80  cases  returned 
as  doubtful  or  as  pseudo-diphtheria,  which  by  bacteriological  examina- 
tion were  proven  to  be  true  diphtheria.  Of  10,776  cases  of  suspected 
diphtheria,  representing  thirteen  series  of  cases  from  different  parts  of 
the  world,  which  were  examined  bacteriologicallj-,  only  8,596  were 
proven  to  be  true  diphtheria. 


DIPHTHERIA.  IOO9 

It  can  not  be  too  often  emphasized  that  the  danger  from  diphtheria 
is  not  over  when  the  throat  has  cleared.  The  most  frequent  cause  of 
death  after  this  time  is  heart  paralysis,  less  frequently  paralysis  of  res- 
IDiration,  nephritis,  or  broncho-pui'umonia. 

Prophylaxis. — In  no  infectious  disease,  smallpox  alone  excepted,  can 
so  much  be  accomplished  in  the  way  of  prevention  as  in  diphtheria. 

Public  funerals  of  children  dying  from  diphtheria  should  invariably 
be  prohibited.  Schools  should  be  closed  whenever  the  disease  is  epi- 
demic. Children  from  families  where  diphtheria  exists  should  not  be 
allowed  to  attend  school,  nor  mingle  in  any  way  with  other  children,, 
for  the  reasons  that  they  may,  while  healthy,  be  the  carriers  of  the  dis- 
ease; and,  what  is  even  more  important,  that  they  may  be  themselves- 
suffering  from  diphtheria  in  an  early  stage  or  in  a  mild  form.  Such 
children  should  be  kept  from  school  for  at  least  two  weeks  after  the  re- 
covery of  the  last  case  in  the  family. 

In  every  large  city,  hospitals  for  diphtheria  patients  should  be  estab- 
lished, not  only  for  the  poor,  but  with  private  rooms  for  cases  develop- 
ing in  hotels  or  other  places  where  isolation  is  impossible.  Every  city 
should  be  provided  with  a  steam  disinfecting  plant,  where  carpets,, 
blankets,  bedding,  etc.,  can  be  sent  from  the  sick-room  for  disinfection. 
It  is  also  desirable  that  every  city  have  a  bacteriological  laboratory, 
where  the  diagnosis  in  all  doubtful  cases  may  be  settled  by  means  of 
cultures,  in  order  that  proper  and  necessary  means  of  prophylaxis  may 
be  taken  in  every  case  of  true  diphtheria,  even  though  it  is  mild,  and 
also  that  unnecessary  expense  and  trouble  may  not  be  imposed  in  cases 
of  pseudo-diphtheria. 

Quarantine. — Not  only  every  undoubted  case  of  diphtheria,  but  every 
suspected  case,  should  be  immediately  isolated.  Quarantine  for  the  lat- 
ter should  continue  until  the  diagnosis  is  settled  either  by  a  bacterio- 
logical examination  or  by  the  course  of  the  disease.  Positive  and  sus- 
pected cases  should  not  be  isolated  together.  The  quarantine  in  every 
instance  must  be  complete.  If  possible,  cultures  should  be  taken  from 
the  throats  of  all  exposed  children.  Those  containing  diphtheria  bacilli 
should  be  quarantined  like  cases  of  di])htheria.  for  they  may  be  equally 
dangerous;  they  sliould  use  gargles  and  sprays,  and  the  nose  and  throat 
should  be  closely  watched. 

Bacteriology  has  furnished  some  very  definite  data  from  which  the 
necessary  duration  of  the  period  of  quarantine  may  be  determined.  In 
this  the  physician  is  to  be  guided  by  the  time  that  the  bacilli  remain  in 
the  throat,  for  the  patient  is  to  be  considered  as  dangerous  while  they 
persist.  This  point  was  investigated  by  the  New  York  Health  Depart- 
ment in  605  cases:  In  304  of  these  the  bacilli  had  disappeared  by  the 
third  day  after  the  membrane  was  gone;  and  in  301  they  persisted  for  a 
longer  tim,e — in  176,  for  seven  days;  in  64,  for  twelve  days;  in  36,  for 


1030  THE  SPECIFIC  INFECTIOUS  DISEASES. 

iifteen  days;  in  12,  for  twenty-one  days;  in  4,  for  twenty-eight  days;  in 
4,  for  thirty-five  days;  and  in  2,  for  sixty-three  days.  Many  of  the  cases 
in  which  the  bacilli  have  persisted  for  an  unusual  time  have  been  those 
of  nasal  diiDhtheria;  in  some  of  these  it  is  doubtless  owing  to  the  fact 
that  the  nasal  sinuses,  especially  the  antrum,  have  been  invaded.  "While 
it  is  unquestionably  true  that  in  a  certain  number  of  cases  these  persist- 
ent bacilli  are  non-virulent,  the  opposite  has  been  frequently  shown.  Of 
15  cases  in  which  the  virulence  was  tested,  virulent  bacilli  were  found  in 
9  at  periods  varying  from  eight  to  twenty-five  days  after  the  membrane 
was  gone.  Tobiesen  found  that  of  46  patients  leaving  the  hospital  un- 
der ordinary  rules,  virulent  bacilli  were  present  in  34  at  the  time  of 
their  discharge.  If  no  culture  tests  can  be  made,  quarantine  should  be 
■continued  in  mild  cases  for  ten  days,  and  in  severe  cases  for  three  weeks, 
after  the  membrane  has  disappeared.  The  danger  after  this  period  in 
either  instance  is  very  slight;  for  even  where  virulent  bacilli  are  found 
long  after  the  membrane  has  disappeared,  their  number  is  usually  small. 
The  rules  above  given  should  be  followed  with  reference  to  children 
returning  to  school  or  mingling  with  other  children,  and  adults  who  are 
thrown  into  close  contact  with  children. 

Treatment  of  suspected  cases.— During  an  epidemic  of  diphtheria,  es- 
pecially in  an  institution,  every  sore  throat  and  nasal  discharge  should 
be  looked  upon  with  suspicion,  and  isolated  pending  the  result  of  a  bac- 
teriological examination,  even  though  no  membrane  is  present.  All 
such  patients  should  be  separated  from  the  other  inmates  of  the  home  or 
institution,  and  while  waiting  for  the  results  of  the  bacteriological  ex- 
amination or  for  positive  symptoms,  antiseptic  gargles  or  sprays  should 
be  used.  If  there  are  patches  on  the  tonsils  or  any  other  visible  mem- 
brane, the  case  should  be  treated  as  true  diphtheria,  in  order  that  no 
time  may  be  lost.  If  the  bacteriological  examination  shows  the  disease 
not  to  be  true  diphtheria,  the  patient  may  be  released  from  quarantine 
in  two  or  three  days,  provided  the  throat  symptoms  disappear.  It  is, 
of  course,  important  that  the  conditions  laid  down  with  reference  to  bac- 
teriological diagnosis  shall  have  been  fulfilled.  Should  symptoms  con- 
tinue, however,  a  second  culture  should  be  taken. 

Immunization  of  persons  exposed. — When  a  case  of  diphtheria  occurs 
in  a  family  or  an  institution,  every  child  that  has  been  exposed  should 
receive  an  immunizing  dose  of  antitoxin.  This  is  a  point  which  has  not 
received  at  the  hands  of  most  practising  physicians  the  attention  which 
it  deserves.  There  can  be  no  doubt  that  for  a  limited  time — from  three 
to  four  weeks — the  serum  confers  almost  complete  protection.  Some  of 
the  most  striking  evidences  of  the  value  of  the  serum  for  immunization 
have  been  obtained  in  ISTew  York  institutions,  under  my  own  observation. 
'The  results  in  these  institutions,  together  with  those  obtained  elsewhere, 
xire  shown  in  the  accompanying  table,  which  was  prepared  by  Biggs. 


DIPHTHERIA. 


1031 


In  the  two  institutions  first  named  in  the  table,  many  infants  under 
three  months  old  were  injected,  and  several  under  a  week  old,  without 
anything  more  than  transient  disturbances.  In  one  of  these  institutions 
21  pregnant  women  and  8  women  in  the  puerperal  state  were  injected; 
there  was  no  reaction  in  any  of  them. 

Table  Shoiving  the  Results  of  Antitoxin  Injections  for  Immunization. 


Place  of  Observation. 

Chil- 
dren 
immu- 
nized. 

Cases  of  diph- 
theria develop- 
ing among 
those  immu- 
nized between 
1  and  30  days. 

Cases 
devel- 
oping 
with  hi 
24  hrs. 

Cases  devel- 
oping after 
m  days. 

Number 

of  cases  of  diphtheria 

tliat  uccurred  in 

the  institutions  previous 

to  immunizatiou. 

NewYork  Infant  Asylum 
(1st  immunization). 

NewYork  Infant  Asylum 
(3d  immunization). 

Nursery  and  Child's  Hos- 
pital. 

New  York  Juvenile  Asy- 
lum. 

New  York  Catholic  Pro- 
tectory. 

Bellevue  Hospital 

Health    Department   in- 
spectors. 

324 
345 

[136 

j-   81 
114 

11 

[333 

1  mild  on  the 
19th  day. 

1  mild  on  the 
13th  day. 

0 

0 
0 

0 

1  mild  on  the 
19th  day. 

0 
0 

0 

0 
1 

0 

3 

6 

4 

0 

0 
0 

0 
(  1,  30th. 
3  ■{  1,  31st. 
(  1,  55th. 

107  cases  in  108  days. 

6  cases  in  12  days. 

j  46  eases  in  90  days. 
]  15  cases  in  18  days. 
j  1 2  cases ;  3  cases  in 

1  2  days. 

5  cases  in  3  days. 

2  cases  in  10  days. 
One  or  more  cases  in 

more  than  90  fam- 
ilies. 

Total 

1,043 

3 

4 

13 

In  the  Bulletin  of  the  New  York  Health  Department  are  brought 
together  twenty-nine  reports,  covering  15,986  injections  of  antitoxin  in 
exposed  persons  for  the  purpose  of  immunization.  The  number  at- 
tacked with  diphtheria  during  the  thirty  days  following  injection  was 
but  79,  or  0-5  per  cent.  Nearly  all  of  these  had  a  mild  form  of  the  dis- 
ease, only  one  case  being  fatal.  Many  of  these  injections  were  made  in 
the  early  days  of  antitoxin,  and  doses  now  regarded  as  insuihcient  were 
given. 

The  dose  for  immunization  is  from  100  to  r;00  units,  the  former 
being  that  required  for  an  infant  under  one  month,  am!  the  latter  for  a 
child  of  twelve  or  fourteen  years;  for  onv  from  two  to  ten  years  the 
usual  dose  is  500  units.  If  the  exposure  is  continuous,  as  in  an  institu- 
tion, the  dose  should  be  repeated  every  three  or  four  weeks.  A  nurse 
in  charge  of  a  diphtheria  case  should,  receive  from  600  to  800  units. 

Diphtheria  so  often  complicates  scarlet  fever  and  measles,  particu- 
larly in  institutions  and  in  hospitals  for  contagious  diseases,  that  special 
consideration  should  be  given  to  such  ]iatients.  It  is  practically  impos- 
sible by  cultures  to  separate  with  absolute  certainty  all  cases  in  which 
diphtheritic  infection  is  present,  from  others;  the  only  safe  rule  is  to 
immunize  every  child  admitted  to  a  scarlet-fever  or  measles  hospital, 
.and  in  institution  epidemics  of  either  of  these  diseases  to  immunize 


1032  THE  SPECIFIC  INFECTIOUS  DISEASES. 

every  child  attacked.  This  rule  has  heen  followed  for  some  years  at  the 
New  York  Foundling  Hospital  with  the  most  striking  benefit. 

Nurses  a7id  physicians. — As  diphtheria  is  contracted,  not  from  the 
breath  of  the  patient  or  the  air  of  the  room,  but  by  receiving  the  bacilli 
into  the  mouth  or  air  passages,  all  possible  means  should  be  taken  to  de- 
stroy the  bacilli  discharged,  and  to  secure  absolute  cleanliness  in  every- 
thing about  the  sick-room.  Nurses  should  never  be  allowed  to  eat  or 
sleep  in  the  sick-room,  and  an  antiseptic  gargle  should  be  used  four  or 
five  times  a  day.  The  hands  should  be  kept  clean,  and  only  such  dresses 
worn  as  can  be  readily  washed  and  disinfected.  It  is  the  nurse  who  is 
most  likely  to  contract  the  disease,  on  account  of  the  continued  ex- 
posure. 

The  physician  should  take  the  same  precautions  as  in  scarlet  fever 
(page  955).  A  pocket  tongue-depressor  should  not  be  used  for  the  ex- 
amination of  the  throat,  but  a  spoon  which  is  kept  in  a  solution  of  car- 
bolic acid,  1  to  40.  In  order  to  prevent  the  coughing  up  of  mucus  or 
membrane  in  the  face  of  the  hospital  physician  who  must  examine  many 
throats,  a  pane  of  ordinary  window  glass  may  be  held  in  front  of  the 
patient's  face  during  throat  inspections. 

The  sick-room. — The  carpets,  hangings,  upholstered  furniture,  every- 
thing in  fact  not  necessary  for  the  patient's  welfare,  should  be  removed, 
especially  books,  toys,  cushions,  etc.  The  room  should  be  a  large  one,  if 
possible  with  an  open  fireplace,  well  ventilated,  and  fresh  air  should  be 
allowed  in  abundance.  The  floor  should  be  washed  once  a  day  with  a 
solution  of  bichloride,  1  to  2,000,  and  dusted  often  with  cloths  moistened 
in  the  same  solution.  All  handkerchiefs,  bed-linen,  and  clothing  re- 
moved from  the  patient  should  be  treated  as  in  a  case  of  scarlet  fever. 
Pieces  of  membrane  and  other  matters  discharged  from  the  patient 
should  be  put  into  a  solution  of  carbolic  acid,  1  to  20,  or  of  bichloride,  1 
to  1,000.  Old  muslin  or  absorbent  cotton  should  be  used  to  cleanse  the 
nose  and  mouth  of  the  patient  and  burned  immediately.  All  vessels  for 
the  reception  of  expectoration  or  other  discharges  should  contain  bichlo- 
ride, 1  to  2,000.  The  bed-linen  should  be  very  frequently  changed,  and 
everything  kept  scrupulously  clean.  In  the  room  should  be  a  large  bowl 
of  carbolic  acid,  1  to  40,  or  some  similar  solution  for  cleansing  the 
hands,  and  a  tray  of  the  carbolic  solution  for  spoons,  sj-ringes,  or  other 
things  used  in  the  treatment  of  the  patient.  All  spoons,  cups,  or  other 
dishes  used  by  the  patient  should  be  carefully  sterilized  by  boiling.  No 
milk  or  other  food  should  be  allowed  to  stand  about  the  room.  There  is 
no  objection  to  the  hanging  of  sheets  moistened  in  carbolic,  bichloride, 
or  other  disinfectant  solutions  before  the  door,  but  neither  this  nor 
hanging  them  about  in  the  sick-room  is  to  be  regarded  as  having  any 
value  in  disinfecting  the  air  of  the  room.  They  create  a  false  sense  of 
security,  and  often  lead  to  the  neglect  of  thorough  cleanliness. 


DIPHTHERIA.  1033 

Disinfection  of  apartments  after  an  attack  should  be  done  as  after 
scarlet  fever  (page  954). 

Treatment. — General  measures. — It  is  important  in  every  case  that 
there  should  be  plenty  of  fresh  air  in  the  room  throughout  the  attack. 
Where  it  is  possible,  it  is  desirable  to  have  two  rooms  for  the  patient,  so 
that  he  can  be  changed  from  one  to  the  other  every  day,  giving  time  for 
thorough  cleanliness  and  airing.  Hospital  patients  should  never  have 
less  than  1,000  cubic  feet  of  air  space,  and  if  possible  1,200  should  be 
allowed.  Small  wards,  containing  five  or  six  beds,  are  much  to  be 
preferred  to  very  large  ones.  Even  in  mild  cases  the  patient  should  be 
kept  in  bed  throughout  the  entire  attack,  and  in  severe  cases  this  should 
be  continued  for  some  time  during  convalescence. 

Nursing  infants  may  be  fed  on  breast  milk  obtained  by  a  breast 
pump,  but  should  not  be  put  to  the  mother's  breast.  The  feeding  of 
older  children  should  be  managed  very  much  as  in  other  cases  of  severe 
illness  (page  222).  Milk  is  the  main  reliance;  it  should  usually  be  di- 
luted, and  for  younger  infants  partially  peptonized.  The  greatest  diffi- 
culty in  feeding  is  seen  in  the  latter  part  of  the  disease,  when  the  pa- 
tients are  septic  and  have  a  strong  aversion  to  food,  when  vomiting  is 
easily  excited  and  when  swallowing  is  difhcult  on  account  of  the  swelling 
and  pain.  It  is  then  that  gavage  (page  62)  is  most  valuable.  This  is 
much  more  successful  with  children  under  three  years  old  than  is 
rectal  feeding.  In  older  children  the  tube  may  be  passed  through  the 
nose. 

Stimulants. — These  should  be  begun  as  soon  as  the  depressing  effects 
of  the  poison  of  diphtheria  are  shown  upon  the  pulse  and  general  con- 
dition of  the  patient.  In  most  cases,  therefore,  they  are  not  needed 
until  the  third  or  fourth  day;  in  a  few  they  may  be  required  from  the 
outset,  and  in  some  they  may  not  be  required  at  all.  The  indications 
for  alcoholic  stimulants  are  marked  prostration,  a  feeble  pulse,  and  a 
weak  first  sound  of  the  heart.  In  regard  to  the  quantity,  half  an  ounce 
of  whisky  or  brandy  in  twenty-four  hours  is  enough  to  begin  with,  for  a 
child  four  years  old.  This  should  be  diluted  with  at  least  eight  parts  of 
water.  In  very  bad  cases  two  or  three  times  as  much  may  be  given; 
but  more  than  this,  except  for  a  short  period,  is  seldom  wise.  The  ex- 
cessive doses  often  used  surely  endanger  the  kidneys.  The  method 
of  administration  should  be  the  same  as  in  other  severe  acute  diseases 
(page  49).  Usually  stimulants  should  not  be  combined  with  milk.  A 
child  is  more  apt  to  rebel  against  the  stimulants  than  the  milk,  and 
it  is  important  that  nothing  be  done  to  interfere  with  the  taking  of 
proper  nourishment.  Other  heart  stimulants  than  alcohol,  though  infe- 
rior to  it,  are  of  value.  Probably  the  most  useful  one  is  strychnine, 
which  should  be  given  as  in  pneumonia  (page  554).  Camjihor  and  car- 
bonate of  ammonia  are  valuable  for  rapid  effect  in  syncopal  attacks,  and 


1031  THE  SPECIFIC  INFECTIOUS  DISEASES. 

digitalis  in  other  cases  where  the  pulse  is  weak  and  arterial  tension  low^ 
but  it  is  not  wise  to  give  it  in  large  doses.  In  eases  of  threatened  heart 
paralysis  occurring  late  in  the  disease  or  during  convalescence,  nothing 
is  so  valuable  as  morphine  hypodermically.  Full  doses  must  be  given 
and  repeated  every  two  to  four  hours,  so  that  the  child  may  be  kept 
completely  under  its  influence. 

Except  for  stimulation  or  the  control  of  special  symptoms  such  a& 
vomiting  or  diarrhoea,  all  internal  medication  should  be  omitted;  for 
there  is  yet  wanting  proof  that  drugs  influence  the  course  or  the  result 
of  the  disease. 

Local  treatment. — Since  the  introduction  of  antitoxin,  opinion  has 
undergone  a  decided  change  with  reference  to  local  treatment.  While 
it  should  not  be  entirely  abandoned,  still  it  is  of  secondary  importance; 
and  under  conditions  where  it  can  be  carried  out  only  with  great  difii- 
culty  and  the  use  of  force  it  is  often  wise  not  to  attempt  it  systematically. 

The  purpose  of  local  treatment,  it  is  now  generally  agreed,  should  be 
cleanliness,  and  not  the  destruction  of  bacilli.  Cleanliness  of  the  nose, 
mouth,  and  pharynx  is  important,  inasmuch  as  one  of  the  chief  dangers 
of  the  disease  is  the  aspiration  of  bacteria  contained  in  the  abundant 
secretions  of  these  parts,  into  the  larynx  and  bronchi.  Our  aim  should 
therefore  be  to  keep  the  parts  as  clean  as  possible  without  too  severely 
taxing  the  strength  of  the  child. 

For  cleansing  the  nose  and  pharynx  only  syringing  can  be  depended 
upon.  Nasal  syringing  is  indicated  when  there  is  much  nasal  discharge, 
whether  membrane  is  visible  in  the  anterior  nares  or  not.  In  septic 
cases  with  a  profuse  fetid  discharge  it  may  be  necessary  to  syringe  the 
nose,  no  matter  how  strongly  the  child  resists.  Whether  it  shall  be 
done,  will  depend  upon  the  condition  of  the  patient's  strength  and  his 
pulse.  The  purpose  in  syringing  is  not  so  much  to  clear  the  nose,  from 
which  absorption  is  slow  and  imperfect,  as  to  flush  the  rhino-pharynx, 
from  which  absorption  is  always  very  active.  Only  bland  solutions 
should  be  employed,  such  as  a  common-salt  solution,  one  per  cent, 
or  a  boric-acid  solution,  one  to  four  per  cent  strength.  For  ordinary 
cases,  the  syringe  and  the  method  described  on  page  57  may  be  used. 
For  some  cases  a  fountain  syringe  possesses  manifest  advantages,  and 
it  is  rather  more  convenient  for  hospital  purposes.  Irrigation  of  the 
pharynx  is  best  done  with  the  fountain  syringe,  and  is  of  especial  value 
where  there  is  much  swelling  or  abundant  discharge.  All  solutions 
should  be  used  as  warm  as  can  be  borne,  and  in  sufficient  quantity  to 
irrigate  the  parts  thoroughly,  a  few  such  irrigations  being  much  bet- 
ter than  a  great  many  partial  ones.  By  a  skilful  nurse  syringing  can  in 
most  cases  be  done  with  comparatively  little  disturbance  to  the  child. 

Slight  nasal  haemorrhages  may  necessitate  less  frequent  syringing, 
and  a  free  haemorrhage  may  require  it  to  be  discontinued.     Astringent 


DIPHTHERIA.  1035 

solutions  of  alum,  supra-renal  extract,  lemon  juice,  etc.,  are  often  bene- 
ficial in  such  cases,  but  they  must  be  used  carefully.  In  children  who 
are  old  enough  gargles  should  be  used.  A  solution  of  boric  acid,  lister- 
ine,  or  Dobell's  or  Seller's  solution  much  diluted,  may  be  employed. 

In  cases  with  a  moderate  nasal  discharge  it  is  usually  sufficient  to 
syringe  three  or  four  times  a  day;  but  in  severe  septic  cases,  with  very 
abundant  discharge,  syringing  should  be  repeated  as  often  as  every  two 
hours  during  the  day  and  every  four  hours  at  night. 

External  applications  to  the  throat  have  practically  no  effect  upon 
the  disease,  but  are  often  useful  to  relieve  pain  and  tension  in  the 
swollen  lymph-glands.  Poultices  should  never  be  employed.  As  a  con- 
tinuous application,  only  cold  is  to  be  advised,  generally  by  an  ice  bag 
well  protected  to  prevent  wetting  the  clothing. 

The  Serum  Treatment. — This  has  been  the  outcome  of  a  long  series 
of  experiments  in  which  many  men  have  had  a  share;  but  it  is  to  Behr- 
ing  pre-eminently  that  the  credit  belongs  for  the  development  of  the 
principles  of  serum-therapy.  It  will  be  sufficient  here  to  indicate  the 
more  important  steps  which  have  led  to  this  discovery.  In  December, 
1890,  Behring  and  Kitasato  published  experiments  which  demonstrated 
that  it  was  possible  for  the  blood  of  an  immunized  animal  (one  which 
had  been  injected  with  the  toxins  of  a  disease  in  gradually  increasing 
doses,  until  a  condition  was  reached  when  such  injections  produced  no 
reaction)  when  injected  into  another  animal  to  convey  immunity,  and 
also  cure  the  disease  if  artificially  produced.  This  w^as  first  shown  to  be 
true  of  tetanus.  In  August,  1893,  Behring  further  show^ed  that  the 
blood  of  an  immunized  animal  had  the  power  both  of  protecting  and 
curing  susceptible  animals  which  had  been  inoculated  either  with  the 
toxins  or  with  the  bacilli  of  diphtheria.  Early  in  the  same  year  he  pro- 
duced from  animals  his  so-called  "  normal "  serum,  which  was  used  in 
his  animal  experiments,  this  being  one  sixtieth  of  the  strength  of  his 
No.  1  serum  now  employed.  The  further  steps  consisted  in  gradually 
increasing  the  strength  of  the  serum  by  the  use  of  stronger  toxins  for 
injection.  In  the  latter  part  of  1893  the  serum  was  first  tried  upon 
diphtheria  patients  in  the  Berlin  hospitals,  and,  although  it  was  still 
very  weak,  encouraging  results  were  observed.  The  new  treatment  at- 
tracted but  little  notice  until  the  Congress  at  Buda-Pesth  in  the  suninicr 
of  1894,  where  Eoux  presented  a  report  of  three  hundred  cases  treated 
in  Paris  under  his  supervision,  with  results  so  striking  that  the  interest 
of  the  entire  medical  profession  was  at  once  aroused.  Since  the  begin- 
ning of  1895  the  serum  treatment  bas  been  tested  on  a  large  scab'  all 
over  the  world. 

Eegarding  the  nature  of  Ibc  antitoxin  and  its  mode  of  action  nuuh 
is  as  yet  unknown.  It  is  produced  l)y  tlie  cells  of  the  body  under  the 
stimulus  of  the  diphtheria  toxin.     It  is  intimately  combined  with  the 


1036  THE  SPECIFIC  INFECTIOUS  DISEASES. 

globulin  of  the  blood,  and  is  itself  possibly  a  globulin.  The  action  of 
the  antitoxin  is  two-fold:  it  directly  neutralizes  the  toxin  produced  by 
the  diphtheria  bacillus  which  is  present  in  the  blood;  it  also  has  some 
eifeet  upon  the  bacilli  themselves  the  nature  of  which  is  not  understood, 
but  it  induces  a  condition  in  the  blood  which  inhibits  the  growth  of  the 
bacilli,  and  thus  arrests  the  membranous  inflammation  which  the  bacilli 
excite. 

Following  the  plan  of  Roux,  the  diphtheria  antitoxin  is  produced  at 
the  present  time  from  the  blood-serum  of  the  horse.  This  is  drawn  into 
sterilized  vessels  and  with  the  addition  of  some  antiseptic  preserved  in 
small  sterilized  bottles,  each  of  which  is  designed  to  contain  a  sufficient 
quantity  for  a  single  dose.  Properly  prepared,  it  will  keep  without  de- 
terioration for  from  three  to  six  months;  but  after  one  year  it  loses 
somewhat  its  antitoxic  properties.  It  should  be  kept  in  a  cool,  dark 
place,  and  after  a  bottle  has  been  opened  it  should  be  used  within  a  few 
days.  Antitoxin  is  now  prepared  in  a  dry  form,  which  is  to  be  pre- 
ferred only  when  it  must  be  kept  for  a  very  long  time. 

The  strength  of  the  serum  is  measured  in  antitoxin  units,  the  unit 
being  an  arbitrary  one  and  representing  the  ability  to  neutralize  a  defi- 
nite quantity  of  diphtheria  toxin.  The  improvements  in  the  produc- 
tion of  the  serum  have  thus  far  consisted  in  increasing  its  strength. 
Behring's  serum  first  used  contained  but  one  unit  in  each  cubic  centi- 
metre. At  present  there  can  be  obtained  from  most  manufacturers  a 
serum  containing  750  antitoxin  units  in  each  cubic  centimetre.  This 
concentration  is  of  immense  advantage  and  has  to  a  large  degree  done 
away  with  the  unpleasant  symptoms,  such  as  pain,  localized  oedema,  and 
eruptions,  which  were  formerly  so  frequent.  It  is  now  rarely  necessary 
to  use  for  a  single  dose  more  than  five  to  ten  cubic  centimetres  of  the 
strongest  serum. 

Method  of  administration  and  dosage. — Special  antitoxin  syringes, 
although  advantageous,  are  no  longer  indispensable.  The  very  large 
needles  made  for  some  of  them  are  decidedly  objectionable.  The  small- 
est needle  through  which  the  serum  will  flow  is  the  best.  Before  mak- 
ing the  injection,  the  skin  should  be  thoroughly  cleansed  with  alcohol; 
the  needle  should  invariably  be  boiled  and  the  whole  syringe  either 
boiled  or  rinsed  with  alcohol.  Care  should  be  taken  to  see  that  all  air 
is  expelled  from  the  syringe.  The  seat  of  injection  is  not  a  matter  of 
great  importance;  my  own  preference  is  for  the  cellular  tissue  of  the 
abdomen  or  outer  surface  of  the  thigh.  If  small  needles  are  used  no 
application  of  adhesive  plaster  is  necessary,  but  the  needle  puncture 
should  be  covered  with  the  finger  for  a  few  moments.  Antitoxin  is  so 
imperfectly  absorbed  by  the  mucous  membranes  of  the  stomach  and  the 
rectum,  that  this  method  of  administration  is  not  to  be  recommended. 

The  dose  of  antitoxin  required  in  a  given  case  is  always  somewhat 


DIPHTHERIA.  1037 

problematical.  It  is  desirable  to  give  enough  to  neutralize  the  diph- 
theria toxin  present  in  the  blood,  and  that  is  always  an  unknown  quan- 
tity, depending  upon  the  stage  of  the  disease,  the  severity  of  the  attack, 
the  extent  of  the  membrane,  and  to  some  degree  upon  the  age  of  the 
patient.  Convinced  now  of  the  essential  harmlessness  of  the  serum,  the 
profession  all  over  the  world  are  quite  in  accord  in  using  doses  much 
larger  than  were  first  employed,  a  practice  which  has  been  fully  justi- 
fied by  the  results  obtained.  For  a  child  over  two  years  old  an  initial 
•dose  for  a  severe  attack,  including  all  laryngeal  cases,  should  not  be 
less  than  4,000  or  5,000  units;  and  this  dose  should  be  repeated  in 
from  six  to  eight  hours,  provided  no  improvement  is  seen.  Children 
under  two  years  should  receive  from  2,000  to  3,000  units.  Cases  of 
exceptional  severity,  where  the  injection  is  given  late,  should  receive 
from  8,000  to  10,000  units,  to  be  repeated  in  from  six  to  eight  hours 
if  the  progress  of  the  disease  is  unfavourable.  Mild  cases  should  re- 
ceive from  2,000  to  3,000  units  as  an  initial  dose,  a  second  being  rarely 
required.  At  the  Boston  City  Hospital  much  larger  doses  than  these 
have  been  used,  the  rule  there  being,  according  to  Burrows,  to  give 
4,000  units  every  two  hours  to  very  severe  cases.  As  much  as  110,000 
units  have  been  given  to  a  single  patient.  It  is  claimed  that  by  these 
immense  doses  cases  otherwise  hopeless  have  been  saved. 

In  view  of  the  fact  that  the  serum  is  liable  to  contamination,  it 
follows  that  only  that  from  a  trustworthy  manufacturer  should  ever 
be  used.  In  the  light  of  recent  experience,  a  law  regulating  its  produc- 
tion and  sale  would  seem  to  be  necessary.  The  serums  chiefly  used  in 
this  country  are  those  of  the  New  York  Health  Department,  Mulford 
&  Company,  Parke,  Davis  &  Co.,  and  Behring's,  all  of  which,  I  believe, 
are  reliable.  The  most  concentrated  serum  which  can  be  obtained 
should  be  selected. 

All  experience  shows  that  the  results  are  greatly  modified  by  the 
time  of  its  administration.  The  serum  can  not  undo  the  serious  damage 
already  done  to  the  cells  of  the  body,  and  this  at  the  time  of  injection 
may  be  so  great  that  death  will  result.  One  who  waits  until  his  cases 
have  grown  alarmingly  worse  under  other  treatment  and  gives  small 
doses,  will  see  little  benefit  from  antitoxin.  In  very  mild  eases,  with 
older  children,  one  may  wait  for  the  result  of  a  bacteriological  examina- 
tion where  such  examinations  are  possible,  but  never  in  a  severe  case 
and  never  in  a  young  child.  In  the  group  of  severe  cases  should  be 
placed  every  one  which  at  the  first  visit  shows  a  pharyngeal  exudate  cov- 
ering more  than  the  tonsils,  also  all  cases  with  symptoms  of  laryngeal 
invasion,  and  all  with  an  exudate  on  the  pharynx  and  a  profuse  nasal 
discharge.  If  in  a  doubtful  case  twelve  hours'  observation  shows  that 
the  membrane  has  spread  from  its  original  seat,  no  further  delay  is  ad- 
missible. Experiments  have  shown  that  after  a  fatal  dose  of  diphtheria 
67 


1038  THE  SPECIFIC  IXFECTIOUS  DISEASES. 

toxin,  an  animal  can  usually  be  rescued  if  tiie  antitoxin  is  administered 
within  forty-eight  hours,  but  rarely  after  that  time.  In  human  diph- 
theria marked  benefit  usually  follows  injections  made  as  late  as  the  third 
day;  but  after  this  time  the  value  of  the  serum  diminishes  very  rapidly 
(see  page  1028),  and  although  striking  examples  of  benefit  are  some- 
times seen  after  later  injections,  they  can  not  be  depended  upon.  On 
the  other  hand,  in  very  severe  or  in  malignant  cases  irreparable  harm 
may  be  done  during  the  first  twenty-four  hours  of  the  attack. 

The  local  effects  of  the  injection  are  a  slight  redness,  pain,  and  usually 
some  transient  cedema.  General  eruptions  are  seen  in  a  considerable 
number  of  cases,  from  three  to  twenty  per  cent  according  to  various 
observers.  A  slight  general  erythema  which  is  of  short  duration  may 
appear  within  a  few  hours  after  the  injection.  The  most  important 
eruptions  come  from  the  eighth  to  the  fourteenth  day  after  the  injec- 
tion, usually  appearing  in  the  form  of  an  urticara.  Although  in  most 
cases  slight  and  transient,  the  body  may  be  covered  and  the  urticaria 
continue  to  be  most  annoying  for  several  days.  Various  forms  of  ery- 
thema have  been  occasionally  observed,  sometimes  fever,  and  in  a  few 
cases  swelling  of  the  joints.  These  symptoms  do  not  occur  with  any 
regularity;  they  are  seen  quite  as  frequently  after  small  as  after  large 
doses,  and  their  cause  is  not  yet  entirely  understood.  They  seem  to  de- 
pend partly  upon  the  susceptibility  of  the  patient  and  partly  upon  some 
peculiarity  in  the  serum  used. 

Tlie  effect  upon  the  diplitlieritic  membrane  is  usually  noticeable  within 
twenty-four  and  often  in  twelve  hours;  it  first  stops  spreading,  and  soon 
begins  to  soft  en,  and  loosen.  The  swelling  of  the  mucous  membrane 
subsides  and  the  local  disease  abates,  very  much  as  when  the  disease 
runs  its  usual  course.  The  striking  thing  after  the  use  of  antitoxin  is 
the  rapidity  with  which  these  changes  take  place,  and  the  abrupt  tran- 
sition from  an  advancing  to  a  retrograde  process.  The  subsidence  of 
the  inflammatory  conditions  in  the  larynx  and  trachea  is  quite  as 
marked  as  in  the  pharynx.  The  symptoms  of  stenosis,  even  when  severe, 
often  diminish  in  a  few  hours,  making  operation  unnecessary  in  a  very 
large  number  of  cases  where  previously  it  seemed  inevitable.  The  mem- 
brane loosens  rapidly  in  the  larynx  and  trachea,  sometimes  necessitating 
the  frequent  removal  of  the  intubation  tube,  where  operation  has  been 
performed.  Improvement  is  also  shown  by  the  cessation  of  the  nasal 
discharge,  the  re-establishment  of  nasal  respiration,  and  the  diminution 
in  the  swelling  of  the  glands  of  the  neck. 

The  effect  upon  the  constitutional  symptoms  is  not  less  striking.  In 
favourable  cases  there  is  seen,  often  in  twelve  hours,  a  fall  in  tempera- 
ture and  improvement  in  the  pulse  and  in  the  nervous  sj^mptoms. 

The  limitations  of  antitoxin. — It  is  important  that  these  should  al- 
ways be  kept  in  mind.    The  serum  must  be  given  early,  for  if  given  late 


DIPnTHERIA.  1039 

it  can  not  nndo  the  mischief  already  done  by  the  diphtheria  toxin. 
Cases  6f  great  severity  often  pass  the  period  when  recovery  is  possible, 
before  the  antitoxin  is  given.  This  period  may  in  some  cases  be  four 
days,  in  others  it  may  be  less  than  twentj'-four  hours.  The  tissues  most 
susceptible  to  the  diphtheria  toxin  are  probably  those  of  the  nervous 
system,*  the  heart,  and  the  kidneys;  and  the  consequences  of  its  action 
may  be  seen  in  the  production  of  nephritis,  in  heart  failure  at  the  height 
of  the  disease,  or  in  later  paralysis  of  the  heart,  respiration,  or  voluntary 
muscles,  in  spite  of  the  fact  that  antitoxin  is  given  at  a  period  early 
enough  to  avert  death  from  local  disease  in  the  larynx  or  bronchi. 
Again,  antitoxin  is  of  no  value  in  cases  of  streptococcus  septicaemia. 
The  early  arrest  of  the  inflammation  excited  by  the  diphtheria  bacillus 
is  unfavourable  to  the  spread  of  streptococcus  infection,  yet  sometimes 
the  latter  gains  such  headway  or  is  of  such  intensity  as  to  involve  al- 
most the  entire  body.  Against  the  phlegmonous  inflammation  of  the 
throat  or  the  cellular  tissue  of  the  neck,  broncho-pneumonia,  and  ne- 
phritis, antitoxin  is  powerless;  and  just  in  proportion  to  the  severity  of 
these  inflammations  are  negative  results  seen. 

Real  and  alleged  dangers  from  antitoxin  injections. — In  the  cases 
where  sudden  death  has  followed  antitoxin  injections,  the  evidence  that 
antitoxin  was  the  cause  of  death  is  not  conclusive.  That  so  very  few 
alleged  instances  of  this  have  occurred  among  the  great  numbers  of  in- 
jections which  have  now  been  made,  is  sufficient  to  establish  the  fact 
that  the  serum  itself  is  harmless. 

The  unfavourable  effects  upon  the  heart,  the  kidneys,  and  the  blood, 
,  attributed  to  antitoxin,  are  to  my  mind  not  proved.  In  a  disease  like 
diphtheria,  where  the  heart  and  kidneys  are  often  and  seriously  affected, 
and  where  cardiac  and  renal  symptoms  in  many  cases  are  suddenly  mani- 
fested, it  is  impossible  to  say,  even  when  such  symptoms  follow  the  in- 
jection of  serum,  that  they  are  not  due  to  the  original  disease.  They 
were  seen  with  great  frequency  before  antitoxin  w^as  known.  Observa- 
tions regarding  the  effect  of  the  serum  upon  the  blood  were  made  by 
Billings,  upon  twenty-nine  cases  of  diphtheria.     He  found  the  reduc- 

*  Experiments  by  Ehrlich,  Dreyer,  and  Madsen  (Zeitsch.  fiir  Hygiene  und  Infect., 
37, 1901)  point  to  a  complex  structure  of  the  diphtheria  poison,  which  seems  to  consist 
of  at  least  two  constituents,  called  by  Ehrlich  the  toxin  and  the  toxon.  The  toxin  is 
rapidly  absorbed  and  produces  fatal  effects  very  quickly,  but  it  also  exhibits  a  great 
aflBnity  for  the  antitoxin,  by  which  it  is  rapidly  neutralized.  The  toxon  is  slowly 
absorbed,  produces  its  effects  when  injected  in  animals  only  after  many  days  or  some- 
times weeks,  and  these  effects  consist  of  characteristic  pareses  of  the  voluntary  muscles. 
The  toxon  exhibits  but  slight  affinity  for  the  antitoxin,  and  is  neutralized  by  it  only 
after  all  the  toxin  has  been  neutralized. 

The  practical  deduction  from  these  experiments  would  seem  to  be,  the  necessity  of 
giving  the  antitoxin  as  a  therapeutic  measure  very  early  in  the  disease  in  order  to 
affect  the  toxin,  and  in  large  doses  in  order  to  counteract  the  effects  of  the  toxon. 


1040  THE  SPECIFIC  INFECTIOUS  DISEASES. 

tion  both  in  the  hsemogiobm  and  the  red  cells  to  be  much  less  than  the 
average  found  in  cases  of  diphtheria  of  similar  severity  not  treated  by 
the  serum. 

At  the  present  time,  after  the  serum  has  been  in  general  use  for 
over  seven  years,  no  evidence  has  been  adduced  as  to  its  danger  or  in- 
jurious effects  which  should  deter  any  one  from  its  use.  Those  which 
have  been  reported  are  to  be  regarded  in  the  light  of  accidents  for  which" 
the  antitoxin  can  not  be  held  responsible. 

Results  with  antitoxin  treatment. — After  seven  years  of  testing  on  so 
extensive  a  scale  as  the  prevalence  of  diphtheria  all  over  the  world  has 
made  possible,  it  would  seem  quite  unnecessary  to  cite  statistics  in  proof 
of  the  value  of  this  remedy.  No  tables  of  figures  are  so  convincing  to  an 
individual  as  personal  experience,  and  by  this  argument  one  by  one  the 
opponents  of  antitoxin  have  been  converted.  There  are  still  some  who 
will  not  apply  the  personal  test;  for  such,  the  following  figures  are  cited, 
which  would  seem  to  any  unprejudiced  mind  absolutely  unanswerable. 

The  effects  of  the  remedy  may  best  be  judged  by  a  consideration 
of  the  following  points:  (1)  The  percentage  mortality  from  diphtheria 
with  serum  treatment  as  compared  with  former  results;  (2)  the  propor- 
tion of  cases  now  requiring  operation  for  laryngeal  stenosis;  (3)  the  re- 
sults in  laryngeal  cases,  both  with  and  without  operation;  (4)  the  effect 
of  the  new  treatment  upon  the  actual  diphtheria  mortality  of  cities  and 
countries  where  it  has  been  used. 

Siegert  *  has  tabulated  from  twenty-three  hospitals  for  children  on 
the  Continent  of  Europe  the  cases  of  diphtheria  treated  and  results  ob- 
tained for  the  years  1890  to  1898  inclusive.  These,  omitting  the  figures 
for  the  transition  year  (1894),  are  as  follows: 


Period. 

Cases  treated. 

Deaths. 

Mortality, 
per  cent. 

Before  the  serum  (1890-93  inclusive) 

16,585 
20,181 

6,889 
3,309 

41-3 

Since  the  serum  (1895-'98  inclusive) 

16-4 

In  1896  the  American  Psediatric  Society  f  undertook  a  collective  in- 
vestigation of  cases  of  diphtheria  treated  by  antitoxin  in  private  prac- 
tice. In  this  report  were  brought  together  5,794  cases,  treated  by  615 
physicians  from  all  parts  of  the  United  States  and  Canada  with  a  gen- 
eral mortality  of  13  nS  per  cent.  In  this  report,  the  tables  of  which  I 
assisted  in  preparing,  was  included  every  case  in  which  the  serum 
had  been  used,  although  it  was  stated  regarding  some  of  them  that 
the  patient  was  moribund  at  the  time  of  injection.  Furthermore,  this 
was  the  first  year  of  antitoxin  in  America;  many  of  the  cases  were 

*  Jahrbuch  filr  Kinderheilkunde.  lii,  56,  1900. 
f  Archives  of  Pfediatrics,  July,  1896. 


DIPHTHERIA. 


1041 


injected  late  in  the  disease,  with  doses  now  regarded  as  entirely  inade- 
quate; much  of  the  serum  used  was  of  an  inferior  quality  and  some  of 
it  without  doubt  absolutely  inert.  The  remedy  being  then  on  trial,  the 
most  severe  cases  were  usually  selected  for  its  use,  as  was  stated  by 
many  of  the  individual  reports.  Of  4,120  cases  receiving  the  antitoxin 
during  the  first  three  days  the  mortality  was  but  7 '3  per  cent. 

The  proportion  of  cases  requiring  operation. — In  Siegert's  tables  are 
given  the  proportion  requiring  operation  for  the  relief  of  laryngeal  ste- 
nosis in  twenty-one  hospitals  before  the  serum  period  and  since  that 
time: 


Period. 

Cases  of 
diphtheria  treated. 

Required  operation. 

1890-93  inclusive  (without  serum) 

1895—98  inclusive  (with  serum) 

16.042 

18,896 

7,570,  or  47-2  per  cent. 
5,204,  or  27-5       " 

The  proportion  of  laryngeal  cases  requiring  operation  is  well  shown 
by  the  two  reports  of  the  American  Pasdiatric  Society.  Of  1,256  laryn- 
geal cases  in  the  first  series,  554,  or  44  per  cent,  recovered  without 
operation;  while  in  the  second  series  of  1,704  laryngeal  cases,  858,  or 
50  per  cent,  recovered  without  operation.  These  figures  are  to  be  com- 
pared with  those  of  pre-antitoxin  days,  when  it  was  estimated  that  not 
more  than  10  per  cent  of  laryngeal  cases  recovered  without  operation. 

Results  in  Cases  of  Laryngeal  Diphtheria  operated  upon. 
I.  Intubation. 


Source  Of  Statistics. 

Number  of  operations. 

Mortality. 

McNaughton  and  Maddren,   chiefly   private 
practice,  America 

5,346,    without  serum 

2,830, 

5,004,    with 

1,170,      " 
)            (  without     " 
[5'470-!with          " 

Per  cent. 
69-4 

23  Continental  hospitals,  1890-1893  (inclusive) 

Same  hospitals,  1895-1898  (inclusive) 

American  Pa^diatric  Society's  Reports,  1896 
and  1897 

57-5 
32-4 

26-0 

Private  practice  in  Europe  and  America:  55 
operators  (Trumpp,  1900) 

65  0 
18-0 

II.   Tracheotomy. 

57  Continental  hospitals,  1890-1893, 10,815, 

Same  hospitals,  1895-1898 6,942, 


without 
with 


59-5 
32-5 


Reduction  in  the  actual  diphtheria  mortality. — In  the  first  of  the 
subjoined  tables  is  given  for  a  period  of  years  the  actual  number  of 
reported  deaths  from  diphtheria  and  membranous  croup,  irrespective  of 
the  growth  in  population;  in  the  second  one  the  number  of  deaths  in 
each  10,000  of  population.  These  figures  can  not  be  open  to  the  question 
which  is  sometimes  raised  concerning  percentage  mortality  statistics. 


1042 


THE  SPECIFIC  INFECTIOUS  DISEASES. 


Table  Showing  Annual  Deaths  from  Diphtheria  and  Croup, 
1887  to  1900  {inclusive). 


London 

Berlin 

Paris 

New  York 

(Manhattan  and  Bronx) 

Chicago 

Boston 

Philadelphia 

Brooklyn 

Denver 

Germany 

(266  towns  over  15,000) 

New  York  State. 
Massachusetts... 


1887   1888    1889    1890    1891    1892    1893    1894 


1,579 
1,392 
1,585 
3,056 

1,405 

410 

858 

1,453 

68 

10,970 

6,490 

1,628 


1.812 
1,195 
1,729 
2,553 

1,297 
589 
523 

1,885 

120 

10,142 

6,710 
1,831 


2,075 
1,210 
1,706 
2,291 

1,509 
683 
727 

1,467 

109 

11,919 

5,930 

2,214 


1,877 
1,601 
1,659 
1,783 

1,261 
462 
748 

1,283 

277 

11,915 

4,954 
1,626 


1,174 
1,106 
1,361 
1,970 

1,358 

285 

1,362 

1,180 

175 

10,484 

4,844 
1,218 


2,182 
1,342 
1,403 
2,106 

1,548 

481 

1,707 

1,137 

89 

12,365 

5,970 
1,455 


3,484 
1,637 
1,266 
2,558 

1,467 
546 

1,238 

878 

106 

16,557 

5,942 
1,394 


2,861 
1,416 
1.009 
2,870 

1,406 

878 

1,452 

1,660 

71 

13,790 

6,616 
1,801 


1895  1896 


2,479 
987 
435 

1,976 

1,632 
654 
1,398 
1,454 
40 
7,611 

5,696 

1,784 


2,793 
559 
444 

1,763 

1,098 
572 
1,201 
1,310 
19 
6,262 

4,640 

1,677 


1897  1898  1899   1900 


2,328 
546 
268 

1,591 

774 
456 

1,514 
998 
43 

5,208 

4,115 
1,426 


1,842 
664 
256 
843 

680 
185 

1,154 

745 

34 

5,220 

2,612 
706 


2,041 
655 
336 
960 

917 
304 
997 
744 
31 
5,111 

2,786 
^1,047 


1,558 
563 
291 

1,121 

797 
537 

1,064 

673 

14 

4,685 

3,306 

11,475 


*  Cases  reported  1899,  7,134. 


+  Cases  reported  1900,  12,641. 


Table  Showing  Average  Annual  Deaths  from  Diphtheria  and  Croup 
per  lOfiOO  of  Population. 


London,  before  antitoxin,  1887-93,     4*8 


Berlin,               " 

10-2 

Paris,                 " 

6-5 

New  York,       " 

14-5 

Chicago,           " 

13-1 

Denver,             " 

12-9 

Philadelphia,   " 

1890-'94,  11-9 

since  antitoxin,  1896-1900,  4-7 
3-7 
1-3 
6-8 
5-0 
1-7 
9-6 


Some  explanation  of  these  figures  is  necessary  that  they  may  be 
fully  appreciated.  The  great  reduction  in  the  death-rate  is  seen  only 
in  those  cities  and  countries  where  the  serum  treatment  has  been  widely 
employed.  Nowhere  in  Europe  is  this  true  to  the  same  degree  as  in 
Paris,  Berlin,  and  Germany  generally;  and  probably  nowhere  in  Eu- 
rope has  it  been  so  little  used  and  so  slow  in  gaining  favour  as  in  Lon- 
don. In  our  American  cities  the  effect  of  the  serum  treatment  upon 
municipal  mortality  figures  has  been  directly  proportionate  to  the  extent 
to  which  the  health  departments  have  believed  in  its  efficacy  and  en- 
couraged its  use  by  furnishing  it  free  to  the  poor,  and  sending  their  own 
inspectors  to  administer  it.  This  is  true  particularly  of  New  York  and 
Chicago;  in  Philadelphia,  on  the  contrary,  the  authorities  have  always 
been  lukewarm,  and  for  a  long  time  were  openly  opposed  to  the  serum 
treatment. 

Summary. — 1.  Behring's  antitoxin  is  a  specific  remedy  for  experi- 
mental diphtheria  in  animals. 

2.  Experience  is  now  sufficient  to  justify  the  statement  that  it  is  so 
in  man,  and  just  to  the  extent  in  which  we  can  fulfil  the  conditions 
which  are  essential  in  experimental  diphtheria. 


DIPHTHERIA.  1043 

3.  These  conditions  are,  that  the  scrum  must  be  administered  early, 
that  the  dose  be  adequate,  and  the  case  be  one  of  pure  diphtheria. 

4.  Experience  shows  the  serum  to  be  much  less  efficacious  in  cases  of 
so-called  mixed  infection  or  septic  diphtheria,  and  that  it  is  valueless  in 
membranous  inflammations  which  are  due  to  streptococci — i.  e.,  pseudo- 
diphtheria. 

5.  The  serum  itself  is  essentially  harmless  both  when  injected  in 
healthy  persons  for  immunization,  or  in  those  suffering  from  diphtheria. 

6.  In  a  young  child  the  serum  should  be  injected  upon  a  clinical 
diagnosis  of  diphtheria  without  waiting  for  bacteriological  confirmation; 
in  older  children  one  may  wait  in  a  mild  case,  but  never  in  a  severe  one, 
particularly  a  laryngeal  case. 

7.  For  all  patients,  but  especially  for  young  children,  the  most  con- 
centrated preparations  of  antitoxin  that  can  be  obtained  should  be 
employed. 

8.  The  actual  mortality  from  diphtheria  (including  membranous 
croup)  has  been  reduced  in  those  cities  and  countries  where  it  has  been 
generally  adopted  by  nearly  50  per  cent;  the  mortality  of  intubated 
cases  has  fallen  from  70  to  less  than  30  per  cent;  of  tracheotomized 
cases  from  60  to  33  per  cent;  the  proportion  of  cases  in  which  operation 
is  required  has  been  reduced  fully  50  per  cent. 

9.  The  evidence  is  conclusive  that  in  laryngeal  diphtheria  the  serum 
in  sufficient  doses  largely  prevents  the  extension  of  the  membrane  into 
the  trachea  and  bronchi,  thus  preventing  broncho-pneumonia. 

10.  It  is  not  yet  possible  to  state  to  what  extent  the  heart,  the 
kidneys,  and  the  nervous  system  are  protected  by  the  serum.  It  is, 
however,  certain  that  such  results  can  not  be  depended  upon  unless 
injections  are  made  early  and  full  doses  given. 

11.  For  a  period  of  from  three  to  four  weeks  the  protection  con- 
ferred by  immunization  is  practically  comiDlete.  The  serum  should 
therefore  be  given  to  every  child  in  an  infected  household  or  institution. 

12.  Gratifying  as  were  the  earlier  results  with  the  serum  treatment, 
they  have  been  constantly  improving,  and  there  is  every  reason  to  be- 
lieve that,  with  larger  experience  both  in  its  preparation  and  its  use, 
still  better  results  will  yet  be  reached.  Certainly  there  is  no  remedy 
for  any  disease  that  has  more  testimony  in  its  favour  than  has  antitoxin 
for  diphtheria. 

Convalescence. — After  a  severe  attack  of  diphtheria  convalescence  is 
always  slow  on  account  of  the  anremia  and  the  depressing  effects  of  the 
disease.  Patients  should  invariably  be  ke\it  in  bed  for  at  least  a  week 
after  the  throat  has  cleared,  and  longer  if  any  tendency  to  cardiac  weak- 
ness is  seen.  The  pulse  should  be  carefully  watched,  and  irregularity, 
intermission,  dicrotism,  or  a  weak  first  sound  of  the  heart,  should  make 
one  apprehensive.    An  abnormally  slow  pulse  is  generally  more  serious 


1044  THE  SPECIFIC  INFECTIOUS   DISEASES. 

than  one  which  is  rapid.  Under  such  circumstances  the  patient  should: 
be  kept  recumbent  and  absolutely  quiet,  since  sudden  and  even  fatal 
syncope  may  be  the  result  of  a  violation  of  these  rules. 

The  extreme  degree  of  anaemia  requires  that  iron  be  given  for  a  con- 
siderable time  during  convalescence,  to  be  followed  by  cod-liver  oil,  wine,. 
and  other  tonics. 

Great  difficulty  is  occasionally  experienced  in  getting  rid  of  the  ba- 
cilli in  the  throat.  The  tonsillar  crypts,  the  adenoid  tissue  of  the  rhino- 
pharynx,  and  the  nasal  sinuses  are  the  places  where  the  bacilli  are  most 
likely  to  remain.  Inasmuch  as  it  is  now  generally  made  a  condition  of 
release  from  quarantine  that  the  throat  shall  have  been  shown  by  cul- 
tures to  be  free  from  bacilli,  this  becomes  a  matter  of  much  importance. 
The  most  efficient  means  appears  to  be  to  syringe  the  nose  gently  three 
or  four  times  daily  with  a  solution  of  bichloride,  1  to  10,000,  to  which 
one  eighth  glycerin  has  been  added,  and  to  use  the  same  solution  as  a 
gargle.  For  children  under  four  years  old  a  simple  salt  solution,  or  a. 
dilute  Dobell's  solution,  should  be  substituted  and  the  gargle  omitted. 

PSEUDO-DIPHTHERIA. 

Synonyms :  False  diphtheria,  streptococcus  diphtheria,  scarlatinal  diphtheria, 
diphtheroid  inflammation,  croupous  tonsillitis. 

At  the  present  time  there  are  included  under  the  term  pseudo-diph- 
theria all  inflammations  of  the  throat  and  upper  air  passages  character- 
ized by  the  production  of  a  false  membrane,  in  which  the  Klebs-Loeffler 
bacillus  is  not  found.  When  these  inflammations  are  primary  they  are 
rarely  serious;  but  when  they  complicate  scarlet  fever  or  measles  they 
may  be  very  severe,  and  frequently  prove  fatal. 

Frequency. — Numerical  statements  regarding  the  relative  frequency 
of  this  disease  and  true  diphtheria  signify  very  little,  because  of  the 
variable  conditions  under  which  observations  have  been  made.  From 
the  investigations  of  Park,  Baginsky,  Martin,  Morse,  and  others,  it 
would  appear  that  in  from  twenty-five  to  thirty-five  per  cent  of  the- 
cases  formerly  sent  to  hospitals  with  a  clinical  diagnosis  of  diphtheria,f 
the  disease  was  pseudo-diphtheria.  Most  of  these  were  mild,  and  were 
regarded  by  many  physicians  as  simply  cases  of  tonsillitis,  the  exceptions- 
being  those  which  were  secondary  to  scarlet  fever  or  measles. 

Of  the  membranous  infiammations  occurring  in  the  diseases  just 
mentioned,  the  great  majority  are  examples  of  pseudo-diphtheria.  Of 
seven  cases  of  membranous  angina  in  measles  and  three  in  scarlet  fever, 
studied  by  Prudden,  all  were  proved  to  be  pseudo-diphtheria;  of  nine- 
teen occurring  with  scarlatina,  studied  by  Park,  only  two  were  found 
to  be  true  diphtheria;  and  of  sixteen  occurring  with  scarlet  fever  and 
three  with  measles,  studied  by  Booker,  none  was  true  diphtheria.  In 
1,000  cases  of  scarlatina  observed  by  McCollom,  only  twelve  per  cent  of 


PSEUDO-DIPHTHERIA.  1045 

those  showing  distinct  membrane  in  the  throat  were  true  diphtheria.  It 
has  been  the  general  experience  of  all  writers  that  when  it  complicates 
other  diseases,  pseudo-diphtheria  nearly  always  occurs  at  the  height 
of  the  primary  disease,  while  true  diphtheria  may  occur  at  any  time, 
even  during  convalescence. 

Etiolog^y. — As  was  first  shown  by  Prudden  in  1888,  and  abundantly 
confirmed  by  others  since  that  time,  this  inflammation  is  usually  due  to 
the  streptococcus;  it  may  be  found  alone,  or  associated  with  the  staphy- 
lococcus aureus  or  albus,  and  occasionally  the  staphylococcus  may  be 
found  alone. 

The  streptococcus  is  very  frequently  found  in  the  throats  of  healthy 
children,  particularly  in  winter  and  in  cities,  and  more  often  in  those 
who  live  in  tenements  or  who  are  inmates  of  hospitals  or  other  institu- 
tions. The  local  conditions  in  the  mucous  membranes  during  an  attack 
of  measles,  scarlet  fever,  and  other  infectious  diseases,  are  especially 
favourable  for  the  development  of  these  germs,  which  at  such  times  are 
very  often  present  in  great  numbers  even  when  no  membrane  is  seen. 

This  form  of  sore  throat  is  more  apt  to  occur  in  houses  with  bad 
drainage  and  other  unsanitary  conditions.  From  the  fact  that  the  strep- 
tococcus is  so  widely  distributed,  attacks  of  pseudo-diphtheria  may 
occur  in  any  place  and  at  any  time,  irrespective  of  epidemic  influences 
or  even  the  occurrence  of  other  cases. 

To  what  degree  these  cases  are  to  be  regarded  as  communicable,  and 
what  precautions  regarding  isolation  and  disinfection  are  required,  are 
questions  of  much  importance.  The  most  extensive  investigations  upon 
these  points  are  those  made  by  the  New  York  Health  Department.  As  a 
result  of  observations  upon  450  cases  which  were  followed,  the  conclu- 
sion was  reached  that  the  disease  was  so  slightly  contagious,  if  at  all, 
and  usually  so  mild,  that  strict  isolation  and  subsequent  disinfection 
were  unnecessary.  Of  113  cases  occurring  in  100  families,  in  only  14 
was  there  a  history  of  exposure  to  a  similar  case;  and  in  only  9  was  there 
another  case  in  the  same  family.  In  many  of  the  latter,  a  common  origin 
appeared  more  probable  than  that  one  case  was  derived  from  another. 

•    They  are  probably  more  contagious  in  the  presence  of  the  poison  of 
scarlet  fevor  or  measles. 

Lesions. — In  the  primary  cases  the  membrane  is  generally  confined 
to  the  tonsils  or  is  chiefly  there,  there  being  only  small  deposits  else- 
where. In  the  secondary  cases,  the  entire  pharynx  may  be  covered  and 
the  disease  may  extend  to  the  nose,  the  mouth,  the  middle  ear,  and  occa- 
sionally to  the  larynx,  trachea,  and  bronchi. 

The  structure  of  the  membrane  resembles  that  of  true  diphtheria, 
and  it  is  impossible  by  a  microscopical  examination  alone  always  to 
separate  the  two  diseases.  In  many  cases  the  membrane  is  softer,  more 
friable,  and  contains  a  relatively  larger  number  of  cells  than  does  that 


x 


1046  THE  SPECIFIC  INFECTIOUS  DISEASES. 

of  true  diphtheria,  but  the  structure  of  the  latter  varies  so  much  that 
it  is  not  safe  to  draw  any  positive  conclusions. 

In  the  mild  cases  the  inflammation  of  the  mucous  membrane  is  a 
superficial  one  and  the  pseudo-membrane  is  not  ver}'  adlierent.  In  the 
severe  cases,  chiefly  the  secondary  ones,  the  process  extends  much  deeper. 
Besides  the  pseudo-membrane  upon  the  surface  there  is  intense  con- 
gestion, oedema,  and  cell-infiltration  of  all  the  lymphoid  and  cellular 
tissue  of  the  pharyns.  It  affects  the  tonsils,  soft  palate,  uvula,  epi- 
.'glottis,  adenoid  tissue  of  the  vault  and  the  entire  pharyngeal  ring,  and 
also  extends  to  the  external  lymph  nodes  and  surrounding  cellular  tissue. 
The  process  both  in  the  throat  and  externally  in  the  neck  may  terminate 
in  resolution,  suppuration,  or  in  necrosis. 

The  streptococci  are  found  in  the  false  membrane,  in  the  underlying 
mucous  membrane,  in  the  lymph  spaces  and  in  the  lymph  nodes.  In  the 
most  severe  cases  there  are  present  the  lesions  of  a  general  streptococcus 
infection.  The  blood  swarms  with  these  germs,  and  they  may  set  up  in- 
flammations in  any  of  the  organs,  but  especially  in  the  lungs  and  the 
Mdneys,  less  frequently  in  the  serous  membranes.  Small  foci  of  sup- 
puration may  be  found  in  any  of  the  viscera. 

Symptoms. — 1.  Tlie  'primary  cases. — The  onset  is  usually  abrupt, 
with  well-marked  symptoms:  there  are  frequently  chilly  sensations,  head- 
ache, vomiting,  general  pains,  and  in  most  cases  the  child  complains  of 
soreness  of  the  throat  and  pain  on  swallowing.  There  are  first  seen  a 
general  redness  and  swelling  of  the  tonsils,  sometimes  of  the  entire 
pharynx;  shortly  afterward  membranous  patches  appear  upon  the  ton- 
sils. These  vary  greatly  in  appearance.  In  colour  they  are  yellow  or 
gray,  often  changing  later  to  a  dirty-olive  tint.  (Plate  XIX,  c.)  The 
membrane  seems  loosely  attached  and  can  frequently  be  wiped  off  with  a 
swab.  It  is  soft  and  friable,  very  rarely  thick,  firm,  or  tenacious.  It  is 
often  irregular  in  its  outline,  which  is  not  sharply  defined.  The  mem- 
brane usually  remains  but  three  or  four  days  and  disappears  rapidly. 
As  a  rule,  it  is  limited  to  the  tonsils,  and  does  not  spread  after  it  first 
forms.  Occasionally,  however,  small  patches  are  also  seen  upon  the 
fauces  or  the  pharynx.  The  oedema  and  other  evidences  of  inflamma- 
tion in  the  throat  are  usually  more  marked  than  in  true  diphtheria,  and 
the  swelling  of  the  lymph  nodes  behind  the  jaw  is  slight.  The  constitu- 
tional symptoms  are  generally  more  severe  during  the  first  two  days,  and 
the  temperature  may  be  103°  or  104°  F.,  but  by  the  third  day  it  falls, 
and  most  of  the  symptoms  subside.  It  is  rare  for  the  disease  to  extend 
either  to  the  nose  or  the  larynx.  Generally  there  are  no  complications 
and  no  sequelse. 

2.  The  secondary  cases. — Some  of  these  are  mild,  and  do  not  differ 
from  those  just  described,  but  most  of  the  severe  cases  are  included  in 
this  group.    The  clinical  picture  of  the  latter  is  that  of  scarlatina  angi- 


PSEUDO-DIPHTHERIA. 


1047 


nosa,  as  given  by  the  older  writers,  and  it  does  not  differ  in  any  essential 
particulars  from  the  septic  form  of  true  diphtheria  (page  1018).  The 
local  symptoms  are  those  of  severe  pharyngeal  diphtheria,  and  the  con- 
stitutional symptoms  those  of  septicaemia. 

When  the  disease  complicates  scarlet  fever,  the  symptoms  may  pre- 
cede the  eruption,  but  they  usually  begin  at  the  height  of  the  primary 
fever — i.  e.,  from  the  second  to  the  fourth  day — and  gradually  increase 
in  severity,  reaching  their  maximum  from  the  fifth  to  the  eighth  day  of 
the  disease.  In  measles  the  throat  symptoms  are  somewhat  later;  they 
begin  at  the  height  of  the  primary  fever,  and  often  increase  while  the 
eruption  fades.  In  most  of  the  severe  scarlatinal  cases  the  disease  in.- 
volves  the  nose  and  the  middle  ear.  In  measles  both  these  complications 
are  less  frequent,  but  there  is  a  much  greater  tendency  to  involve  the 
larynx,  and  if  the  larynx  in  a  young  child,  the  process  is  almost  invariably 
complicated  by  broncho-pneumonia.  In  some  cases  the  larynx  is  invaded 
when  there  is  no  membrane  in  the  pharynx;  but  this  is  very  infrequent 
unless  the  disease  is  true  diphtheria.  Catarrhal  laryngitis  in  a  young 
child  may  produce  symptoms  which  are  practically  identical  with  those 
of  the  membranous  form,  and  there  is  little  doubt  that  many  cases  com- 
plicating measles  in  which  the  latter  diagnosis  is  made  are  really  exam- 
ples of  catarrhal  laryngitis,  particularly  if  no  membrane  is  visible  in 
the  throat. 


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Fig.  186. — Pseudo-diphtlieria  foUowincj  measles.  The  chart  begins  at  the  time  of  the  full  erup- 
tiou  in  a  severe  case  of  measles.  On  third  day  temperature  fell,  witli  fading  eruption,  and 
child  seemed  convalescent.  With  secondary  rise  in  temperature,  the  tonsils,  whicli  before 
had  been  only  red,  showed  membranous  patches,  the  exudation  rapidly  spreading  until  the 
entire  pharynx  was  covered ;  throat  symptoms  very  severe,  with  great  swelling  of  cervical 
glands,  but  the  membrane  did  not  extend  beyond  the  pharynx.  From  sixth  to  twelfth  day 
a  most  profound  septicasmia,  so  that  life  was  despaired  of.  The  patient  was  a  vigorous  child, 
and,  escaping  both  nephritis  and  pneumonia,  made  a  good  recovery.  Convalescence  quite 
rapid  ;  no  sequela;.  Kepeated  cultures  were  made  from  the  throat,  but  all  showed  only 
streptococcL    Patient  a  girl  four  years  old.    Case  observed  in  private  practice. 

Secondary  cases  as  a  class  are  characterized  by  high  temperature 
(Fig.  18G),  rapid,  feeble  pulse,  great  prostration,  and  delirium,  apathy 


^' 


^ 


1048  THE  SPECIFIC  INFECTIOUS  DISEASES. 

or  stupor,  and  often  albuminuria.  In  fatal  cases  death  usually  occurs 
at  the  height  of  the  disease,  from  asthenia,  broncho-pneumonia,  or 
nephritis,  sometimes  from  laryngitis.  If  none  of  these  complications 
develop,  patients  may  withstand  the  toxic  symptoms  even  when  they  are 
very  severe.  If  the  attack  terminates  in  recovery,  the  local  disease  fol- 
lows very  much  the  same  course  as  in  diphtheria.  The  subsequent  anae- 
mia is,  however,  less  severe,  and  none  of  the  dangers  of  convalescence 
connected  with  cardiac  or  respiratory  pa.ralysis  are  present. 

There  may  be  in  connection  with  the  local  process  in  the  throat,  deep 
sloughing  of  the  tonsils  or  adjacent  structures,  suppuration  of  the  lym- 
phatic glands  or  in  the  cellular  tissue  of  the  neck,  occasionally  followed 
by  serious  hsemorrhage.  However,  these  complications  are  rare,  and  if 
the  patient  survives  the  danger  of  the  acute  stage  of  the  disease,  he 
usually  recovers. 

Diagnosis. — The  clinical  features  which  distinguish  pseudo-diph- 
theria from  true  diphtheria  have  already  been  considered  (page  1023). 
It  is  impossible  in  any  case  to  be  certain  of  the  diagnosis  except  by  cul- 
tures; for,  although  by  clinical  symptoms  alone  one  may  in  the  great 
majority  of  cases  be  certain  that  a  given  case  is  one  of  true  diphtheria, 
to  say  that  any  membranous  inflammation  of  the  throat  is  not  diph- 
theria is  impossible.  The  bacteriologists  have  taught  us  to  be  cautious 
in  pronouncing  too  positively  upon  even  mild  cases,  as  it  has  been  shown 
that  some  of  them  may  be  caused  by  most  virulent  diphtheria  bacilli 
(page  1014), 

In  the  secondary  cases  the  diagnosis  by  clinical  symptoms  is  more  ac- 
curate. A  membrane  which  appears  in  the  throat  early  in  the  course  of 
measles  or  scarlet  fever,  or  at  the  height  of  the  primary  disease,  is  usually 
due  to  the  streptococcus;  while  one  which  develops  late  or  after  the  pri- 
mary fever  has  subsided,  is  frequently  due  to  the  diphtheria  bacillus. 

Prognosis. — There  is  no  more  striking  contrast  between  true  and 
pseudo-diphtheria  than  in  their  mortality  when  they  are  seen  side  by 
side.  Of  117  primary  cases  of  pseudo-diphtheria  observed  by  Park  in 
the  Willard  Parker  Hospital,  New  York,  the  mortality  was  3-5  per  cent; 
of  127  cases  of  true  diphtheria  seen  in  the  same  institution  at  the  same 
time,  the  mortality  was  34*5  per  cent.  In  a  group  of  154  hospital  cases 
reported  by  Baginsky,  there  were  118  of  true  diphtheria,  with  a  mor- 
tality of  38*2  per  cent,  and  34  cases  of  primary  pseudo-diphtheria,  with 
a  mortality  of  5-5  per  cent.  From  the  same  hospital,  Philip  has  pub- 
lished a  report  upon  376  cases:  332  of  these  were  true  diphtheria,  with 
a  mortality  of  37  per  cent;  31  were  cases  of  primary  pseudo-diphtheria, 
with  no  mortality.  The  Bulletin  of  the  New  York  Health  Department 
contains  a  report  upon  324  cases  of  pseudo-diphtheria  in  children,  with 
a  mortality  of  9,  or  2*8  per  cent;  4  of  the  fatal  cases  complicated  scarlet 
fever;  of  the  primary  cases,  the  mortality  was  but  l"o  per  cent.    These 


PSEUDO-DIPHTHERIA.  1049 

were  not  hospital  cases.  From  the  above  data  the  deduction  seems  war- 
ranted that  in  a  chikl  previously  healthy,  primary  pseudo-diphtheria  is 
not  a  serious  disease. 

Turning  now  to  the  secondary  cases,  we  find  very  different  condi- 
tions. From  the  best  available  statistics  it  would  appear  that  the  usual 
mortality  of  pseudo-diphtheria,  when  it  is  secondary  to  scarlet  fever  and 
measles,  is  from  15  to  20  per  cent.  However,  when  these  diseases  prevail 
epidemically  in  institutions,  the  mortality  is  often  higher  than  this. 

Prophylaxis. — In  primary  cases  strict  quarantine  is  unnecessary  after 
the  question  of  diagnosis  has  been  settled.  Cases  of  pseudo-diphtheria 
occurring  in  measles  or  scarlet  fever  should  certainly  be  separated  from 
uncomplicated  cases.  By  way  of  prevention,  something  can  be  done  in 
these  diseases  by  keeping  both  nose  and  throat  as  clean  as  possible  during 
severe  attacks  by  the  use  of  an  antiseptic  mouth-wash  or  gargle,  and  a 
nasal  spray.  For  young  children  only  weak  solutions  should  be  em- 
ployed, such  as  a  diluted  DobelFs  or  Seller's  solution,  1:  10,000  bichloride, 
or  a  one-per-cent  solution  of  boric  acid. 

Treatment. — Every  child  with  a  membranous  patch  on  its  throat  re- 
quires close  watching;  if  under  three  years  old  diphtheria  antitoxin 
should  be  administered,  pending  the  result  of  a  bacteriological  examina- 
tion. In  all  cases  with  doubtful  diagnosis  this  should  invariably  be 
done.  The  primary  cases  require  only  the  treatment  of  an  attack  of 
tonsillitis  (page  308). 

In  the  secondary  cases  local  treatment  should  be  begun  with  the 
appearance  of  the  first  patch  upon  the  tonsils.  In  mild  cases  the  use  of 
gargles  and  antiseptic  throat  sprays  is  sufficient.  In  the  severe  cases 
local  treatment  should  be  thorough  and  energetic,  but  not  repeated  too 
frequently.  It  is  seldom  necessary  to  disturb  a  very  sick  child  for  local 
treatment  oftener  than  every  two  hours  by  day  and  every  four  hours  by 
night.  The  nose  should  be  syringed  with  warm,  bland  solutions  but  not 
too  forcibly.  For  the  pharynx  stronger  solutions  may  be  employed  as 
hot  as  can  be  borne.  In  order  to  clear  the  secretions  from  behind 
the  swollen  tonsils  a  short  piece  of  a  soft  catheter  may  be  attached  to 
the  tip  of  the  syringe,  which  should  be  inserted  well  back  behind  the 
molar  teeth.  Where  the  swelling  and  cedema  are  great,  benefit  may 
result  from  frequent  spraying  with  solutions  containing  supra-renal  ex- 
tract, also  from  inhaling  hot  vapour  impregnated  with,  eucalyptol,  ben- 
zoin, etc.  For  a  local  germicidal  effect  swabbing  is  most  reliable;  strong 
solutions  should  be  used  Init  not  frequently  repeated — e.  g.,  1:  500  bichlo- 
ride of  mercury  or  a  1 0-per-cent  solution  of  nitrate  of  silver,  from  one  to 
three  times  a  day.  As  an  external  application  nothing  is  so  beneficial  as 
the  ice-bag,  which,  whenever  there  is  great  adenitis  and  cellulitis,  should 
be  constantly  used  covered  with  thin  flannel,  and  kept  well  up  against 
the  throat  by  a  four-tailed  bandage. 


1050  THE  SPECIFIC  INFECTIOUS  DISEASES. 

The  general  management  of  these  cases  as  to  feeding,  stimulants^ 
etc.,  is  the  same  as  in  diphtheria.  Aside  from  stimulants  no  internal 
medication  should  be  attempted  with  young  children.  Those  who  are 
older  may  take  with  advantage  tr.  f  erri  chlor.,  gtt.  v  to  x,  with  glycerin, 
every  three  or  four  hours.  The  use  of  streptococcus  antitoxin  in  these 
eases  has  thus  far  been  attended  with  very  little  success,  and  can  not  yet 
be  recommended. 


CHAPTEE   IX. 

TYPHOID  FEVER. 

Typhoid  fever  is  an  acute  infectious  disease  due  to  a  specific  germ 
— Eberth^s  bacillus.  It  may  affect  the  foetus  in  utero,  or  the  newly  born 
child,  and  it  is  seen  in  infancy  and  throughout  childhood. 

Fcetal  typlioid. — Morse  *  (Boston)  has  collected  the  evidence  bear- 
ing upon  foetal  infection,  from  which  the  following  conclusions  seem, 
warranted:  Infection  of  the  child  from  the  mother  is  a  frequent  but  not 
an  invariable  occurrence.  The  bacilli  may  pass  directly  from  the  ma- 
ternal into  the  foetal  circulation.  The  foetal  form  of  the  disease  is  a 
general  blood-infection,  since  the  intestines  are  not  functionally  active. 
The  most  common  result  is  death  of  the  foetus  and  consequent  abor- 
tion; but  the  child  may  be  born  .alive  still  suffering  from  infection,. 
and  die  in  a  short  time  because  of  its  feeble  resistance.  AYhether  a 
foetus  may  recover  completely  and  be  born  alive  and  well,  is  not  yet 
established. 

Infantile  typlioid. — Much  difference  of  opinion  exists  regarding  the 
frequency  with  which  typhoid  fever  occurs  in  infancy.  Some  clini- 
cians hold  the  opinion  that  the  disease  is  of  very  common  occurrence^ 
but  is  often  unrecognised  because  of  the  absence  of  many  of  the  symp- 
toms which  are  characteristic  at  a  later  age.  They  regard  every  pro- 
tracted fever  not  malarial  and  not  dependent  upon  a  local  inflammation 
as  presumably  typhoid.  The  symptoms  from  which  we  may  regard  the 
question  of  typhoid  as  established  will  be  considered  under  Diagnosis. 
I  have  never  seen  an  undoubted  case  of  typhoid  under  two  years  of  age,, 
and  I  believe  it  to  be  rare,  at  least  in  iSTew  York.  ISTo  case  recognised  as 
typhoid  occurred  under  two  years  of  age  during  my  eight  years'  service 
in  the  New  York  Infant  Asylum,  where  about  ten  thousand  cases  of 
acute  illness  were  treated  and  over  seven  hundred  autopsies  made;  nor 
in  my  thirteen  years'  service  at  the  Babies'  Hospital  where  about  the 
same  number  of  autopsies  have  been  made.  Xo  case  has  been  recog- 
nised as  typhoid,  either  in  the  wards  or  the  post-mortem  room  of  the 

*  Archives  of  Pjediatrics.  December,  1900. 


TYPHOID  FEVER.  1051 

New  York  Foundling  Hospital  during  the  past  twenty-five  years.  Ty- 
phoid has  been  seen  by  Murchison  at  six  months  and  by  Ogle  at  four 
and  a  half  months,  the  diagnosis  being  in  both  instances  confirmed  by 
autopsy;  also  by  Griffith  at  seven  months  and  by  Taylor  at  eight 
months,  with  fairly  typical  symptoms.  It  is  during  epidemics  that  most 
of  the  infantile  cases  are  seen;  sporadic  instances  of  infantile  typhoid 
should  always  be  regarded  with  suspicion,  and  J  believe  that  most  cases 
so  diagnosticated  are  questionable.  Even  in  epidemics  it  is  surprising 
that  so  few  infants  are  attacked.  In  that  of  Montclair,  N.  J.,  in  189-4, 
of  115  cases,  only  3  were  under  two  years;  in  that  of  Stamford,  Conn., 
in  1895,  of  406  cases  only  4  were  under  two  years. 

TypJioid  in  childhood  is  by  no  means  rare,  but  it  is  not  until  after  the 
fifth  year  that  it  can  be  said  to  occur  frequently.  The  following  figures, 
embracing  groups  of  cases  reported  by  eight  writers,  represent  the  rela- 
tive frequency  with  which  the  disease  is  seen  at  the  different  ages:  Of 
970  cases,  8  per  cent  occurred  under  five  years,  42  per  cent  between  five 
and  ten  years,  and  50  per  cent  between  ten  and  fifteen  years. 

Typhoid  fever  is  almost  invariably  contracted  by  drinking  water  or 
milk  (see  page  139)  which  contains  the  germs  of  the  disease.  The  in- 
frequency  of  typhoid  in  infants  is  explained,  in  part  at  least,  by  the  fact 
that  most  of  the  water  and  a  large  part  of  the  milk  taken  is  previously 
boiled,  or  heated  in  some  manner. 

Lesions. — Typhoid  in  young  children  is  so  seldom  fatal  that  oppor- 
tunities for  a  study  of  the  lesions  have  been  limited.  In  a  general  way 
they  resemble  those  of  adults  except  in  severity.  In  a  considerable 
number  of  the  cases  the  pathological  process  in  the  intestines  does  not 
go  on  to  ulceration;  and  when  ulcers  form  they  are  seldom  large  or 
deep,  and  perforation  is  very  rare.  Montmollin  gives  the  following 
facts  concerning  23  autopsies,  most  of  them,  however,  being  in  children 
over  eight  years  old:  ulcers  were  present  in  17  cases;  they  were  situ- 
ated in  the  lower  ileum  in  16,  and  in  10  they  were  only  there;  in  the 
ascending  colon  in  9,  and  only  there  in  one  case;  perforation  occurred  in 
3  cases,  in  every  instance  in  the  lower  ileum.  Autopsies  made  upon 
infants  may  show  even  less  severe  intestinal  lesions  than  those  men- 
tioned. In  fact,  some  cases  in  which  the  clinical  diagnosis  was  beyond 
question,  have  shown  only  moderate  redness  and  swelling  of  Fever's 
patches,  the  solitary  follicles  and  the  mesenteric  lymph  nodes — lesions 
which  are  exceedingly  frequent  in  cases  of  simple  diarrhoea.  In  a 
doubtful  case  such  post-mortem  findings  do  not  establish  the  diagnosis 
of  typhoid.  Indeed,  they  prove  nothing  unless  cultures  from  the  intes- 
tinal contents,  the  mesenteric  glands,  or  other  organs,  show  the  typhoid 
bacillus.  Enlargement  of  the  spleen  is  practically  constant.  The  de- 
generative changes  in  the  heart,  the  kidneys,  and.  the  liver  arc  much 
less  frequent  and  generally  less  severe  than  in  adults. 


/ 


1052  THE  SPECIFIC  INFECTIOUS  DISEASES. 

Symptoms. — The  peculiar  features  of  typhoid  in  early  life  are  seen 
only  in  children  under  ten  years  old;  for  after  this  time  the  disease  does 
not  differ  essentially  from  the  adult  type.  In  brief,  the  typhoid  of  early 
childhood  may  be  described  as  a  fever  characterized  more  often  by  nerv- 
ous symptoms  than  by  intestinal  symptoms. 

Onset. — A  sudden  onset  with  well-marked  symptoms — fever,  pros- 
tration, vomiting,  etc. — is  not  uncommon;  in  fact,  it  is  quite  as  fre- 
quently seen  as  the  insidious  beginning  with  lassitude,  headache,  coated 
tongue,  anorexia,  and  gradual  rise  in  temperature.  In  cases  developing 
abruptly  it  often  appears  as  if  an  acute  indigestion  had  been  the  means 
of  precipitating  the  attack.  The  most  frequent  initial  symptom  is  vomit- 
ing; a  chill  is  rare.  Epistaxis  occurs  as  an  early  symptom  rather  less 
frequently  than  in  adults. 

Condition  of  the  bowels. — There  is  no  constant  relation  between  the 
severity  of  the  intestinal  lesions  and  the  condition  of  the  bowels.  Tak- 
ing large  groups  of  cases  together,  diarrhoea  is  present  in  about  half  the 
total  number.  It  is  rarely  profuse,  from  two  to  four  discharges  a  day 
being  the  average.  The  appearance  of  the  stools  is  seldom  character- 
istic; they  are  usually  thin  and  fluid,  often  containing  mucus.  Consti- 
pation may  be  present  at  the  beginning  only,  or  throughout  the  attack. 
Tympanites  is  generally  moderate,  and  is  often  entirely  absent;  it  usu- 
ally accompanies  constipation.  Marked  iliac  tenderness  and  gurgling 
are  infrequent. 

Spleen. — By  the  end  of  the  first  week  this  is  almost  invariably  found 
to  be  enlarged  to  a  sufficient  degree  to  be  recognised  by  palpation. 
Usually  the  spleen  extends  but  an  inch  or  an  inch  and  a  half  below  the 
ribs,  but  at  times  it  may  be  three  inches  or  more;  persistent  enlarge- 
ment always  indicates  that  the  disease  is  not  at  an  end  even  though  the 
temperature  has  reached  the  normal,  and  a  relapse  should  be  expected. 

Eruption. — It  is  the  experience  of  nearly  all  who  have  seen  much  of 
typhoid  in  children  that  the  eruption  is  less  constant,  less  abundant, 
and  less  characteristic  than  in  adults.  Of  670  cases  in  Morse's  *  collec- 
tion, it  was  noted  in  but  60  per  cent.  The  typical  eruption  consists  of 
small,  scattered,  rose-coloured  spots,  which  appear  chiefly  or  solely 
upon  the  abdomen  at  the  beginning  of  the  second  week.  They  come  in 
successive  crops,  each  one  of  which  generally  lasts  three  days,  the  whole 
duration  of  the  eruption  being  about  ten  days. 

Prostration,  emaciation,  etc. — As  a  rule  the  prostration  is  quite  suffi- 
cient to  keep  a  child  in  bed  after  the  first  few  days.  The  general  weak- 
ness after  this  time  is  in  direct  proportion  to  the  height  of  the  tempera- 
ture. Loss  of  flesh  is  steady  and  usually  marked;  and  in  a  prolonged 
attack  there  may  be  extreme  emaciation. 

*  Typhoid  Fever  in  Childhood,  with  an  Analysis  of  384  Cases ;  Boston  Medical  and 
Surgical  Journal,  February  27,  1896. 


TYPHOID   FEVER. 


1053 


DAY 

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Temperature. — In  the  cases  with  a  gradual  onset,  the  typical  tem- 
perature curve  is  one  which  rises  steadily  for  from  two  to  seven  days, 
fluctuates  within  the  limits  of  one  to  three  degrees  during  the  second 
week,  and  steadily  declines  during  the  third  week,  reaching  the  normal 
on  the  average  at  the  end  of  the  third  week.  In  cases  with  an  abrupt 
onset,  the  temperature  rises  at  once  to  from  102.5°  to  105°  F.,  but  sub- 
sequently may  run  the  same  course  as  in  the  first  group. 

The  following  are  the  most  important  variations  from  the  tempera- 
ture curve  of  adults:  The  initial  rise  is  much  more  frequently  rapid; 
during  the  second  week 
the  remittent  character  is 
less  marked,  this  probably 
depending  upon  the  fact 
that  ulceration  is  less  fre- 
quent and  less  extensive; 
the  average  duration  is 
shorter.  In  young  chil- 
dren the  proportion  of 
cases  in  which  the  fever 
lasts  only  from  eight  to 
fourteen  days  is  quite 
large  (Fig  187).  After  the 
age  of  ten  years  the  type 
of  the  fever  is  much  like 
that  seen  in  adults.  The  maximum  temperature  in  the  mild  cases  is 
103°  or  101°  F.;  in  the  severe  ones  it  often  reaches  105°  or  106°  F.,  but 
rarely  goes  above  this  point.  The  range  is  usually  higher  than  in  adult 
cases  of  the  same  severity.  At  the  beginning  of  convalescence  a  sub- 
normal temperature  is  very  frequent,  and  by  many  writers  is  considered 
to  be  the  rule.  A  secondary  rise  is  most  frequently  due  to  errors  in 
diet,  but  may  occur  from  the  development  of  complications.  A  sudden 
fall  indicates  either  perforation  or  intestinal  hasmorrhage. 

Relapses  were  present  in  8-4  per  cent  of  533  cases  collected  by 
Morse.    They  follow  about  the  same  course  as  in  adults  (Fig.  188). 

Nervous  symptoms. — As  a  rule,  these  are  more  prominent  in  severe 
cases  than  the  intestinal  symptoms,  and  are  directly  proportionate  to 
the  height  of  the  temperature.  The  extreme  nervous  symptoms  be- 
longing to  the  typhoid  state  in  adults  are  rare  in  childhood,  except  in 
patients  over  ton  years  old.  Headache  and  mild  delirium  at  night  are 
very  frequent,  the  former  being  seen  in  the  majorily  of  e;ises.  Young- 
children  are  usually  dull,  apathetic,  and  ol'len  in  a  stale  of  semi-stupor. 
Occasionally  the  disease  may  closely  simulale  meningitis.  The  nervous 
symptoms  are  usually  most  severe  in  llie  second,  or  early  in  the  third 
week,  and  subside  as  llie  teni|iei-;il  ni'e  (ieeliiies. 
08 


Fig.  187. — Typhoid  fever  of  short  duration  in  a  child 
thirteenmonthsold.  Spleen  enlarged  :  eruption  typi- 
cal ;  no  diarrhoea  and  only  moderate  abdominal  dis- 
tention. There  were  two  other  cases  in  the  family, 
all  being  due  to  the  same  cause — infected  milk. 
(After  JSorthrup.) 


1054 


THE  SPECIFIC  INFECTIOUS  DISEASES. 


Pulse. — This  is  increased  in  frequency,  but  not  to  the  degree  that 
is  seen  in  most  diseases  of  childhood  with  a  similar  elevation  of  temper- 
ature. The  force  and  rhythm  of  the  pulse  are  usually  good,  irregular- 
ity, very  low  tension,  and  dicrotism  being  rare  as  compared  with  adults. 


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Fig.  188.— Typhoid  fever  with  relapse.  Child  two  and  a  half  years  old ;  early  temperature  high 
and  symptoms  typical ;  natural  fall  on  fourteenth  day ;  rise  on  seventeenth  day  apparently 
due  to  otitis  ;  relapse  on  twenty-fourth  day,  with  fresh  eruption  and  return  of  splenic  swell- 
ing which  had  disappeared.  Temperature  was  subnormal  at  the  end  both  of  primary  and 
secondary  fever. 

Urine. — A  small  amount  of  albumin  is  found  in  the  urine  of  most 
of  the  severe  cases  at  the  height  of  the  disease,  and  is  due  to  acute  renal 
degeneration;  but  a  marked  degree  of  nephritis  is  infrequent.  In  from 
one-fourth  to  one-third  of  the  cases  typhoid  bacilli  are  found  in  the 
urine,  generally  in  joure  culture.  They  usually  appear  in  the  latter 
part  of  the  disease,  the  second  or  third  week,  and  may  continue  for 
months  or  even  years.  They  are  sometimes  accompanied  by  evidence 
of  cystitis  or  neiohritis.  Their  number  is  in  some  cases  so  large  as  to 
render  the  urine  turbid;  in  others  they  give  no  indication  of  their  pres- 
ence. Ehrlich's  diazo  reaction  is  usually  present  at  the  height  of  the 
fever. 

Intestinal  licemorrhage. — Of  946  collected  cases,  mainly  from  hospital 
reports,  intestinal  haemorrhage  occurred  in  30,  or  about  three  per  cent; 
the  majority  of  these  were  in  children  over  ten  years  old.  Of  24  col- 
lected cases  of  hemorrhage  in  children,  10  terminated  fatally.  The 
youngest  case  of  this  nature  which  has  come  under  my  own  notice  was 
in  a  child  of  four  and  a  half  years. 

Intestinal  perforation. — This  is  even  more  rare  than  hEemorrhage. 
In  1,028  collected  cases,  this  accident  occurred  but  twelve  times,  or  in 
1*1  per  cent.  Eight  of  these  proved  fatal.  Perforation  is  indicated  by 
a  sudden  fall  in  the  temperature,  with  collapse;  usually  there  is  vomiting 
and  the  rapid  development  of  tympanites. 

Complications  and  Sequelae. — The  complications  of  typhoid  in  early 
life  are  infrequent  and  usually  mild.  Bronchitis  is  present  in  mos.t  of  the 
severe  cases.  Pneumonia  has  been  noted  in  9  per  cent  of  the  cases 
reported  by  various  authors.  Both  serous  and  purulent  effusions  into 
the  chest  are  occasionally  seen,  and  sometimes  abscess  of  the  lung. 


TYPHOID  FEVER.  1055 

Complications  referable  to  the  nervous  system  are  not  very  frequent, 
but  are  of  much  interest.  Meningitis  is  extremely  rare.  Morse  has  col- 
lected twenty-one  cases  of  aphasia,  in  two  of  which  it  was  clearly  due  to 
embolism;  in  the  remainder,  however,  it  apparently  was  not  dependent 
upon  any  organic  lesion.  In  two  thirds  of  the  cases  it  came  on  during 
convalescence,  and  in  nearly  all  complete  recovery  occurred  after  an 
average  duration  of  three  weeks.  Aphasia  usually  followed  a  severe 
type  of  the  disease,  and  in  most  of  the  cases  was  not  accompanied  by  any 
other  paralysis  or  by  mental  disturbance.  Insanity  is  a  rare  sequel  of 
typhoid  in  children,  the  usual  type  being  acute  mania.  Adams  (Wash- 
ington) has  reported  two  examples  of  this,  both  terminating  in  recovery. 
Chorea  is  seen  rather  oftener  than  after  the  other  infectious  diseases. 

Otitis  is  not  an  infrequent  complication,  occurring  much  oftener  than 
in  adults.  It  is  principally  seen  in  young  children  and  during  the  cold 
season.  Among  the  less  frequent  complications  may  be  mentioned:  paro- 
titis, which  is  usually  suppurative  and  is  seen  in  septic  cases;  abscess  of 
the  liver,  examples  of  which  have  been  reported  by  Bokai,  Asch,  and 
others;  gangrenous  inflammation  of  the  mouth  or  genitals;  pericarditis, 
endocarditis,  and  peritonitis,  suppurative  inflammations  of  joints,  mul- 
tiple abscesses  and  furunculosis.  Tuberculosis  of  the  lungs  or  bones  not 
infrequently  follows  typhoid. 

Diagnosis. — The  diagnostic  symptoms  of  typhoid  are  the  Widal  blood 
reaction,  the  discovery  of  the  bacilli  in  the  urine  or  fseces,  the  eruption, 
the  course  of  the  temperature,  the  enlargement  of  the  spleen  and  the 
abdominal  symptoms — diarrhoea,  tympanites,  intestinal  hasmorrhage, 
and  perforation. 

The  Widal  reaction  is  present  at  some  period  in  from  95  to  98  per 
cent  of  the  cases,  and  thus  becomes  the  most  valuable  single  symptom 
for  diagnosis.  It  is  seldom  obtained  before  the  seventh  day  and  fre- 
quently not  until  the  tenth;  it  may  not  be  present  until  convalescence 
or  a  relapse.  Eepeated  tests  should  always  be  made  if  the  first  reac- 
tion is  negative  or  doubtful;  and  the  tests  should  be  made  by  an  ex- 
perienced pathologist.  The  reaction  is  therefore  of  much  less  value  for 
an  early  than  for  an  exact  diagnosis.  A  positive  reaction  may  be  present 
if  the  patient  has  previously  had  typhoid,  something  much  less  likely  to 
be  the  case  with  children  than  with  adults;  in  rare  instances  it  has  been 
obtained  in  other  diseases  or  in  health  where  no  history  of  previous 
typhoid  existed.  Both  these  conditions,  however,  are  very  exceptional, 
and  a  positive  reaction  may  as  a  rule  be  taken  to  establish  tlie  diagnosis. 

Typhoid  bacilli,  according  to  the  observations  of  Park  (Xew  York), 
may  be  demonstrated  in  the  stools  by  culture  in  about  40  per  cent  of 
the  cases.  They  are  found  in  the  urine,  usually  in  the  latter  ])art  of 
the  disease,  in  about  one-third  the  cases.  Their  discovery  in  cither  of 
these  discharges  is  conclusive  evidence  of  jiri'vious  or  I'xisliiig  lyphoid. 


1056  THE  SPECIFIC  INFECTIOUS  DISEASES. 

An  examination  of  both  urine  and  faeces  should,  if  possible,  be  made  in 
all  "doubtful  cases. 

The  course  of  the  temperature  is  an  important  aid  to  diagnosis,  but 
alone  is  not  to  be  depended  upon.  The  characteristic  feature  is  a  fever 
which  continues  for  two,  three,  or  four  weeks,  and  subsides  sponta- 
neously. The  variations  from  the  adult  type  have  already  been  men- 
tioned, also  the  frequency  of  the  eruption,  the  enlargement  of  the  spleen, 
and  the  abdominal  symptoms.  We  are  not  warranted,  I  think,  in  making 
the  diagnosis  of  typhoid,  if  repeated  tests  fail  to  show  the  Widal  reac- 
tion  or  if  the  eruption  and  splenic  enlargement  are  absent,  and  no  bacilli 
can  be  demonstrated  in  the  discharges,  no  matter  what  the  course  of  the 
tem|)erature  may  be. 

One  should  be  very  slow  to  make  the  diagnosis  of  typhoid  in  a  child 
under  two  years  old,  unless  the  disease  is  epidemic.  The  great  majority 
of  sporadic  cases  reported  as  occurring  in  infancy  are  probably  not 
typhoid.  After  the  fifth  year  the  disease  is  more  frequent,  and  its 
symptoms  in  general  resemble  those  of  adults,  except  in  severity. 

A  differential  diagnosis  is  to  be  made  from  malarial  fever,  ileo-colitis, 
meningitis,  tuberculosis,  and  from  other  ill-defined  continuous  fevers 
of  unknown  origin.  From  malarial  fever  the  diagnosis  is  to  be  made  by 
the  temperature  curve,  the  organisms  in  the  blood,  and  the  effect  of 
quinine.  In  most  of  the  cases  of  malaria  the  temperature  will  be  found 
to  touch  the  normal  at  some  time  in  the  twenty-four  hours.  The  admin- 
istration of  full  doses  of  quinine  is  a  diagnostic  test  of  much  practical 
importance;  an  irregular  or  remittent  fever  which  yields  promptly  to 
quinine  is  most  certainly  not  typhoid. 

Ileo-colitis  and  typhoid  fever  are  not  often  confounded.  The  former 
is  chiefly  seen  in  the  first  three  years  of  life,  a  time  when  typhoid  is 
rare.  The  intestinal  symptoms  of  ileo-colitis  are  marked  even  though 
the  temperature  is  not  high,  and  they  are  altogether  more  severe  than 
is  usual  in  typhoid;  while  enlargement  of  the  spleen,  tympanites,  and 
the  eruption  are  not  present. 

The  cerebral  symptoms  of  typhoid  may  be  difficult  to  distinguish  from 
meningitis,  unless  one  has  watched  their  development.  Irregular  respira- 
tion, a  slow,  irregular  pulse,  localized  paralysis  and  complete  coma  are 
seldom,  if  ever,  seen  in  typhoid,  and  a  retracted  abdomen  very  rarely, 
while  the  enlarged  spleen  and  the  peculiar  eruption  are  not  seen  in 
meningitis.  In  typhoid  with  pronounced  nervous  symptoms  the  tem- 
perature is  usually  higher  than  in  meningitis. 

General  tuberculosis  very  often  resembles  typhoid  so  closely  that  a 
differential  diagnosis  is  almost  impossible  until  local  signs  of  tuberculosis 
have  appeared,  usually  in  the  lungs.     (See  page  1078.) 

Prognosis. — Of  2,623  cases  collected  from  the  reports  of  twelve  differ- 
ent writers,  the  mortality  was  5 '4  per  cent.    These  are,  however,  almost 


TYPHOID   FEYEE.  1057 

all  taken  from  hospital  reports,  where  as  a  rule  the  mildest  eases  are  not 
brought  for  treatment.  The  mortality  of  the  disease  in  children  over 
three  years  old  probably  does  not  exceed  3  or  -i  per  cent.  Death  seldom 
occurs  from  the  disease  itself,  but  usually  from  some  accident  or  com- 
plication, the  most  frequent  being  pneumonia  and  intestinal  hajmor- 
rhage  or  perforation.  Griffith's  collection  of  cases  occurring  in  infancy 
indicate  a  much  higher  mortality  for  this  period.  The  death-rate  for 
the  first  year  reached  nearly  50  per  cent. 

Treatment. — The  usually  low  mortality  of  this  disease  shows  how 
successful  all  methods  of  treatment  are  likely  to  be  considered.  In  the 
great  majority  of  cases  very  little  active  treatment  is  required.  Every 
patient  with  typhoid  should  be  put  to  bed  and  kept  there  during  the 
febrile  period,  and  a  few  days  beyond  it,  no  matter  how  mild  the  attack 
may  be.  A  fluid  diet  should  be  prescribed  in  every  case,  milk  or  animal 
broths,  which  should  be  given  regularly  every  three  hours,  but  not 
pushed  greatly  beyond  the  desire  of  the  patient.  Milk  may  be  diluted 
or  partially  peptonized,  and  kumyss  or  matzoon  may  be  substituted  for 
it  if  the  stomach  is  irritable.  Plenty  of  water  should  be  allowed,  unless 
it  disturbs  the  stomach. 

Both  the  urine  and  faeces  should  be  immediately  and  thoroughly  dis- 
infected by  a  solution  of  carbolic  1 :  20.  If  the  movements  are  in  a  cham- 
ber or  a  bed-pan  they  should  be  covered  with  this  solution  for  at  least 
six  hours  before  they  are  thrown  into  the  water-closet.  If  napkins  or 
diapers  are  used,  they  should  be  soaked  in  some  effective  antiseptic  so- 
lution for  twelve  hours  and  then  thoroughly  boiled.  Sheets  stained  by 
discharges  should  be  treated  in  the  same  way,  and  all  bed-linen  should 
be  boiled  for  two  hours  apart  from  the  washing  of  the  family.  The 
efficiency  of  urotropin  in  removing  typhoid  bacilli  from  the  urine  seems 
now  to  be  well  established.  It  should  be  given  at  the  close  of  the  attack 
in  doses  of  three  to  five  grains,  three  times  a  day,  and  continued  for  a 
week  or  ten  days. 

Diarrhoea  calls  for  treatment  only  when  the  movements  exceed  four 
or  five  in  twenty-four  hours.  If  no  more  than  this  number  are  present, 
they'  should  not  be  interfered  with.  Opium  and  bismuth  are  undoubt- 
edly the  best  means  for  controlling  excessive  diarrhoea,  but  care 
should  be  taken  that  they  are  not  pushed  to  the  degree  of  inducing 
constipation. 

Constipation  early  in  the  disease  may  be  relieved  by  calomel,  followed 
by  the  salines,  or  castor  oil,  but  all  active  purgation  should  be  avoided. 
Later  in  the  disease  daily  irrigation  of  tlio  colon  with  tcjiid  water  is 
better  than  anything  else.  On  the  wliole,  cousl  ipntion  is  more  trouble- 
some to  overcome  tlinn  diarrli(i':i. 

Tyiiipnniles  is  rarely  severe  ('1ioiil;1i  lo  re(|iiii'c  1rc;it  mcni :  il  may  be  re- 
lieved liy  (iii'pentine  stupes,  by  a  glycerin  suppository,  or  a  small  glycerin 


1058  THE   SPECIFIC   INFECTIOUS   DISEASES. 

injection  (one  teaspoonful  of  glycerin  to  two  ounces  water),  or,  better  still, 
by  the  use  of  the  rectal  tube. 

Whenever  the  temperature  goes  above  103°  F.,  antipyretic  measures 
are  indicated.  In  mild  cases,  sponging  with  cold  water  or  wdth  alcohol 
and  tepid  water,  equal  parts,  is  generally  sufficient.  In  cases  which  do 
not  yield  to  such  measures,  baths  should  be  employed.  For  young  chil- 
dren the  graduated  bath  (page  48)  should  be  used ;  for  those  who  are 
older  the  bath  should  be  from  ?5°  to  85°  F.,  its  duration  depending  upon 
the  amount  of  reduction  affected.  The  body  should  be  actively  rubbed. 
during  the  bath  to  prevent  shock  and  cardiac  depression.  The  only  contra- 
indications to  the  bath  are  extreme  prostration  with  great  cardiac  weak- 
ness, or  the  existence  of  intestinal  haemorrhage.  The  ease  with  which  the 
cold  bath  can  be  employed  in  children  makes  it  especially  valuable.  The 
cold  pack  (pages  47  and  48)  may  be  substituted  for  the  bath  where  circum- 
stances make  the  latter  impracticable.  The  bath  or  pack  should  be  repeated 
in  an  average  case  in  from  two  to  four  hours,  or  whenever  the  temperature 
has  risen  to  103°  F.  The  method  of  applying  cold  which  causes  the  least 
disturbance  to  the  patient  is  the  one  which  should  always  be  selected. 

The  milder  nervous  symptoms — headache,  restlessness,  sleeplessness, 
etc. — may  be  relieved  by  an  occasional  dose  of  phenacetine,  either  alone  or 
in  combination  with  the  bromides,  or  by  cold  or  tepid  sponging ;  the 
more  severe  ones  usually  occur  with  high  temperature,  and  are  best  con- 
trolled by  the  cold  bath. 

Stimulants  in  most  of  the  cases  are  not  called  for.  They  are  to  be 
given  according  to  the  indications  afforded  by  the  pulse,  the  first  sound 
of  the  heart,  and  the  child's  general  condition.  They  are  seldom  needed 
earlier  than  the  middle  of  the  second  week;  they  should  be  well  diluted. 
Brandy  or  whisky  is  to  be  preferred  to  wines,  and,  unlike  the  milk,  they 
may  be  given  at  frequent  intervals  whenever  the  patient  will  take  them 
best.  Intestinal  haemorrhage  calls  for  absolute  quiet,  morphine  h^'poder- 
mically,  and  an  ice-coil  to  the  abdomen,  nothing  being  given  by  mouth 
except  stimulants,  turpentine,  and  possibly  opium.  Intestinal  perfora- 
tion is  successfully  treated  only  by  early  laparotomy. 


CHAPTEE    X. 

TUBERCULOSIS. 

TuBEECULOSis  is  an  infectious  communicable  disease,  due  to  the 
bacillus  tuberculosis  of  Koch.  It  may  be  local  or  general,  and  may  in- 
volve any  organ  and  almost  any  structure  in  the  body. 

Etiolog-y. — Frequency. — Mliller,  in  500  autopsies  upon  children  in 
Munich,  found  tuberculosis  in  40  per  cent  of  the  cases;  in  30  per  cent 


TUBERCULOSIS.  1059 

death  was  due  to  tuberculosis,  and  in  the  remaining  10  per  cent  tubercu- 
losis was  found  at  autopsy  in  patients  dying  from  other  diseases.  I  do  not 
think  it  is  so  frequent  in  this  country,  for,  of  726  consecutive  autopsies  in 
the  New  York  Infant  Asylum,  tuberculosis  was  found  in  only  58,  or  8  per 
cent  of  the  cases ;  6  per  cent  of  the  deaths  were  due  to  tuberculosis,  and  in 
2  per  cent  the  children  died  from  other  diseases.  Of  319  consecutive  autop- 
sies in  the  Babies'  Hospital,  tuberculosis  was  found  in  41,  or  14  per  cent. 

Predisposing  causes. — The  predisposition  to  tuberculosis  is  general  or 
local.  General  j)redisposition  may  be  inherited  directly  from  parents  who 
have  themselves  suffered  from  tuberculosis,  or  from  those  who,  in  conse- 
quence of  syphilis,  alcoholism,  or  any  other  constitutional  vice,  have  trans- 
mitted a  feeble  constitution  to  their  children.  Inherited  predisj^osition  is 
exceedingly  common,  and  really  signifies  a  diminished  resistance  of  the 
cells  of  the  body  to  tuberculous  infection.  It  should  be  distinguished 
from  the  very  exceptional  condition  of  congenital  tuberculosis,  where  in- 
fection takes  place  before  birth.  General  predisposition  includes  the 
child's  surroundings,  in  so  far  as  they  affect  the  constitution  and  lower 
the  general  vitality.  Children  reared  in  the  city,  either  in  institutions 
or  in  crowded  tenements,  are  more  frequently  affected  than  those  who 
have  had  the  advantage  of  the  best  surroundings,  not  only  because  of  their 
increased  chances  of  exposure,  but  also  from  their  feebler  resistance. 
Marasmus,  intestinal  diseases,  and,  in  fact,  any  debilitating  general  or 
local  disease,  may  predispose  to  tuberculosis. 

A  local  predisposition  is  created  by  any  pathological  condition  of  the 
mucous  membranes  or  organs  most  exposed  to  infection.  The  most  im- 
portant are  repeated  attacks  of  bronchitis,  broncho-pneumonia,  or  pleurisy, 
and  chronic  catarrhal  inflammation  of  the  mucous  membrane  of  the  nose  or 
pharynx,  so  frequently  associated  with  enlarged  tonsils  or  adenoid  growths 
of  the  pharynx.  Much  less  frequently  the  local  predisposition  is  the  result 
of  some  previous  disease  of  the  intestines. 

The  role  played  by  other  diseases  in  the  development  of  tuberculosis  is 
an  important  one,  and  until  recently  but  little  understood.  In  a  very 
large  number  of  cases  tuberculosis  develops  as  a  sequel  of  one  of  the 
acute  infectious  diseases,  particularly  measles,  pertussis,  or  epidemic  in- 
fluenza. In  such  cases  there  has  probably  existed  previously  a  latent  tuber- 
culosis, usually  in  the  bronchial  lymph  nodes.  This  process,  sometimes 
long  quiescent,  under  the  stimulus  of  a  new  infection  may  be  awakened  to 
activity.  It  is  to  be  noted  tliat  it  is  the  infectious  diseases  that  are  in- 
timately associated  with  pulmonary  complications,  which  are  liable  to  be 
followed  by  tuberculosis. 

Age. — No  age  is  exempt  from  tuberculosis.  It  was  formerly  believed 
that  the  disease  was  rare  in  infancy,  but  recent  observations  have  shown 
that,  although  its  form  is  somewhat  different,  it  is  more  frequent  in  in- 
fancy than  at  any  period  of  later  childhood.     Statistics,  taken  chiefly  from 


1060  THE  SPECIFIC  INFECTIOUS  DISEASES. 

two  institutions  where  children  up  to  four  years  of  age  are  received,  give 
the  following  results,  the  diagnosis  being  confirmed  by  autopsy  in  nearly 
every  case  under  two  years  old : 

Under  three  months 5  cases 

From  three  to  six  months 21  " 

"       six  to  twelve  months 31  *' 

"       twelve  to  eighteen  months 29  " 

"       eighteen  to  twenty-four  months 10  " 

"       two  years  to  five  years 32  " 

Over  five  years 15  " 

Total 143    " 

It  will  be  seen  that  the  first  year  furnished  57  cases,  the  second  year 
39,  and  the  succeeding  three  years  but  32  cases. 

Mode  of  infection. — The  possibility  of  intra-uterine  infection,  or  the 
direct  transmission  of  tuberculosis,  has  been  demonstrated  by  cases  re- 
corded by  Birch-Hirschfeld,*  Lehmann,  Bar  and  Renon  and  others.  In 
the  case  first  referred  to,  the  organs  of  a  foetus,  taken  from  a  woman  dying 
from  general  tuberculosis,  were  found  to  contain  tubercle  bacilli,  although 
no  tuberculous  lesions  were  present ;  bacilli  were  found  in  the  capillaries 
of  the  liver ;  inoculations  from  the  spleen  and  kidney  produced  the  dis- 
ease in  animals ;  and  the  placental  tufts  were  filled  with  bacilli.  In  Leh- 
mann's  case  there  were  tuberculous  lesions  in  the  placenta  as  well  as  in 
the  child's  organs. 

Intra-uterine  infection  is  highly  probable  in  many  of  the  cases  of  chil- 
dren born  of  tuberculous  mothers,  who  develop  the  disease  during  the 
first  few  months  of  life,  although  they  may  show  no  evidence  of  it  at 
birth.  Among  my  own  cases  there  were  five  which  died  of  tuberculosis 
during  the  first  three  months.  One  of  these  children  was  but  twenty 
days  old.  It  was  born  prematurely  of  a  mother  who  at  the  time  was  suf- 
fering from  advanced  tuberculosis,  and  died  from  that  disease  shortly 
after  the  child.  Besides  other  lesions,  the  autopsy  showed,  in  the  case  of 
the  mother,  tuberculosis  of  the  endometrium.  In  this  instance  the  infec- 
tion of  the  child  certainly  took  place  before  birth. 

In  another  case,  a  child  died  of  general  tuberculosis,  with  wide-spread 
lesions,  at  the  age  of  seven  weeks.  The  mother  of  this  infant  died  from 
tuberculosis  eleven  days  after  the  birth  of  the  child.  Intra-uterine  infec- 
tion must,  however,  be  considered  rare  in  comparison  with  the  frequency 
with  which  infection  takes  place  after  birth,  instead  of  being,  as  was 
formerly  supposed,  very  common. 

Tuberculosis  may  be  communicated  by  direct  inoculation,  as  in  the 
case  of  a  bite  from  a  person  suffering  from  the  disease,  several  instances 
of  which  are  on  record.     The  rite  of  circumcision  performed  by  a  rabbi 

*  Wiener  medicinische  Blatter,  No.  17,  1891. 


TUBERCULOSIS.  KmU 

suffering  from  tuberculosis  is  also  known  to  have  caused  the  disease.  One 
of  the  most  striking  instances  of  direct  infection  is  that  reported  by 
Eeich.*  In  a  town  of  about  1,300  inhabitants,  the  obstetric  practice  was 
divided  between  two  midwives.  Within  fourteen  months  no  less  than 
ten  infants,  who  had  been  delivered  by  one  of  these  women,  died  of  tuber- 
culous meningitis.  In  none  of  these  families  was  there  a  history  of  tuber- 
culosis. This  midwife  was  found  to  be  suffering  from  pulmonary  tuber- 
culosis, and  died  from  that  disease.  It  was  her  custom  to  remove  the 
mucus  from  the  mouth  of  the  newly-born  infants  by  direct  mouth-to- 
mouth  aspiration,  and  then  to  establish  respiration  by  blowing  into  the 
nose.  In  the  practice  of  the  other  midwife,  who  was  healtliy,  no  cases  of 
tuberculosis  occurred,  although  she  treated  the  newly-born  infants  in  tlie 
same  fashion. 

The  following  instance  of  infection  has  recently  come  to  my  notice  : 
Two  little  girls  were  much  in  the  room  and  about  the  bed  of  a  young 
woman  who  was  suffering,  it  was  afterward  discovered,  from  pulmonary 
tuberculosis.  Within  three  months  of  that  time,  and  within  six  weeks  of 
each  other,  both  died  of  tuberculous  meningitis. 

Examples  might  be  multiplied  indefinitely  of  cases  where  children 
have  contracted  the  disease  from  a  close  exposure  to  nurses  or  other  per- 
sons in  the  household.  More  frequently,  however,  the  mode  of  infec- 
tion can  not  be  traced,  the  exposure  doubtless  being  in  most  of  these 
cases  long  antecedent  to  the  development  of  symptoms. 

Aside  from  accidental  inoculation  already  mentioned,  the  tubercle 
bacilli  may  gain  an  entrance  to  the  body  cither  through  the  respiratory  or 
the  alimentary  tract  or  the  skin — the  lust,  however,  being  so  very  rare  that 
it  need  only  be  mentioned.  In  infancy  and  early  childhood,  infection 
through  the  respiratory  tract  is  the  rule.  This  is  conclusively  shown  by  the 
situation  of  the  primary  lesions  (pages  407  and  10(34).  The  source  of  the 
bacilli  in  the  inspired  air  is  mainly  the  sputum  of  patients  suffering  from 
pulmonary  tuberculosis,  wliich  dries  and  becomes  part  of  the  dust  of  the 
street,  of  the  railroad  car,  the  home,  or  the  hos})ital.  Bacilli  may  be  taken 
into  the  alimentary  tract  with  milk  from  tuberculous  cows  or  tubercu- 
lous women.     Infection  in  this  way   I   believe  to  be  very  rare.f     Unless 

*  Berliner  klinische  Wochenschrift,  No.  37,  1878. 

f  In  this  connection  the  following  incident  is  interesting  as  hearing  upon  the  other 
side  of  the  question  :  Near  a  large  American  city  was  a  fancy  stock  farm  of  registered 
Jersey  cows,  which  supplied  milk  for  table  use  and  infant  feeding  to  a  large  number 
of  families  in  the  wealthiest  part  of  the  city,  for  a  period  of  over  ten  years.  At  the 
end  of  that  time  the  tuberculin  test  was  used  for  the  fii"st  time,  and  45  per  cent  of 
these  cows  were  found  to  bo  tuberculous,  and  were  killed  by  order  of  the  State  Board 
of  Health.  Tin'  diagnosis  was  confirmed  l)y  autopsies  upon  the  animals  in  every 
instance.  An  investigation  was  instituted  among  the  children  who  had  been  fed 
upon  this  milk,  but  in  only  one  case  of  many  hundreds  could  it  be  learned  tliat  tuber- 
culosis had  developed,  and   in   this  instance  it  was  by  no  means  established  that  the 


1062  THE  SPECIFIC   INFECTIOUS  DISEASES. 

the  udder  is  the  seat  of  disease,  the  number  of  bacilli  in  cow's  milk  is  so 
small  that  the  chances  of  infecting  a  child  after  these  bacilli  have  passed 
the  stomach  are  exceedingly  small.  Its  possibility  even  is  questioned  by 
many  good  authorities.  The  same  may  be  said  regarding  the  transmis- 
sion ■  of  tuberculosis  through  the  milk  of  a  nurse.  Infection  from  the 
meat  of  tuberculous  animals  is  doubtless  a  possibility,  but  hardly  more. 
Bollinger's  experiments  in  feeding  animals  with  the  expressed  juice  of 
such  meat  gave  negative  results. 

The  Various  Paths  of  Infection  adopted  by  the  Tubercle  Bacillus. — 
The  tubercle  bacilli  which  enter  the  body  with  the  inspired  air  are  ar- 
rested upon  the  mucous  membrane  of  the  upper  or  the  lower  respiratory 
tract ;  upon  which  one  of  these,  is  largely  determined  by  local  conditions 
in  the  various  mucous  membranes.  Both  clinical  experience  and  animal 
experiments  indicate  that  the  bacilli  may  pass  through  a  mucous  mem- 
brane without  inducing  in  it  a  tuberculous  disease,  but  that  penetration 
is  much  easier  if  the  mucous  membrane  is  the  seat  of  a  catarrhal  inflam- 
mation, or  if  the  epithelium  has  been  injured.  The  bacilli  are  taken  up 
by  the  lymphatics  from  the  surface  of  the  mucous  membrane  upon  which 
they  have  lodged,  and  are  carried  to  the  nearest  lymph  nodes,  where, 
for  a  considerable  time  at  least,  they  are  arrested.  It  has  long  been  a 
familiar  clinical  fact  that  the  great  majority  of  children  who  suffer  from 
tuberculosis  of  the  cervical  lymph  nodes  escape  general  tuberculous  in- 
fection, so  eminent  an  authority  upon  this  subject  as  Treves  considering 
this  to  be  a  very  exceptional  result. 

It  is  not  infrequent,  in  autopsies  both  upon  children  and  adults  dying 
from  various  non-tuberculous  diseases,  to  find  tuberculosis  limited  to  the 
bronchial  lymph  nodes.  In  a  series  of  125  autopsies  at  the  New  York 
Foundling  Asylum  upon  children  with  tuberculosis,  Xorthrup*  found 
13  such  cases,  these  being  children  who  had  died  from  acute  non- 
tuberculous  diseases.  Many  confirmatory  reports  have  been  published 
by  Bollinger  (Munich)  and  others.  I  have  myself  seen  it  in  a  number 
of  instances. 

H.  P.  Loomis  f  (New  York)  made  inoculation  experiments  with  the 
bronchial  lymph  nodes  taken  from  the  bodies  of  thirty  persons  dying  by 
violence  or  from  acute  disease,  in  whom  no  evidence  of  tuberculosis  in  any 
other  part  of  the  body  could  be  found  at  autopsy.  From  eight  of  the  cases 
he  produced  tuberculosis  in  animals  by  inoculation.     Arnold  has  shown 

milk  had  been  the  source  of  infection.  It  should  be  stated  that  this  was  before  the 
days  of  sterilizing  milk  for  infant  feeding.  Besides  the  families  who  took  the  milk 
in  the  manner  mentioned,  the  employees  at  the  farm  were  accustomed  to  drink  the 
skimmed  milk  in  large  quantities  daily  as  a  beverage  in  the  place  of  water.  Many  of 
them  continued  to  do  this  for  years,  and  yet  not  one  of  them  developed  tuberculosis. 

*  New  York  Medical  Journal,  February  21,  1891. 

t  The  Medical  Record,  December  20,  1890. 


TUBERCULOSIS.  1063 

by  experiments  with  dust  inhalation  in  animals,  that  in  a  short  time  the 
bronchial  lymph  nodes  were  filled  with  dust,  though  the  bronchi  and 
alveoli  were  free ;  but,  however  prolonged  the  inhalation,  dust  was  never 
found  in  the  lymphatic  vessels  beyond  the  nodes. 

Arriving  at  the  lymph  node,  the  bacilli  light  up  a  tuberculous  inflam- 
mation of  varying  degrees  of  intensity,  depending  upon  their  number 
and  upon  local  conditions.  This  inflammation  may  pass  through  the 
usual  changes  of  tuberculous  glands — congestion,  swelling,  cell  prolifera- 
tion and  caseation ;  or  the  process  may  be  arrested  at  any  point,  and  the 
products  of  inflammation  become  encapsulated  by  a  proliferation  of  fibrous 
tissue,  in  which  condition  they  may  remain  latent  in  the  body  for  an  in- 
definite number  of  years — possibly  for  a  lifetime.  This  is  what  occurs  in 
older  and  more  vigorous  children,  and  it  is  consistent  with  every  outward 
sign  of  health ;  but  it  is  a  smouldering  ember  which  at  any  time  may  be 
fanned  into  flame  under  the  stimulus  of  an  inflammation  excited  by  some 
other  cause. 

In  infants  and  young  children,  the  tendency  is  always  for  the  bacilli  to 
lodge  first  in  the  bronchial  lymph  nodes,  probably  on  account  of  the 
favourable  conditions  for  entrance  existing  in  the  bronchi  and  lungs.  In 
those  who  are  delicate  and  have  but  little  resistance,  the  process  in  the 
lymph  nodes  is  likely  to  go  on  to  caseation  and  softening,  and  secondarily 
to  this  process  in  the  glands,  the  lung  may  become  infected.  Of  91  cases 
observed  by  Northrup,  in  which  the  mode  of  infection  could  be  pretty 
accurately  traced,  in  88  it  was  primarily  in  the  bronchial  lymph  nodes. 
The  manner  of  the  extension  of  the  disease  to  the  lung  is  not  always  easy 
to  trace ;  but  in  many  instances  it  has  been  shown  to  be  the  result  of 
the  softening  of  one  of  these  small  tuberculous  lymph  nodes,  which  then 
ulcerates  through  the  wall  of  one  of  the  small  bronchi  or  a  blood-vessel, 
in  this  way  distributing  its  bacilli  through  the  lung. 

Although  this  is  the  course  usually  taken  by  bacilli  when  they  are  in- 
haled, it  is  not  always  the  case.  Lesions  in  the  lungs  are  occasionally 
found  where  the  lymph  nodes  are  not  involved ;  and  there  are  other  cases 
in  which  advanced  changes  exist  in  the  lung,  while  only  the  earlier  ones 
are  seen  in  the  lymph  nodes.  In  these  cases,  which  perhaps  are  to  be 
considered  as  exceptional,  the  tuberculous  process  probably  begins  in 
the  walls  of  the  small  bronchi,  the  alveoli,  or  in  the  connective-tissue 
septa. 

Tubercle  bacilli  entering  the  alimentary  tract  rarely  cause  lesions  of 
the  gastric  mucous  membrane,  or  through  it  reach  the  lymphatic  circula- 
tion. In  the  intestines,  however,  more  favourable  conditions  exist.  It  is 
possible  for  the  bacilli  to  reach  the  mesenteric  lymph  nodes  without  caus- 
ing disease  of  the  intestinal  mucous  membrane,  but  I  believe  it  to  be  ex- 
ceedingly rare;  for  by  careful  search  I  have  seldom  failed  to  find  intes- 
tinal ulceration  where  the  lymph  nodes  were  manifestly  tuberculous. 


1064 


THE   SPECIFIC  INFECTIOUS  DISEASES. 


Lesions, — In  the  following  table  are  given  the  different  lesions  of  tu- 
berculosis as  they  were  found  in  119  autopsies,  of  which  I  have  notes. 
These  represent  the  lesions  of  infancy  and  early  childhood,  66  per  cent  of 
these  children  being  two  years  old  or  under.  There  are  introduced  for 
comparison,  the  statistics  of  131  autopsies  from  the  Pendlebury  Hospital 
Eeports  (Manchester,  England).  Very  few  of  the  cases  in  this  series  were 
under  three  years,  the  hospital  admitting  only  older  children  : 

Frequency  of  the  Different  Visceral  Lesions  of  Tuberculosis. 


Organs. 


Lungs 

Pleura  

Bronchial  lymph  nodes. 

Brain 

Liver 

Spleen 

Kidneys 

Stomach 

Intestines 

Mesenteric  lymph  nodes 

Peritonaeum 

Pericardium 

Endocardium 

Thymus 

Suprarenal  capsules. .  . . 
Pancreas 


Personal  cases ; 

119  autopsies  (chiefly  under 

three  years). 

Pendlebury  Hospital  Reports ; 

131  autopsies  (chiefly  over 

three  years). 

117 

99 '0  per  cent. 

122 

93  •  0  per  cent. 

69 

58-0       " 

100 

76-0       " 

108 

96-0       " 

91 

70-0       " 

40 

37-0       " 

60 

46-0       " 

77 

65-0       " 

86 

65-0       « 

88 

75-0       " 

76 

58-0       " 

46 

39-0       " 

54 

41-0       " 

5 

4-0       " 

1 

0-8       " 

40 

37-0       " 

65 

50-0       " 

38 

35-0       " 

77 

59-0       " 

10 

9-0       " 

37 

28-0       " 

7 

60       " 

4 

8-0       " 

1 

0-8 

3 

2-5       " 

1-7       " 

2 

2 

1-6       " 

3 

2-5       " 

The  varieties  of  tuberculosis  seen  at  different  ages. — During  the  first 
two  years  of  life,  tuberculosis,  with  great  uniformity,  involves  first  the 
bronchial  lymph  nodes  and  the  lungs.  It  is  most  frequently  the  pul- 
monary process  which  is  the  cause  of  death,  and  next  to  the  lungs,  death  is 
due  to  tuberculosis  of  the  brain.  It  is  rare  for  any  other  local  tuberculous 
process  to  be  fatal  at  this  time  of  life.  Of  72  cases  of  tuberculosis  in  the 
first  two  years  of  life,  in  which  the  exact  nature  of  the  lesions  was  deter- 
mined by  autopsy,  the  lungs  were  extensively  involved  in  all ;  but  death 
was  due  to  meningitis  in  13,  in  only  one  to  tuberculous  peritonitis,  and  in 
one  to  hsemorrhage  from  a  tuberculous  ulcer  of  the  intestine.  During 
infancy,  meningitis  is  rare  except  when  associated  with  pulmonary  tuber- 
culosis ;  but  after  the  second  year,  meningitis  is  relatively  more  frequent. 
Of  the  deaths  from  tuberculosis  during  the  third  year,  meningitis  was 
present  in  over  one  half  the  number.  After  this  time  it  frequently  exists 
with  few  and  sometimes  with  no  lesions  in  the  lungs,  it  being  often  sec- 
ondary to  tuberculosis  of  the  bones  or  lymph  nodes. 

Beginning  with  the  third  year,  tuberculosis  of  the  bones,  cervical  and 
mesenteric  lymph  nodes,  peritonaeum,  and  intestines,  becomes  more  frequent, 
and  in  any  of  these  organs  it  may  occur  as  the  principal  lesion,  although 
at  autopsy  the  lungs,  even  at  this  age,  are  rarely  found  free  from  infection. 


TUBERCULOSIS.  10(55 

Pidmonary  Lesions.— As  compared  with  adults,  the  pulmonary  tuber- 
culosis of  children  is  more  widely  diffused,  and  the  predominance  of  cases 
in  which  the  lesion  is  at  the  upper  lobes,  though  less  marked,  still  exists. 
The  peculiarities  are  principally  seen  in  children  under  two  years.  In 
those  who  have  passed  the  sixth  or  seventh  year,  the  pathological  processes 
resemble  those  of  adult  life.  In  my  own  autopsies  the  oldest  lesions  were 
found  G9  times  in  one  of  the  upper  lobes  (left  35,  right  34) ;  23  times  in 
the  right  middle  lobe,  and  35  times  in  one  or  other  of  the  lower  lobes 
{left  24,  right  11).  Although  localized  tuberculous  processes  are  frequently 
met  with  in  patients  dying  from  other  diseases,  those  who  die  from  tuber- 
culosis usually  show  wide-spread  lesions  of  the  lungs,  and  the  younger  the 
child  the  more  diffuse  they  are. 

1.  Miliary  tuberculosis  of  the  lungs. — In  nearly  every  case  of  pulmo- 
nary tuberculosis,  miliary  tubercles  are  found  in  some  part  of  the  lung; 
usually  they  are  seen  upon  the  surface  and  in  scattered  areas  in  the 
vicinity  of  some  older  process.  Occasionally  in  older  children,  but 
very  rarely  in  infants,  they  are  distributed  through  nearly  the  whole  of 
both  lungs. 

In  some  places  the  lung,  with  the  exception  of  these  gray  granulations, 
appears  quite  normal ;  in  others  it  is  congested,  and  shows  between  the 
tubercles  the  lesions  of  simple  broncho-pneumonia  in  its  various  stages. 
There  is  also  an  acute  bronchitis  of  the  middle-sized  and  smaller  bronchi. 
The  microscope  shows  that  the  tubercles  usually  develop  in  the  walls  of 
the  small  bronchi  or  the  blood-vessels,  or  very  close  to  these  structures. 
In  their  gross  appearance,  the  lungs  in  these  cases  resemble  those  in  ordi- 
nary acute  broncho-pneumonia,  with  the  exception  that  everywhere  upon 
the  surface  and  throughout  the  substance  of  the  lung  are  seen  the  small 
gray  granulations,  and  in  most  cases  some  small  yellow  tuberculous  nod- 
ules. The  pleura  is  usually  normal  except  for  the  presence  of  the  tuber- 
cles. This  form  of  the  disease  rej)resents  the  rapid  dissemination  of 
tubercle  bacilli  throughout  the  lungs,  the  miliary  tubercles  being  the 
result  of  the  inflammation  excited  by  their  presence. 

2.  Tuberculous  broncho-pneumonia. — This  is  the  most  frequent  and 
the  most  characteristic  form  of  tuberculosis  in  infants  and  young  chil- 
dren, and  it  is  the  one  which  at  this  age  usually  causes  death.  In  this 
form  of  disease  there  are  produced  in  the  lung,  caseous  nodules,  or  larger 
-caseous  areas,  some  of  which  have  usually  undergone  softening  by  the 
time  the  case  comes  to  autopsy.  The  process  generally  runs  a  somewhat 
subacute  course.  With  the  lesions  mentioned  there  are  always  associated 
those  of  simple  broncho-pneumonia. 

The  pleura  is  involved  in  almost  every  case.  There  may  be  simply 
dense  connective-tissue  adhesions  which  bind  the  lung  firmly  to  the  chest 
wall,  or  the  pleura  may  be  greatly  thickened  and  contain  caseous  deposits. 
■Occasionally  empyema  is  seen,  but  it  is  almost  always  sacculated  and  small. 


1066  THE   SPECIFIC   INFECTIOUS   DISEASES. 

Both  lungs  are  usually  involved,  but  one  to  a  much  greater  degree  than 
the  other.  There  are  found  large  areas  of  consolidation  which  some- 
times involve  an  entire  lobe,  but  more  often  areas  are  seen  in  several  lobes. 
These  portions  of  the  lung  appear  much  firmer  and  harder  than  in  ordi- 
nary pneumonia.  The  upper  lobes  are  more  often  affected  than  the 
lower,  and  especially  that  part  of  the  lobe  which  is  near  the  root  of  the 
lung,  on  account  of  its  frequent  association  with  tuberculosis  of  the 
bronchial  glands ;  the  disease  very  often  extends  forward  from  this  point 
to  the  middle  lobe  of  the  right,  or  the  corresponding  part  of  the  left  lung. 
On  section  the  affected  part  of  the  lung  usually  shows  many  caseous 
nodules  varying  in  size  from  a  pin's  head  to  a  walnut,  which  appear  of  a 
pale  yellow  colour,  and  resemble  caseous  lymph  nodes.  They  contain  giant 
cells  and  are  usually  filled  with  bacilli,  those  which  have  softened  con- 
taining yellow  pus.  There  is  nearly  always  seen  in  some  part  of  the 
lung  a  large  caseous  area;  and  not  infrequently  there  may  be  diffuse 
caseation  of  almost  an  entire  lobe  (Fig.  189).  Sometimes  no  spot  of 
softening  is  seen  even  in  these  large  areas,  but  in  the  great  majority 
of  them  there  are  found  cavities  of  variable  size  with  ragged  but  not 
dense  walls. 

Softening  and  excavation  represent  the  final  stages  of  the  process  in 
tuberculous  pneumonia.  It  has  been  shown  by  Prudden  that  these  changes 
are  chiefly  or  entirely  due  to  other  pathogenic  organisms — usually  the 
streptococcus  or  staphylococcus — and  not  to  the  tubercle  bacillus.  Soften- 
ing usually  begins  in  the  centre  of  a  caseous  part,  often  at  several  points 
at  the  same  time.  Areas  of  excavation  large  enough  to  deserve  the  name 
of  cavities  were  present  in  thirty-five  of  seventy  two  autopsies  upon  tuber- 
culous patients,  two  years  old  and  under.  They  are  found  in  the  great 
majority  of  the  cases  in  which  continuous  pulmonary  symptoms  have  been 
present  till  death.  They  vary  in  size  from  a  cherry  to  a  hen's  egg,  and 
sometimes  a  much  larger  one  is  seen  (Fig.  190).  They  are  usually  rather 
deeply  seated,  and  partially  or  entirely  filled  with  caseous  masses  or  pus, 
but  very  seldom  perforate  the  pleura,  causing  pneumothorax  or  pyo-pneu- 
mothorax.  It  is  rare  in  a  young  child  to  find  cavities  surrounded  by  dense 
fibrous  walls  such  as  are  seen  in  older  children  or  in  adults;  for  in  infancy 
the  process  of  softening  once  begun  usually  advances  steadily  until  the 
death  of  the  patient. 

It  is  very  frequent  to  find  at  autopsy  small  cavities  surrounded  by 
larger  areas  of  caseous  pneumonia,  and  these  in  turn  surrounded  by  a 
zone  of  simple  pneumonia  through  which  are  scattered  many  miliary 
tubercles.  Often  the  lesions  mentioned  will  be  present  in  one  lobe,  while 
the  other  lobe  or  the  opposite  lung  will  show  only  the  changes  of  a  simple 
pneumonia. 

The  bronchial  lymph  nodes  are  in  these  cases  invariably  found  to  be 
tuberculous,  and  not  only  those  at  the  root  of  the  lung,  but  if  a  dissectioa 


TUBERCULUSIS. 


1067 


is  made,  a  chain  of  these  tuberculous  gluuds  will  be  found  to  follow  the 
larger  bronchi  for  some  distance  into  the  lung  (Fig.  l'J3).  Sometimes 
one  may  discover  one  of  these  which  has  softened  and  ulcerated  through 
into  a  small  bronchus,  and  in  this  way  has  spread  the  infection  through- 
out that  part  of  the  lung. 

Microscopical  examination  of  these  cheesy  nodules  shows  that  they 
most  frequently  begin  as  tuberculous  deposits  in  the  walls  of  the  small 


Fia.  189 


Fig.' 189..— Tuberculous  pneumonia.  A  vertical  section  throufrh  the  muldlc  ot  the  right  lung 
of  a  child  thirteen  months  old.  The  greater  part  of  the  upper  lobe  is  Uniformly  caseous— a 
dirtuse  tuberculous  pneumonia;  near  the  centre  the  commencement  ot  a  cavity  is  seen ;  be- 
low it  has  the  appearance  of  a  consolidation  from  simple  pneumonia.  The  part  ot  the  lower 
lobe  shown  is  normal.  ,  •         r    i 

Fig.  190.— Cavity  from  breaking  down  of  tuberculous  pneumonia:  another  view  ot  the  same 
luno',  the  section  beinff  made  very  near  the  posterior  border  of  the  lung.  The  cavity  occu- 
pies'at  this  point  nearlv  the  whole  of  the  upper  lobe.  At  autopsy  this  cavity  contained  nu- 
merous loose  caseous  ma.sses,  the  largest  being  the  size  of  a  marble.  The  lower  lobe  is 
normal.    (For  history  .«ee  Fig.  19G.) 

bronchi,  either  in  the  mucous  membrane,  the  fibrous  coat,  or  the  lymphat- 
ics ;  sometimes,  however,  they  begin  in  the  walls  of  a  small  vein  or  artery. 
Cell  proliferation  takes  place,  separating  the  coats  of  the  bronchus  or 
blood-vessel,  and  partly  or  entirely  obstructing  its  lumen.    Softening  may 


1068 


THE  SPECIFIC   INFECTIOUS   DISEASES. 


take  place  and  the  contents  be  discharged  into  the  bronchus  or  blood- 
YBSsel.     About   this   focus  other  changes   of   an  inflammatory  character 


^1*. ' 


''   ■  y^^i^J^^Ji^^^O'-i-^fi^Ki^f  ■'■A'* 


V.^v 


■^ 


;s*;-;^^y^ 


Fig.  191., — A  small  tuberculous  nodule  surrounded  by  lung  tissue  which  shows  only  slight  in- 
flammatory changes.  The  centre  of  the  nodule  is  necrotic  ;  at  its  periphery  is  shown  infil- 
tration with  round  cells  and  several  giant  cells.     (From  Karg  and  Schmorl.) 

occur,  as  a  result  of  which  each  cheesy  nodule  is  surrounded  by  a  zone 
of  simple  broncho-pneumonia  (Fig.  191)  which  tends,  in  a  measure  at 
least,  to  limit  the  tuberculous  process.  The  larger  caseous  areas  are 
formed  by  an  extension  of  this  process  to  the  zone  of  pneumonia 
which  surrounds  it ;  but  in  its  further  growth  it  is  still  preceded  by 
a  simple  pneumonia  (Fig,  193).  The  rapidity  with  which  the  lesions 
advance  differs  much  in  the  different  cases,  and  is  greatly  modified  by 
the  patient's  age  ;  in  infants  the  progress  is  apt  to  be  continuous  until 
the  death  of  the  patient ;  in  older  children  it  is  usually  slower,  and  is 
often  interrupted  by  longer  or  shorter  intervals  of  arrest  and  even  of  par- 
tial retrogression.  Such  periods  are  marked  by  the  absorption  of  the  sim- 
ple inflammatory  products  in  the  zone  of  pneumonia  surrounding  the 
tuberculous  nodule,  accompanied  by  improvement  in  the  symptoms  and 


TUBERCULOSIS. 


1069 


often  by  a  disappearance  of  some  of  the  physical  signs.  During  these  times 
of  quiescence  there  is  an  opportunity  for  the  organization  of  the  cells  in- 
filtrating the  alveolar  walls  and  septa  into  a  more  or  less  resistant  fibrous 
wall  which  acts  as  a  barrier  against  the  advance  of  the  pathological  jiro' 
cess. 

Not  infrequently  one  sees  in  the  post-mortem  room  one  or  two  caseous, 
or  less  frequently  calcareous,  nodules  encapsulated  by  firm,  organized  con- 
nective tissue  where  a  most  careful  search  fails  to  showanv  other  tubercu- 


:^.:':d^ 


B- 


'  ftf     'J  "'M- 


^^ 


Fig.  192.— Pulmoiiiirv  tuberculosis,  showing  ana-  ■  ivulous  pneumonia  and  eoncrlomerate 

tubercles.  In  the  trreater  part  of  the  specinicu  the  air  vesicles  are  lillcd  with  the  products 
of  simple  pneumonia.  The  larger  dark  areas.  A  A  .1,  are  spots  of  tuberouhnis  pneumonia, 
while  oxBB  only  single  air  vesicles  or  groups  of  two  or  three  are  affected  by  the  tuber- 
culous process.  'JThe  specimen  shows  a  comparatively  early  stage  of  the  nrocess,  of  wliich 
the  late  stage  is  represented  by  Fig.  172.  Patient,  a  child  three  months  old ;  the  svmptoms, 
those  of  simple  acute  pneumonia.  Tiiere  were  conglomerate  tubercles  scattered  through 
both  lungs,  and  large  areas  of  cheesy  pneumonia  in  the  lett  lower  lobe. 

lous   lesion  in  tlie  lung.     If,  however,  the  nodules  are  widely  scattered 
through  the  lung,  such  an  arrest  of  the  process  is  not  to  be  expected. 
3,  Chronic  pulmonary  tuberculosis,  chronic  phthisis. — With  the  patho- 
(i9 


1070  THE  SPECIFIC   INFECTIOUS   DISEASES. 

logical  process  as  it  is  seen  in  adults,  we  have  nothing  to  do  in  infants 
and  very  young  children.  In  those  who  have  reached  the  age  of  eight 
or  ten  years  the  disease  is  essentially  the  same  as  in  adult  life,  and  need 
not  be  described  here. 

In  little  children  the  nearest  approach  to  this  condition  is  seen  in  the 
cases  of  tuberculous  broncho-pneumonia,  which  run  a  slow,  irregular, 
and  somewhat  chronic  course.  The  essential  features  of  the  process  in 
these  patients  is  a  chronic  interstitial  broncho-pneumonia  with  tubercu- 
lous nodules  which  rarely  undergo  softening,  but  usually  become  encap- 
sulated. 

The  gross  lesions  closely  resemble  those  of  simple  chronic  broncho- 
pneumonia (page  579).  There  are  the  same  generalized  pleuritic  adhe- 
sions and  the  shrunken  cicatricial  condition  of  the  part  of  the  lung  most 
affected,  with  bronchiectasis,  compensatory  emphysema,  etc.  The  tuber- 
culous nodules  are  old  and  for  the  most  part  converted  into  dense  fibrous 
tissue  in  the  centre  of  which,  however,  some  softened,  caseous  areas  are 
often  seen.  Lesions  like  those  described,  which  may  be  regarded  as  a 
form  of  recovery,  are  usually  found  in  patients  who  have  died  of  other 
diseases ;  sometimes  in  those  who  have  died  of  other  forms  of  tuberculosis 
— of  the  brain,  bones,  or  peritonseum ;  at  other  times  they  are  associated 
with  a  recent  process  in  some  other  jaart  of  the  lung.  The  bronchial 
glands  may  be  somewhat  enlarged  and  contain  encapsulated  caseous 
masses,  or  they  may  be  calcareous. 

Bronchial  lymph  nodes  {hronchial  glands). — The  prominence  of  the 
lesions  of  the  lymph  nodes  is  one  of  the  most  striking  features  of  tuber- 
culosis in  infancy  and  early  childhood.  Those  which  are  most  frequently 
affected  are  connected  with  the  bronchi.  The  lymph  nodes,  to  which  the 
term  "  bronchial  glands "  is  generally  applied,  consist  of  three  groups : 
the  first  of  which  surround  the  trachea ;  the  second  are  situated  at  the 
bifurcation  of  the  trachea  and  surround  the  primary  bronchi ;  while  the 
third  follow  the  course  of  the  bronchi  into  the  lung,  being  found,  accord- 
ing to  anatomists,  as  far  as  the  fourth  division.  The  anatomical  relation 
of  the  different  groups  should  be  borne  in  mind,  since  upon  them  the 
symptoms  principally  depend.  The  first  group,  or  the  peri-tracheal  lymph 
nodes,  are  in  relation  with  the  superior  vena  cava,  the  pulmonary  artery, 
the  pneumogastric  and  recurrent  laryngeal  nerves ;  the  second  group,  at 
the  bifurcation  of  the  trachea,  with  the  oesophagus,  pneumogastric  nerve, 
and  aorta ;  the  third  group,  with  the  bronchi  and  the  branches  of  the 
bronchial  and  pulmonary  arteries  and  veins. 

All  the  groups  are  usually  involved  at  the  same  time,  but  in  varying 
degrees,  and  in  most  cases  those  belonging  to  one  lung  to  a  greater  extent 
than  the  other ;  in  my  own  cases  those  of  the  right  side  have  more  often 
been  involved  than  those  of  the  left.  There  may  be  simply  two  or  three 
tumours  as  large  as  a  hazelnut,  or  there  may  be  a  mass  two  or  three  inches 


PLATE    XXI. 


Tuberculosis  of  the  Tracheo-Brontiiial  Lymph  Nodes. 

From  a  fairly  nourished  cliild,  four  months  old,  wlio  was  under  observation  for 
three  weeks,  with  slight  fever  and  a  most  severe,  teasing,  dry  cough,  wiiieh  was  almost 
constant,  and  upon  which  no  treatment  seemed  to  have  the  slightest  eiTect.  At  first 
there  were  no  signs  of  disease  in  the  lungs  ;  later  tiiere  were  a  few  coarse  scattered 
rales. 

There  were  small  tuberculous  deposits  throughout  both  lungs,  with  quite  a  large 
area  of  cheesy  pneumonia  in  the  right  middle  lobe,  and  scattered  miliary  tubercles  in 
other  organs. 


TUBERCULOSIS. 


1071 


in  diameter,  which  is  made  up  of  ten  to  twenty  of  these  nodes  fused 
together  by  inflammatory  products,  completely  surrounding  the  trachea 
and  both  the  large  bronchi.  It  is  rare  that  the  individual  glands  are 
more  than  an  inch  in  diameter,  and  most  of  tliem  are  smaller  than  this. 


Fig.  193. — Tuberculous  bmncliial  lyiniih  nodes.  Section  of  tlic  lunir  <>f  mi  infant  tlircujjh 
cheesy  bronchial  lympli  nodes  at  the  root  of  tlie  lunj,',  and  adjacent  cheesy  masses,  several 
of  which  have  softened  at  the  centre ;  the  lung  otliorwise  normal ;  life-size.  (After 
Northrup.) 

A  well-marked  but  not  unusual  example  of  this  condition  is  shown  in 
Plate  XXI.  There  is  usually  found  a  chain  of  the.>^o  tuberculous  glands 
following  the  course  of  the  large  bronchi  for  some  distance  into  the  lung; 
sometimes  these  are  almost  as  large  as  the  e.x'ternal  group  (Fig.  103);  at 
other  times  they  arc  not  noticed  unless  a  somewhat  careful  dissection  is 


;^0Y2  THE   SPECIFIC   INFECTIOUS   DISEASES. 

made.  The  process  is  not  infrequently  more  advanced  in  these  deeply- 
seated  glands  than  in  those  situated  at  the  root  of  the  lung ;  and  lesions 
here  are  also  more  important,  as  it  is  very  frequently  through  them  that 
the  lung  becomes  infected. 

The  pathological  changes  through  which  these  glands  pass  as  a  result 
of  tuberculous  infection,  are  very  similar  to  those  already  described  with 
reference  to  the  cervical  glands  (page  870).  Suppuration  is  less  frequent 
than  in  the  region  of  the  neck,  while  calcific  degeneration  is  much  m.ore 
so.  This  applies  especially  to  children  over  three  years  old.  In  infancy 
suppuration  is  not  infrequent  in  the  bronchial  glands,  while  at  this  age 
calcification  is  extremely  rare.  Infection  of  these  lymph  glands  is  not 
always  followed  by  general  tuberculosis  or  even  by  infection  of  the  lung. 
Although  the  process  has  gone  on  to  caseation,  these  inflammatory  prod- 
ucts with  bacilli  may  become  encapsulated,  and  may  remain  innocuous  for 
an  indefinite  period.  The  bacilli  may  die  or  may  exist  here,  living,  for 
years.  At  any  time  the  old  process  may  be  lighted  up,  and  a  more  or  less 
rapid  dissemination  of  tubercle  bacilli  take  place  through  the  lungs  or 
through  the  whole  body.  Latent  tuberculosis  more  frequently  exists  in 
the  bronchial  lymph  nodes  than  in  any  other  structure  in  the  body. 

Secondary  lesions  may  be  produced  by  these  lymph  nodes.  The 
pneumogastric  and  recurrent  nerves  may  be  surrounded  by  one  of  these 
cheesy  masses  which  causes  pressure  and  irritation.  The  oesophagus,  the 
trachea,  or  the  bronchi,  may  be  compressed  or  opened  by  ulceration.  The 
superior  vena  cava  usually  suffers  only  compression,  but  this  or  any  of  the 
other  large  vessels  may  be  opened.  Ulceration  may  also  take  place  into 
one  of  the  large  or  small  bronchi  or  the  trachea.  If  the  gland  has  softened 
and  broken  down,  and  if  the  bronchus  is  a  small  one,  the  only  result  of 
this  may  be  a  rapid  spreading  of  tuberculous  infection  throughout  the 
lung.  If  sudden  rupture  occurs,  a  large  caseous  mass  may  escape  into  the 
trachea,  or  a  large  bronchus,  with  a  result  similar  to  that  produced  by  any 
other  foreign  body.  If  suppuration  occurs,  the  abscess  may  rupture  into 
the  surrounding  cellular  tissue,  causing  mediastinal  or  retro-oesophageal 
abscess  (page  314).  This  may  open  externally  at  the  suprasternal  notch, 
or  in  the  first  or  second  intercostal  space,  or  may  ulcerate  into  any  of  the 
large  vessels,  the  oesophagus,  or  the  pericardium,  or  may  burrow  down- 
ward into  the  peritoneal  cavity. 

Pleura. — This  is  rarely  normal  in  any  case  of  tuberculosis.  In  acute 
general  tuberculosis  the  only  lesion  may  be  a  deposit  of  miliary  tubercles 
upon  the  visceral  pleura.  In  most  of  the  other  cases  there  are  found 
fibrous  adhesions  over  the  part  of  the  lung  involved,  binding  it  to  the 
pericardium,  the  diaphragm,  or  the  chest  wall.  The  amount  of  thicken- 
ing of  the  pleura  varies  a  good  deal,  but  is  rarely  great.  In  about  one 
fifth  of  my  own  autopsies  tuberculous  nodules  were  found  in  the  pleura ; 
with  these  lesions  there  is  usually  considerable  thickening.     Pleurisy  with 


TUBERCULOSIS.  1073 

a  haemorrhagic  exudation  is  very  rare  in  the  tuberculosis  of  early  child- 
hood. Empyema  is  also  rare,  being  seen  in  but  five  per  cent  of  my 
cases,  and  then  it  was  small  and  sacculated.  Pneumothorax  and  pyo- 
pneumothorax are  very  rare  in  children  under  three  years  of  age  ;  they 
were  not  seen  in  any  of  my  cases. 

Heart. — It  is  exceptional  for  the  pericardium  to  be  affected  even  in 
the  most  generalized  forms  of  miliary  tuberculosis.  In  such  cases  the 
usual  lesion  is  a  deposit  of  a  few  gray  tubercles  upon  the  visceral  surface. 
In  chronic  cases  other  lesions  analogous  to  those  of  the  pleura  may  be 
seen,  but  all  are  rare  in  childhood.  In  a  single  instance  I  have  seen 
miliary  tubercles  upon  the  endocardium.  They  are  extremely  rare,  and 
the  development  of  cheesy  nodules  in  the  heart  is  almost  unknown  in 
early  life. 

Brain. — Tuberculosis  of  the  brain  is  not  uncommon  during  infancy, 
being  then  associated  in  nearly  all  cases  with  general  tuberculosis,  and 
especially  with  tuberculous  pneumonia;  but  it  is  relatively  twice  as  fre- 
quent after  the  second  year.  There  may  be  found  miliary  tubercles  alone, 
or  these  may  be  accompanied  by  inflammatory  products — tuberculous 
meningitis — or  there  may  be  caseous  nodules.  Miliary  tubercles  are  fre- 
quently found  in  small  numbers  in  cases  which  have  presented  no  symp- 
toms. The  lesions  of  tuberculous  meningitis  have  already  been  described 
(page  759).  Cheesy  nodules  are  rare  in  infancy,  being  noted  in  but  2-5 
per  cent  of  my  own  autopsies,  which  were  mainly  on  children  under  three 
years  old  ;  while  in  the  Pendlebury  Hospital  cases,  including  those  between 
four  and  twelve  years  old,  they  were  noted  in  24*4  per  cent.  These  nod- 
ules vary  in  size  from  a  pea  to  a  child's  fist ;  they  are  usually  associated 
with  tuberculous  meningitis,  but  they  may  exist  alone.  "When  they  are 
large  they  rank  as  cerebral  tumours,  being  most  frequently  seen  in  the 
cerebellum.    They  rarely  soften,  but  may  be  the  seat  of  calcareous  deposits. 

Liver. — This  is  frequently  involved  in  general  tuberculosis,  although  it 
is  doubtful  if  it  is  ever  the  seat  of  primary  infection  except  in  the  con- 
genital cases.  Usually  the  only  lesion  is  the  presence  of  miliary  tubercles 
on  its  surface  and  in  its  substance,  and  in  most  cases  these  are  not  numer- 
ous. They  are  found  in  about  two  thirds  of  the  cases.  In  a  smaller 
number  there  are  tuberculous  nodules  of  various  sizes.  In  nearly  every 
protracted  case  the  liver  is  markedly  fatty.  In  very  late  cases  of  tubercu- 
losis of  the  bones,  it  is  frequently  the  seat  of  amyloid  degeneration. 

f>pleen. — This  is  more  frequently  affected  than  the  liver,  but  in  very 
much  tlie  same  way.  In  most  of  the  cases  of  general  tuliercnlosis,  miliary 
tubercles  are  present  in  tiie  spleen,  these  beiiiu;  usually  numei'ous.  both 
upon  the  surface  and  throughout  the  organ.  Not  infro(]Ucntly  small  tuber- 
culous nodules  are  also  seen,  but  there  are  rarely  any  which  are  larger  than 
a  pea.  The  size  of  the  spleen  is  not  altered  if  only  miliary  tubercles  are 
present;  but  with   the  tuberculous    nodules  it    may    he    much   enlarged. 


1074  THE  SPECIFIC   INFECTIOUS   DISEASES. 

Amyloid  degeneration  is  found  under  the  same  conditions  as  in  the 
liver. 

Stomach. — Tuberculosis  of  the  stomach  is  one  of  the  rare  lesions ;  both 
its  contents  and  its  acid  reaction  seem  to  protect  it  against  direct  infection 
from  the  mouth.  Tuberculous  ulcers  were  seen  in  five  of  my  autopsies, 
which  is  a  larger  proportion  than  is  usually  noted. 

Intestines. — These  are  less  seriously  affected  in  infancy  than  in  older 
children,  which  is  rather  surprising  when  we  consider  how  susceptible  are 
the  intestines  of  infants  to  other  forms  of  infection.  The  explanation  of 
this  difference  seems  to  me  to  be  this  :  Intestinal  infection  is  nearly  always 
secondary  to  disease  of  the  lungs ;  primary  lesions  being  extremely  rare. 
Infants  usually  die  from  the  more  rapid  tuberculous  processes  in  the 
lungs  or  brain  before  there  has  been  time  or  opportunity  for  intestinal 
infection  to  occur.  The  opportunities  for  such  infection  depend  upon  the 
number  of  bacilli  which  are  coughed  into  the  pharynx  and  swallowed.  In 
infancy  this  number  is  small,  because  of  the  many  who  die  of  tuberculous 
pneumonia  or  meningitis  before  extensive  softening  in  the  lungs  has  taken 
place.  In  older  children  the  slower  course  of  the  pulmonary  disease  gives 
ample  time  for  intestinal  infection,  while  the  more  extensive  softening  and 
excavation  are  accompanied  by  the  discharge  of  a  much  larger  number  of 
bacilli.  The  intestinal  lesions  and  those  of  the  mesenteric  lymph  nodes 
with  which  they  are  almost  invariably  associated,  are  described  on  page  361. 

Peritonceum. — In  infancy  the  peritouEeum  is  not  often  involved  even 
in  general  tuberculosis,  and  at  this  age  it  is  very  rare  for  it  to  be  the  seat 
of  the  principal  tuberculous  process.  This  occurred  but  once  in  my  own 
119  autopsies.  In  older  children  it  is  more  frequent;  of  the  131  Pendle- 
bury  Hospital  cases,  the  peritonaeum  was  involved  in  37,  or  twenty-eight 
per  cent.  In  most  cases  of  general  tuberculosis  there  are  only  deposits 
of  miliary  tubercles ;  less  frequently  there  are  tuberculous  nodules  Avith 
other  inflammatory  products.  The  lesions  in  these  cases  are  described  with 
Diseases  of  the  Peritonaeum  (page  466). 

Thymus  gland. — In  three  of  my  cases  tuberculous  nodules  were  found 
in  the  thymus  body,  the  size  varying  from  a  small  pea  to  a  hazelnut. 
Some  of  the  largest  nodules  had  undergone  softening  at  the  centre.  All 
these  were  cases  showing  widely  disseminated  tuberculous  lesions. 

Pancreas. — In  three  of  my  cases  this  organ  also  was  the  seat  of  small 
tuberculous  nodules,  all  of  them  being  cases  of  general  tuberculosis. 

Uro-genital  organs. — Serious  tuberculosis  of  any  part  of  the  urinary 
tract  is  very  rare  in  children.  Miliary  tubercles  were  found  in  the  kid- 
neys in  about  one  third  of  my  autopsies  on  tuberculous  patients.  They 
are  generally  few  in  number.  Tuberculous  nodules  of  the  kidney  I  have 
seen  but  once  in  a  young  child.  They  are  very  rare  before  the  fourteenth 
year  (page  '666).  In  two  of  my  autopsies  tuberculous  nodules  were  found 
in  the  suprarenal  capsules.    Tuberculosis  of  the  testicle  has  been  observed 


THE  CLINICAL   FORMS  OF   TUBERCULOSIS.  1075 

in  rare  instances  among  children,  although  not  in  one  of  my  own  series. 
Koplik  (New  York)  has  reported  several  cases. 

Tuberculosis  of  the  bones  and  of  the  external  lyni[ih  nodes  have  al- 
ready been  described  (pages  870  and  883). 

THE   CLINICAL   FORMS   OF   TUBERCULOSIS. 

I.  General  Tuberculosis. — Cases  of  tuberculosis  present  a  wide 
variety  in  their  symptomatology.  Almost  every  case  possesses  some  pecul- 
iar features  which  depend  upon  the  constitution  of  the  patient,  the  source 
of  infection,  the  rapidity  with  which  the  bacilli  are  disseminated  through 
the  body,  or  the  numbers  in  which  they  enter.  The  general  symptoms 
usually  precede  the  local  ones,  but  in  probably  the  majority  of  cases  they 
are  masked  and  unrecognised.  It  is  not  often  jDossible  to  recognise  tuber- 
culosis until  the  process  is  quite  well  advanced  in  some  one  organ.  The 
early  symptoms  in  most  cases  are  very  indefinite  and  susceptible  of  many 
explanations. 

1.  Cases  Resembling  Infantile  Marasmus. — In  early  infancy,  tubercu- 
losis often  gives  at  first  and  for  a  long  time  only  the  symptoms  of  maras- 
mus. Infants  are  pale  and  thin,  they  do  not  gain  in  weight,  and  finally 
become  emaciated.  There  is  nothing  characteristic  about  these  symp- 
toms, and  it  should  be  remembered  that  they  depend  much  more  fre- 
quently upon  simple  marasmus  than  upon  tuberculosis.  There  may  be  no 
cough  and  no  fever  sufficient  to  attract  attention,  and  the  case  may  even 
go  on  to  a  fatal  termination  without  any  symptoms  except  those  of  in- 
fantile marasmus.  This  I  have  seen  at  least  a  dozen  times  in  cases  that 
came  to  autopsy. 

More  frequently,  however,  there  are  developed  toward  the  end  of  the 
disease  both  the  symptoms  and  signs  of  pulmonary  disease  and  fever. 
These  are  generally  found  together,  as  the  process  in  the  lungs  is  the  cause 
of  the  rise  of  temperature.  The  febrile  symptoms  are  often  not  seen  until 
the  last  two  or  three  weeks  of  life.  The  course  of  the  temperature  is  ir- 
regular. It  is  never  of  the  hectic  type  and  rarely  high.  The  usual  range 
is  between  100°  and  102°  F.  The  pulmonary  symptoms  are  generally  few 
and  not  very  well  marked.  There  is  usually  some  cough,  but  it  is  rarely 
severe.  The  breathing  is  more  rapid  than  would  be  explained  by  the 
temperature  alone.  Severe  dyspncea  and  cyanosis  are  rare,  and  are  seen 
only  at  the  cloae  of  the  disease.  The  physical  signs  are  those  of  either 
localized  bronchitis  or  of  broncho-pneumonia. 

The  other  symptoms  usually  relate  to  the  digestive  tract.  'I'licrc  may 
be  indigestion,  witli  occasional  vojnitiui,^  and  green  undigeslod  stuols,  or 
there  may  be  diarrhd-a.  Tlie  intestinal  syniptdins  di-pend  on  the  general 
condition  of  the  child  and  the  constitutional  disease,  rarely  ui)on  a  tuber- 
culous process  in  the  stoinadi  oi*  l)()\vcls. 

If  the  case  has  gone  on  to  the  development  of  constant  fever  and  rec- 


10Y6  THE   SPECIFIC   INFECTIOUS  DISEASES. 

ognisable  physical  signs  which  slowly  spread,  the  infant's  fate  is  sealed. 
The  progress  of  the  case  from  this  time  is  steadily  downward,  and  the 
child  can  live  at  most  but  a  few  weeks.  Death  generally  occurs  from  pro- 
gressive asthenia  without  the  development  of  any  new  symptoms.  Occa- 
sionally toward  the  close,  cerebral  symptoms  rapidly  develop,  and  the 
child  is  carried  off  in  a  few  days  by  tuberculous  meningitis ;  sometimes 
there  is  a  rapid  spreading  of  the  disease  in  the  lungs,  and  death  occurs 
with  symptoms  of  simple  acute  pneumonia. 

Diagnosis. — The  difficulty  in  diagnosis  is  chiefly  during  the  first  year 
of  life.  Every  circumstance  in  the  patient's  surroundings  and  family 
history  which  bears  upon  the  development  of  tuberculosis  must  be 
weighed  to  establish  the  fact  of  inheritance  or  of  exposure  to  contagion. 
In  simple  wasting,  the  usual  history  is  that  the  infant  was  plump  and  well 
nourished  at  birth.  A  sufficient  cause  for  its  condition  can  in  most 
cases  be  found  in  improper  or  insufficient  nourishment  or  the  want  of 
proper  care.  (See  causes  of  marasmus,  page  236.)  Often  the  wasting 
follows  some  acute  disease  of  infancy,  most  frequently  some  form  of  gas- 
tro-intestinal  disease. 

In  tuberculosis,  the  infant  may  show  all  the  signs  of  malnutrition  at 
birth,  but  in  most  cases  they  are  of  later  development.  They  either  come 
without  adequate  cause,  or  are  associated  with  pulmonary  disease  or  they 
follow  measles  or  pertussis.  No  explanation  of  the  wasting  can  be  dis- 
covered in  the  food,  the  surroundings,  or  in  the  condition  of  the  digestive 
organs.  Diarrhoea  and  vomiting  more  frequently  follow  than  precede  it. 
The  above  facts  are  sufficient  to  warrant  a  suspicion  only  that  tubercu- 
losis is  present  until  some  local  manifestation  occurs,  usually  in  the  lungs. 
The  early  wasting  without  adequate  cause,  followed  by  the  gradual  devel- 
opment of  low  fever,  and  finally  the  appearance  of  signs  of  subacute 
broncho-pneumonia,  form  the  most  characteristic  features  of  general  tu- 
berculosis in  early  infancy.  Yet  all  these  symptoms  are  occasionally  met 
with  in  cases  in  which  the  autopsy  shows  none  of  the  lesions  of  tubercu- 
losis, for  simple  broncho-pneumonia  frequently  occurs  in  patients  suffer- 
ing from  marasmus ;  but  in  such  cases  fever  is  usually  slight  and  it  may 
be  absent. 

The  wasting  and  cachexia  of  hereditary  syphilis  sometimes  resemble 
tuberculosis,  but  the  early  history  in  syphilis  is  usually  so  characteris- 
tic, and  other  symptoms  of  the  disease  ai'e  so  rarely  wanting,  that  the 
mistake  is  not  likely  to  be  made  if  a  patient  is  submitted  to  a  careful  ex- 
amination. In  the  absence  of  definite  syphilitic  symptoms  the  chances 
are  greatly  in  favour  of  tuberculosis. 

2.  Cases  in  Older  Children  with  Symptoms  Resembling  a  Continued 
Fever. — Before  the  development  of  fever  in  these  cases,  there  is  usually 
quite  a  protracted  period  of  very  indefinite  symptoms,  each  one  of  which 
alone  is  unimportant,  but  all  of  which  taken  together  should  excite  sus- 


THE   CLINICAL  FORMS   OF   TUBERCULOSIS.  lUTT 

picion.  Such  children  are  usually  delicate ;  they  are  persistently  ana-mic 
without  sufficient  reason;  they  often  show  a  loss  in  weight;  there  is  a 
marked  cachexia,  sometimes  a  capricious  appetite,  and  a  digestion  easily 
disturbed.  In  some  of  them  a  change  in  disposition  is  observed,  and 
they  become  peevish  or  fretful  and  are  disinclined  to  muscular  exertion. 
All  these  symptoms  indicate  a  gradual  decline  in  the  general  health. 

This  clinical  picture  may  be  due  to  many  causes,  but  it  should  always 
arouse  in  the  mind  of  the  physician  a  suspicion  of  incipient  tuberculosis, 
particularly  in  a  child  who  by  surroundings  or  inheritance  is  predisposed 
to  that  disease.  After  these  indefinite  symptoms  have  lasted  a  few  weeks 
fever  is  added.  Sometimes  the  prodromal  symptoms  are  absent  or 
unnoticed  and  fever  is  the  first  evident  symptom.  ^.Fhis  fever  is  peculiar 
in  that  it  comes  without  evident  cause  and  without  any  local  manifesta- 
tions of  disease.  The  temperature  is  not  often  high,  but  it  is  continuous. 
The  tymj^anites  and  the  rose-coloured  spots  are  not  present,  but  the  gen- 
eral aspect  of  the  patient  is  strikingly  like  that  belonging  to  typhoid 
fever. 

After  the  fever  has  lasted  from  one  to  three  weeks  there  develop  some 
signs  of  localized  tuberculosis,  generally  in  the  lungs,  or  the  fever  may 
decline  gradually,  and  although  the  patient  improves  he  does  not  get 
well.  He  is  still  weak  and  does  not  gain  in  weight,  and  the  thermometer 
shows  the  existence  of  a  very  slight  amount  of  fever.  Before  long  he 
may  grow  rapidly  worse  and  the  course  of  the  temperature  becomes  irreg- 
ular, with  alternate  exacerbations  and  remissions.  Such  an  irregular  and 
inexplicable  fever  sometimes  puzzles  the  physician  for  three  or  four  weeks 
before  the  characteristic  features  which  stamp  the  process  as  tuberculous 
are  present.  One  general  symptom  is  almost  invariably  associated  with 
the  fever,  viz.,  wasting.  This  may  not  be  rapid,  but  is  progressive.  Tiie 
tuberculous  cachexia  is  frequently  unmistakable  ;  but  in  most  of  the  cases 
one  must  wait  for  the  process  to  advance  far  enough  in  some  one  of  the 
organs  to  give  local  signs  or  symptoms  before  he  can  be  sure  of  tuberculo- 
sis. In  four  cases  out  of  five  this  is  in  the  lungs.  Less  frequently  it  is 
in  the  peritonseum,  the  brain,  or  a  general  infection  of  the  lymph  glands 
throughout  the  body.  If  in  the  lungs,  the  process  manifests  itself  as  a 
broncho-pneumonia  whose  tuberculous  character  may  be  suspected  from 
its  localization— the  apex  or  the  middle  of  the  lung  in  front— but  chielly 
from  the  fact  that  the  general  symptoms,  fever  and  wasting,  have  for  so 
long  a  time  preceded  the  local  signs  of  disease.  Fi'oin  this  time,  the 
course  of  the  disease  may  be  that  of  a  typical  tuberculous  broncho- 
pneumonia. 

If  the  tuberculous  process  is  localized  in  the  brain,  we  liavc  duliicss, 
vomiting,  headache,  apathy,  irregular  jiulse,  irregular  respiration,  and 
finally  convulsions  and  coma— in  short,  the  symptoms  of  tuberculous 
meningitis;   if  in   the  pcriton;\3um,  we  have  abdominal  distoTition  from 


1078  THE   SPECIFIC   INFECTIOUS  DISEASES. 

gas  or  fluid,  tenderness,  pain,  diarrhoea,  or  constipation ;  if  in  the  lymph 
glands,  there  is  a  general  enlargement  of  those  situated  in  the  neck,  and 
sometimes  those  of  the  axillary  and  inguinal  regions,  with  symptoms  indi- 
cating similar  changes  in  those  at  the  root  of  the  lung. 

Diagnosis. — In  distinguishing  general  tuberculosis  from  typhoid  fever, 
very  great  stress  is  to  be  laid  on  the  family  and  previous  history  of  the 
patient  and  the  surroundings,  as  favouring  tuberculosis.  On  the  other 
hand,  the  prevalence  of  typhoid  fever  in  the  family,  the  neighbourhood, 
or  the  institution  in  which  the  case  occurs,  is  important.  The  extreme 
infrequency  of  typhoid  in  children  under  two  years  old  should  always 
lead  the  physician  to  scrutinize  very  carefully  every  case  in  which  he  is 
disposed  to  make  such  a  diagnosis  at  that  time  of  life.  In  typhoid,  the 
course  of  the  fever  is  more  regular  than  in  tuberculosis,  but  less  so  than 
in  the  typhoid  of  adults,  and  the  spleen  in  nearly  every  case  is  sufficiently 
enlarged  to  be  easily  felt  below  the  ribs.  The  rose  spots  are  usually  pres- 
ent. But  the  most  conclusive  evidence  is  that  afforded  by  the  blood 
reaction  in  Widal's  serum-test ;  without  this,  by  the  gradual  cessation 
of  the  fever  in  the  third  or  fourth  week  and  complete  recovery  of  the 
patient. 

In  tuberculosis,  on  the  contrary,  the  fever  is  less  regular.  It  common- 
ly shows  wider  fluctuations,  the  spleen  is  not  usually  enlarged,  and  there 
are  no  rose  spots.  Tympanites  and  abdominal  tenderness  are  sometimes 
seen,  but  the  fever  shows  no  disposition  to  stop  after  the  third  week, 
and  the  wasting  is  continuous.  The  signs  in  the  lungs,  at  first  few,  in- 
crease from  day  to  day.  In  most  cases  one  must  wait  for  ten  days  at 
least,  and  in  many  three  weeks,  before  a  positive  diagnosis  can  be  made. 

II.  TuBEECULOUs  BROif cho-Pneumoj^ia.— TMs  occurs  clinically  un- 
der the  following  conditions  :  (1)  It  may  begin  in  the  lungs  or  extend  to 
the  lungs  from  the  bronchial  glands,  the  symptoms  in  either  case  being 
essentially  pulmonary  from  the  outset.  (2)  It  may  follow  either  form 
of  general  tuberculosis  described— that  resembling  marasmus  in  infants, 
or  that  resembling  a  continued  fever  in  older  children.  In  both  of  these 
the  pulmonary  symptoms  develop  gradually  in  the  course  of  the  general 
symptoms  of  the  disease.  (3)  It  may  occur  in  the  course  of  any  of  the 
forms  of  local  tuberculosis,— of  the  bones,  peritonaeum,  intestines,  external 
lymph  glands,  or  skin.  In  such  cases  the  invasion  of  the  lungs  frequently 
marks-  the  last  stage  of  the  process.  (4)  It  may  follow  any  of  the  infec- 
tious diseases,  especially  measles  or  pertussis,  even  though  they  are  not  com- 
plicated by  broncho-pneumonia,  but  more  frequently  when  they  are.  (5) 
It  may  follow  single  or  repeated  attacks  of  simple  bronchitis  or  pneumonia. 

Clinically  the  cases  may  be  divided  into  three  groups :  First,  the  most 
rapid  ones,  lasting  from  one  to  three  weeks ;  secondly,  those  running  a 
more  protracted  course,  with  a  duration  of  from  three  weeks  to  three 
months ;  thirdly,  those  which  are  more  or  less  chronic.     In  the  first  two 


THE  CLINICAL   FORMS  OF  TUBERCULOSIS.  1079 

groups  the  progress  is  nearly  always  steadily  downward,  and  a  fatal  ter- 
mination the  almost  inevitable  result;  in  the  third  form  the  course  is  more 
irregular,  and  marked  by  a  series  of  exacerbations  and  remissions. 

1.  The  Most  Rapid  Cases. — In  this  form  of  the  disease  there  are  found 
scattered  through  certain  portions  or  nearly  the  whole  of  both  lungs,  mili- 
ary tubercles  and  minute  tuberculous  nodules,  the  intervening  parts  of 
the  lung  being  involved  more  or  less  seriously  in  a  simple  inflammation. 
In  most  of  the  cases  the  clinical  picture  is  that  of  simple  acute  broncho- 
pneumonia, for  it  is  to  the  accompanying  broncho-pneumonia,  and  not  to 
the  scattered  tuberculous  deposits  themselves,  that  the  symptoms  and  the 
physical  signs  are  due.  The  development  of  the  disease,  although  acute, 
is  not  usually  abrupt.  There  are  present,  fever,  cough,  dyspnoea,  acceler- 
ated respiration,  prostration,  and  sometimes  cyanosis.  The  temperature 
in  these  cases  is  never  hectic,  but  its  course  is  a  somewhat  irregular  one 
the  usual  range  being  between  100°  and  104°  F.  In  most  of  the  cases  it 
differs  in  no  respect  from  the  temperature  of  simple  broncho-pneumonia. 
Sometimes  it  is  seen  that  the  general  symptoms  are  severe  and  the  phys- 
ical signs  wide-spread,  and  yet  the  range  of  temperature  is  not  high.  To 
be  sure,  this  is  occasionally  seen  in  a  simple  broncho-pneumonia,  but  it  is 
more  frequent  in  tuberculosis.  The  cough  early  in  the  disease  is  slight, 
but  later  becomes  severe  and  often  distressing.  In  infants  and  young 
children  it  may  be  of  a  paroxysmal  character,  resembling  pertussis.  Ex- 
pectoration is  wanting  in  infancy,  and  is  not  often  seen  in  those  under 
seven  years,  so  that  bacilli  in  the  sputum  is  a  symptom  of  only  a  small 
number  of  cases.     Bloody  expectoration,  likewise,  is  rare  in  children. 

The  conditions  in  the  lungs  which  give  physical  signs  are  bronchitis 
of  the  smaller  tubes,  with  areas  of  complete  or  partial  consolidation.  In 
character,  these  signs  are  identical  with  those  of  simple  broncho-pneu- 
monia (page  .543).  They  may  be  scattered  throughout  the  whole  of  both 
lungs ;  but  when  localized  they  are  more  frequently  in  the  upper  than  in 
the  lower  lobes,  and  rather  more  frequently  in  front  than  behind.  Al- 
though both  lungs  are  involved,  they  are  usually  not  affected  to  the  same 
degree.  The  patient  may  die  before  signs  of  complete  consolidation  are 
present;  more  often  there  are  during  the  last  few  days  small  areas  of 
partial  consolidatiou,  as  shown  by  broncho-vesicular  breathing,  exagger- 
ated voice,  and  slight  dulness.  These  signs  may  be  due  to  the  simple 
broncho-pneumonia,  and  are  often  found  in  the  lower  lobes  behind. 
Large  areas  of  complete  consolidation,  with  pure  bronchial  breathing, 
bronchial  voice,  and  marked  dulness  are  infrequent. 

From  the  beginning  of  acute  symptoms  the  progress  of  the  disease  is 
steadily  downward,  death  resulting  from  the  same  causes  as  in  simple 
broncho-pneumonia.  The  end  is  marked  by  cyanosis,  great  dyspnoea, 
weak  pulse,  and  extreme  prostration.  In  a  few  cases  there  develop  shortly 
before  death  cerebral  symptoms,  indicating  tuberculous  disease  of  the 


1080 


THE   SPECIFIC   INFECTIOUS   DISEASES. 


brain.  Such  symptoms  may  be  the  first  to  lead  the  physician  to  suspect 
the  process  to  be  a  tuberculous  one.  In  these  cases  death  may  occur  in 
convulsions  in  two  or  three  days  from  the  first  cerebral  symptoms.  In 
other  cases  the  course  is  slower,  with  the  typical  symptoms  of  meningitis. 
2.  Tlie  More  Protracted  Cases. — In  this  form  of  the  disease  there  are 
found  in  the  lungs  caseous  nodules,  with  larger  areas  of  caseous  pneu- 
monia, and  usually  some  spots  of  softening.  The  process  is  not  usually  so 
generalized  as  in  the  cases  just  described,  but  as  in  them  there  is  always 


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Fig.  194..— Tuberculosis  followinof  measles.  Child  sixteen  months  old,  inmate  of  an  institu- 
tion. Chart  begins  on  fifth  day  of  a  severe  but  uncomplicated  attack  of  measles,  and  shows 
a  natural  decline  to  normal.  Fever  then  returned  and  continued  till  death,  twelve  weeks 
later.  Eecord  for  the  period  which  is  omitted  was  much  like  that  which  iramediatelv  pre- 
cedes and  follows.  Early  symptoms  not  acute,  only  slow  wasting,  slight  cough  and  fever, 
with  scattered  rales  throughout  chest.  Signs  of  consolidation  not  distinct  tiireighth  week, 
then  present  in  right  upper  lobe.  Toward  the  end,  rapid  emaciation,  marked  pulmonary 
symptoms,  and  signs  of  cavity  at  right  apex.  Autopsy  showed  a  large  cavity,  extensive 
tuberculous  deposits  throughout  both  lungs  and  in  nearly  all  abdominarorgans.' 

associated  a  certain  amount  of  simple  pneumonia.  This  is  the  most  fre- 
quent and  most  characteristic  form  of  pulmonary  tuberculosis  in  infancy 
and  early  childhood.  Its  usual  duration  is  from  one  to  three  months;  its 
course  is  then  steady  and  uninterrupted.  In  its  slower  or  subacute  form 
it  lasts  from  three  to  six  months,  and  its  course  is  then  more  irregular. 

The  mode  of  onset  will  depend  upon  the  conditions  under  which  the 
disease  develops.  When  the  general  symptoms  of  tuberculosis— fever  and 
wasting, — have  preceded  those  in  the  lungs,  the  evolution  of  the  latter 
is  gradual,  with  cough,  rapid  breathing,  dyspnoea,  increased  prostration. 


THE   CLINICAL   FORMS  OF   TUBERCULOSIS. 


lOSl 


etc.  When  the  pulmonary  symptoms  are  present  from  the  beginning,  tliey 
are  the  same  as  in  simple  broncho-pneumonia,  with  the  exception  that  they 
usually  come  on  less  acutely.  The  latter  is  true  of  cases  which  are  second- 
ary to  some  other  form  of  tuberculosis  in  the  bones,  peritonaeum,  etc. 

When  pulmonary  tuberculosis  follows  measles  (Fig.  19-i)  or  whooping- 
cough  which  has  been  complicated  by  simple  pnenmonia,  the  early  symp- 
toms may  present  no  unusual  features.  After  two  or  three  weeks  the  tem- 
perature gradually  falls,  and  the  physical  signs  improve,  but  neither  quite 
disappears.  The  cough  continues,  though  its  severity  somewhat  abates. 
In  the  course  of  a  few  weeks  the  child,  who  has  meanwhile  improved  some- 
what in  his  general  condition,  becomes  distinctly  worse,  often  without  any 
assignable  cause.  The  temperature  rises  to  102°  or  103°  F. ;  the  cough 
increases,  and  an  extension  of  the  disease  in  the  lungs  is  evident  by  the 
physical  signs.  In  other  cases  the  progress  of  the  disease  after  the  pneu- 
monia which  complicated  measles  is  without  an  intervening  period  of 
apparent  improvement.  It  sometimes  happens  that  the  attack  of  measles 
or  whooping-cough  is  not  accompanied  by  any  serious  pulmonary  symp- 
toms, and  the  case  goes  on  to  apparent  recovery,  except  that  there  remain 
anemia,  a  slight  cough,  and  fever.  The  temperature,  although  not  high, 
persists ;  but  it  may  be  two  or  three  weeks  before  there  are  present  definite 
symptoms  and  signs  of  disease  in  the  lungs. 

Fever  is  a  constant  accompaniment  of  all  active  tuberculous  processes 
in  the  lungs  in  the  child  as  in  the  adult,  it  being  absent  only  during  the 
periods  of  remission  which  occur  in  the  cases  of  slow  and  irregular  prog- 


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Fig.  1'.i5. — Tuberculous  pneumonia,  general  tuberculosis.  Patient  eleven  months  old,  and  under 
observation  at  the  time  he  was  taken  sick.  Chart  of  entire  illness  is  given.  Disease  began 
as  an  acute  pneumonia  in  lower  part  of  left  axilla  and  spread  to  entire  lower  lobe.  Early 
signs  of  consolidation;  at  end  of  two  weeks,  flatness  so  marked  tiiat  a  needle  was  inserted, 
fluid  being  suspected.  Vomited  frequently,  and  had  loose  discharges  from  bowels  through- 
out the  illness  ;  abdomen  much  swollen  for  last  two  weeks.  Autopsy  showed  cheesy  pneu- 
monia of  part  of  the  upper  and  the  entire  left  lower  lobe,  where  were  two  small  cavities. 
Eeeent  tubercles  found  throuirhout  right  lung,  and  e.\tensive  deposits  in  abdominal  organs 
with  peritonitis,  intestinal  ulcers,  etc. 

ress.  It  is  a  very  important  guide  to  the  progress  of  the  disease.  The 
early  fever  depends  chiefly  upon  the  coexisting  broncho-pneumonia, 
and  its  course  resembles  that  of  simple  pneumonia  of  the  protracted 
variety.  There  is  no  typical  curve.  The  fever  is  not  often  steadily  high, 
and  in  many  cases  it  is  never  high  (Fig.  195).     It  frequently  runs  for 


1082 


THE  SPECIFIC   INFECTIOUS  DISEASES. 


several  days  between  99°  and  102°  F.,  and  then,  without  evident  cause, 
rises  to  104°  F.  or  over;  again,  it  may  be  scarcely  over  100°  F.  for  days 
together.  In  infants  the  morning  temperature  is  frequently  subnormal, 
although  the  evening  temperature  may  be  102°  or  103°  F.  Even  toward 
the  close  of  the  disease,  when  softening  and  breaking  down  are  actively 
going  on,  the  regular  hectic  temperature  of  adults  is  rarely  seen  in  a 
young  child  (Fig.  196).    While  the  presence  of  fever  is  of  great  signifi- 


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Fig.  196. — Tuberculous  pneumonia,  with  extensive  softening  and  excavation.  A  delicate  child, 
thirteen  months  old  ;  weight,  ten  pounds ;  came  under  observation  four  weeks  before  death, 
with  consolidation  at  apex  of  right  lung.  Signs  increased  in  intensity,  and  extended  in  area 
until  there  were  heard,  from  clavicle  to  below  the  nipple,  exaggerated  bronchial  voice  and 
breathing  and  many  moist  rales;  percussion  note  was  flat;  behind,  the  same  signs  at  ex- 
treme apex.  No  distinct  signs  of  a  cavity ;  no  hectic  fever ;  no  sweating.  Autopsy  showed 
large  cavity  (Fig.  190)  at  right  apex  partly  tilled  with  caseous  masses ;  clii!'use  caseous  pneu- 
monia (Fig.  189)  of  the  rest  of  right  upper  lobe,  with  scattered  deposits  in  the  other  lobes, 
the  opposite  lung,  and  a  few  in  the  abdominal  organs. 

cance,  its  course  has  almost  no  diagnostic  importance  in  early  life.  Espe- 
cially should  one  beware  of  drawing  the  conclusion  that,  because  the  fever 
is  not  hectic,  there  is  no  breaking  down  of  the  lung. 

Sweating  belongs  only  to  the  late  stage  of  the  disease,  and  is  usually 
associated  with  the  hectic  type  of  fever ;  both  these  are  regular  symptoms 
in  children  over  seven  years  old,  but  not  in  very  young  children. 

Wasting,  like  fever,  is  characteristic  of  all  active  tuberculous  processes. 
Whenever  they  are  associated,  tuberculosis  should  always  be  suspected, 
no  matter  how  obscure  the  other  symptoms  may  be.  The  wasting  is  not 
always  rapid,  but  it  is  usually  continuous  while  fever  lasts.  During  the 
periods  of  temporary  improvement,  children  may  not  only  cease  to  lose, 
but  may  actually  gain  in  weight.  In  the  early  stage  of  the  disease,  wast- 
ing is  especially  suggestive  when  it  continues  without  apparent  cause 
after  measles  or  pertussis,  or  when  it  persists  under  other  circumstances 
in  spite  of  a  good  appetite  and  apparently  good  digestion.  It  may  at 
first  be  so  slight  as  not  to  be  noticed  unless  the  scales  are  employed.  In 
obscure  cases  this  steady  loss  of  weight  is  a  point  of  much  diagnostic 
value,  and  is  frequently  overlooked.  Toward  the  close  of  the  disease  there 
is  rapid  and  frequently  extreme  emaciation. 

Cough,  although  almost  invariably  present,  shows  no  peculiarities.  It 
may  be  hard,  dry,  or  suppressed ;  it  sometimes  occurs  in  paroxysms  re- 


THE   CLINICAL   FORMS  OF  TUBERCULOSIS.  1083 

sembling  pertussis,  which  may  or  may  not  depend  upon  the  presence  of 
enlarged  bronchial  glands. 

Expectoration  is  absent  in  infants,  the  matters  coughed  up  being 
swallowed.  In  children  over  seven  years  old,  we  often  get  a  profuse  muco- 
purulent expectoration,  but  it  is  very  exceptional  below  this  age. 

Haemoptysis  is  a  rare  symptom,  but  not  unknown  even  in  young  chil- 
dren. Henoch  has  reported  a  case  of  fatal  haemoptysis  in  a  child  ten 
months  old,  where  the  haemorrhage  was  due  to  the  rupture  of  an  aneurism 
in  the  wall  of  a  cavity.  Herz,  in  247  clinical  cases  of  tuberculosis  in  chil- 
dren, records  8  of  hsemoptysis — 4  of  them  under  five  years,  and  the  young- 
est only  eighteen  months  old.  The  records  of  131  autopsies  on  tubercu- 
lous children  in  the  Pendlebury  Hospital,  show  that  haemoptysis  was  four 
times  a  cause  of  death ;  two  of  these  patients  were  under  five  years,  and 
one  was  only  twelve  months  old.  I  have  never  met  with  a  case  of  hemop- 
tysis under  five  years  old.  As  in  adults,  fatal  haemoptysis  is  usually  due 
to  the  opening  of  a  large  vessel  by  ulceration  in  the  wall  of  a  cavity,  which 
is  sometimes  in  the  lung  and  sometimes  in  one  of  the  bronchial  glands. 

The  respiration  in  all  cases  of  tuberculous  pneumonia  is  accelerated, 
and  usually  out  of  proportion  to  the  rise  in  temperature.  As  the  lung 
becomes  more  and  more  extensively  invaded  there  is  constant  dyspnoea. 
The  pulse  is  rapid  in  the  early  stage,  and  continues  so  throughout  the 
disease ;  toward  the  end  it  becomes  weak  and  irregular.  Irregular  respi- 
ration and  a  slow,  irregular  pulse,  may  occur  at  any  time  from  the  develop- 
ment of  cerebral  complications. 

Pleuritic  pains  in  the  chest  are  not  frequent  in  children.  Gastro-in- 
testinal  symptoms,  such  as  indigestion,  vomiting,  diarrhoea,  etc.,  are  gen- 
erally present,  but  are  not  peculiar  in  this  disease.  They  usually  depend 
upon  the  patient's  general  condition,  only  exceptionally  upon  tuberculous 
disease  of  the  stomach  or  intestines.  The  characteristic  symptoms  of 
intestinal  tuberculosis — abdominal  pain,  tenderness,  uncontrollable  diar- 
rhoea, and  intestinal  ha3morrhage — are  not  often  met  with  in  children 
under  five  years.  With  such  symptoms,  and  sometimes  when  they  are 
doubtful  or  absent,  careful  palpation  of  the  abdomen  may  disclose  the 
presence  of  enlarged  mesenteric  glands.  When  these  are  not  readily  felt 
through  the  abdominal  walls,  they  may  sometimes  be  discovered  by  a  rec- 
tal examination  after  the  method  of  Carpenter  (London). 

The  spleen  is  often  enlarged,  sometimes  very  much  so,  but  this  does 
not  occur  with  sufficient  frequency  to  be  of  much  diagnostic  value.  It 
may  be  due  to  tuberculous  deposits,  to  causes  connected  with  the  lungs  or 
heart,  or  to  fever.  The  liver  is  never  enlarged  from  tuberculous  de})08its, 
but  may  be  so  from  amyloid  or  fatty  degeneration,  or  from  obstructed 
circulation,  as  in  the  case  of  the  spleen. 

Dropsy  is  rare  and  seen  only  toward  the  close  of  the  disease.  It  may 
depend  upon  anemia,  upon  complicating  nephritis,  especially  amyloid  de- 


1084  THE   SPECIFIC   INFECTIOUS   DISEASES. 

generation,  upon  cardiac  or  pulmonary  conditions  leading  to  interference 
with  the  return  circulation,  or  upon  pressure  of  tuberculous  retro-perito- 
neal or  mesenteric  glands  upon  the  inferior  vena  cava.  Clubbing  of  the 
fingers  is  occasionally  seen  in  cases  running  a  very  protracted  course,  and 
is  due  to  obstructed  circulation. 

Anemia  is  commonly  associated  with  wasting,  and  it  is  of  special  im- 
portance where  the  latter  is  slight  or  absent.  It  is  a  frequent  sequel  of 
acute  disease  in  infancy  when  not  dependent  on  tuberculosis ;  when,  how- 
ever, it  is  associated  with  low  fever,  cough,  and  persistence  of  rales  in  the 
chest,  it  should  always  excite  apprehension. 

3.  Chronic  Tuberculous  Pneumonia. — In  young  children  this  is  a  chronic 
interstitial  pneumonia  associated  with  tuberculous  deposits.  These  cases 
have  usually  had  their  beginning  in  one  of  the  more  acute  forms  just  de- 
scribed. The  primary  attack  runs  a  tedious,  protracted  course;  there  is 
a  slow  convalescence  and  apparent  recovery,  although  this  is  not  complete. 
Often  a  slight  cough  remains,  or  returns  from  the  slightest  exposure  or 
other  exciting  cause.  The  child  does  not  regain  his  former  weight  or 
vigour,  and  careful  examination  of  the  lungs  shows  that  some  abnormal 
signs  remain.  There  are  frequently  present  feeble  breathing  and  slight 
dulness  over  the  affected  part  of  the  lung,  and  occasionally  friction- 
sounds  may  be  heard. 

After  a  few  months,  possibly,  the  child  has  another  attack  resembling 
the  first  and  running  the  same  tedious  course.  It  is  accompanied  by  fever, 
cough,  and  perhaps  there  is  a  fresh  consolidation  of  some  part  of  the  lung, 
generally  in  the  neighbourhood  of  the  old  disease.  All  active  symptoms 
finally  subside,  and  most  of  the  signs  of  recent  disease  disajDpear ;  but  it  is 
usually  found  then  that  the  lung  is  not  quite  in  so  good  condition  as  it 
was  before  this  second  illness.  The  acute  attacks  may  be  repeated  several 
times  and  pass  under  the  name  of  bronchitis,  broncho-pneumonia,  or 
pleurisy.  They  may  extend  over  a  period  of  two  or  three  years  or  even 
longer.  The  general  health  in  the  interval  is  not  good,  there  being  present 
in  most  cases  anasmia,  with  the  usual  symptoms  of  malnutrition  ;  the  chil- 
dren are  regarded  as  being  very  delicate. 

The  course  of  this  disease  thus  differs  in  no  essential  particulars  from 
that  of  simple  chronic  broncho-pneumonia  (page  579);  the  physical  signs 
likewise  are  identical  in  character,  although  they  may  differ  in  their  loca- 
tion. They  are  generally  found  in  the  same  situations  as  are  the  signs  in 
tbe  more  rapid  forms  of  pulmonary  tuberculosis  in  early  childhood.  A 
fatal  result  in  these  cases  is  usually  brought  about  in  one  of  three  ways: 
(1)  by  the  development  of  acute  tuberculous  pneumonia  or  miliary  tuber- 
culosis of  the  lungs,  occurring  with  the  symptoms  of  one  of  the  previous 
exacerbations  which  has  come  on  without  apparent  cause  or  perhaps  has 
followed  an  attack  of  measles  or  whooping-cough ;  (2)  by  tuberculous 
meningitis ;  (.3)  by  a  simple  acute  broncho-pneumonia. 


THE   CLINICAL   FORMS   OF   TUBERCULOSIS.  1085 

Physical  Signs  of  Tuberculous  Pneumonia. — Speaking  generally,  there 
is  no  difference  iu  a  young  child  between  the  signs  of  a  tuberculous  and 
those  of  simple  broncho-pneumonia  except  in  their  jDosition  ;  for  cavities, 
although  they  are  present  at  autopsy  in  most  of  the  cases,  are  very  rarely 
of  such  size  and  so  situated  as  to  be  recognised  during  life.  In  children 
over  seven  or  eight  years  old,  and  sometimes  in  those  of  five  or  six,  the 
signs  are  essentially  like  those  in  adults. 

By  reference  to  the  description  of  the  lesions  (page  lUGo)  it  will  be 
noted  that  the  upper  lobes  are  the  seat  of  the  most  advanced  disease  twice 
as  frequently  as  the  lower  lobes,  and  the  right  lung  rather  more  frequently 
than  the  left.  When  the  disease  is  in  the  upper  lobes  it  is  rarely  at  the 
extreme  apex,  and  when  it  is  in  the  lower  lobes  it  is  very  exceptional  to 
find  it  at  the  base,  posteriorly.  The  region  most  often  involved  is  the 
middle  zone  of  the  lung.  If  the  signs  appear  first  behind  they  are,  in  the 
great  majority  of  cases,  in  the  interscapular  space ;  if  in  the  lateral  part 
of  the  chest,  they  are  in  the  middle  or  upper  part  of  the  axilla ;  if  in 
front,  they  are  in  the  mammary  region,  more  frequently  above  than  below 
the  nipple,  but  rarely  extending  quite  to  the  clavicle.  In  other  words,  it 
is  near  the  root  of  the  lung  that  the  disease  most  frequently  begins,  spread- 
ing thence  forward  more  often  than  backward.  The  explanation  of  this 
is  found  in  the  fact  that  the  disease  in  infants  and  young  children  so  often 
extends  from  the  lymph  nodes  at  the  root  of  the  lung  to  the  lung  itself. 
The  physical  signs  themselves  may  be  grouped  under  four  heads,  corre- 
sponding to  the  pathological  conditions  existing  in  the  various  stages 
of  the  disease — viz.,  (1)  localized  bronchitis;  (2)  partial  consolidation; 
(3)  complete  consolidation  ;  (4)  excavation.  The  early  signs  in  the  fii'st 
two  stages  are  identical  with  those  described  in  broncho-pneumonia  (page 
499),  those  of  the  third  stage  being  the  signs  of  the  persistent  form  (page 
502).  As  a  rule,  however,  the  transition  of  the  signs  from  one  stage  to 
another  is  much  slower  in  tuberculous  than  in  simple  broncho-pneumonia. 

As  stated  in  the  description  of  the  lesions,  cavities  are  found  in  the 
lungs  in  the  majority  of  cases  of  infants  dying  from  tuberculosis  of  the  lungs. 
It  is,  however,  rare  that  they  can  be  recognised  in  children  under  three 
years  old.  From  three  to  eight  years  they  give  more  positive  signs,  and 
after  eight  years  practically  the  same  signs  as  in  adults.  The  reason  why 
in  infancy  cavities  are  so  seldom  recognised  during  life  is  because  they 
are  generally  small,  often  centrally  located,  nearly  always  filled  with  thick 
pus  or  cheesy  matter,  and  rarely  communicate  freely  with  the  bronchi. 
On  the  other  hand,  it  is  very  common  to  find  signs  in  young  children 
which,  if  heard  in  adults,  would  be  regarded  as  almost  positive  evidence  of 
a  cavity,  although  none  is  present.  These  signs  are  cracked-pot  reso- 
nance and  cavernous  breathing.  They  are  not  usually  due  to  bronchi- 
ectasis, since  this  condition  belongs  to  chronic  cases,  and  especially  to 
older  children;  but  most  frequently  to  consolidation  about  a  large  bron- 
70 


3^086  THE   SPECIFIC   INFECTIOUS  DISEASES. 

chus  superficially  situated — viz.,  below  the  clavicle,  high  in  the  axilla  and 
in  the  interscapular  region.  The  wide  area  over  which  this  broncho-cav- 
ernous breathing  is  heard,  is  one  of  the  most  striking  points  of  difference 
from  the  signs  of  a  cavity. 

Course,  Duration,  and  Termination. — Whatever  may  be  the  evolution 
of  the  symptoms,  and  the  variations  are  almost  endless,  the  cases  fall  readily 
into  two  groups, — those  in  which  the  progress  is  rapid  and  steady  and  those 
in  which  it  is  slow  and  intermittent.  The  duration  of  the  first  group  is 
from  four  to  eight  weeks.  Fever  is  constant,  wasting  progressive,  and  the 
physical  signs  show  a  steady  advance  of  the  disease  in  the  lungs.  Dyspnoea 
becomes  severe  and  constant ;  the  pulse  grows  more  and  more  rapid  and 
feeble ;  and  death  occurs  from  exhaustion,  pulmonary  oedema,  or  syncope, 
less  frequently  from  meningitis. 

In  the  second  group  the  duration  is  from  two  to  twelve  months.  The 
course  can  not  better  be  described  than  as  a  succession  of  attacks  of 
broncho-pnenmonia,  sometimes  separated  by  an  interval  of  several  weeks, 
at  other  times  one  coming  on  before  the  first  is  fairly  over.  During 
exacerbations  the  symptoms  resemble  those  of  the  first  form,  there  being 
marked  fever,  wasting,  cough,  and  dyspnoea.  The  child  may  seem  hope- 
lessly ill  when,  without  any  special  reason,  a  change  for  the  better  occurs, 
the  acute  symptoms  abating  and  the  signs  of  consolidation  in  great  meas- 
ure disappearing.  Toward  the  end  of  the  disease  the  pulmonary  and 
constitutional  symptoms  become  constant,  and  frequently  there  are  added 
symptoms  due  to  extension  of  the  tuberculous  process  to  other  parts  of 
the  body — the  brain,  peritonseum,  intestines,  mesenteric  glands,  etc. 
These  cases  die,  as  do  the  more  acute  ones,  from  the  local  disease  in 
the  lungs  or  from  general  infection. 

Diagnosis. — The  evidence  upon  which  a  diagnosis  of  tuberculosis  is 
made,  is  of  two  kinds — that  which  relates  to  the  patient  and  that  which 
relates  to  the  local  disease.  In  any  case,  a  diagnosis  is  reached  by  weigh- 
mg  the  evidence  as  a  whole  rather  than  by  relying  upon  the  presence  of 
particular  symptoms  or  physical  signs.  One  should  investigate  the  family 
historv,  surroundings,  and  previous  condition  of  the  patient;  also  the 
mode  of  onset,  and  course  of  the  disease,  and  consider  the  evidence 
afforded  by  the  examination  of  the  patient. 

A  careful  examination  of  the  family  history  should  be  made  to  deter- 
mine, first,  the  existence  of  phthisis  in  the  parents  or  in  other  members 
of  the  family,  near  or  remote.  Children  more  often  inherit  a  predis- 
position from  the  mother  than  from  the  father,  and  are  more  likely  to 
contract  it  from  her,  owing  to  the  closer  contact.  It  is  not  enough  sim- 
ply to  investigate  the  question  of  phthisis.  Inquiry  should  be  made  re- 
garding meningitis,  disease  of  the  cervical  glands,  spine,  hip,  knee,  or 
ankle,  especially  in  the  other  children  of  the  family.  These  points  are 
important  not  only  to  establish  the  fact  of  heredity  but  also  the  probable 


THE  CLINICAL  FORMS  OF  TUBERCULOSIS.  1087 

chances  of  exposure.  Other  conditions  favourable  for  acquiring  the  dis- 
ease should  he  considered,  such  as,  in  a  private  family,  exposure  to  nurses 
or  other  members  of  the  household;  also  whether  the  surroundings  have 
been  such  as  would  give  opportunities  for  infection,  as  in  cases  where 
a  child  has  been  reared  in  a  tenement  house,  or  has  been  long  an  inmate 
of  a  hospital  or  other  institution.  In  the  child's  previous  history,  it  is 
important  to  know  whether  there  have  been  other  manifestations  of 
tuberculosis  in  the  cervical  glands,  spine,  hip,  knee,  or  ankle,  or  the 
skin;  also  whether  he  has  been  liable  to  attacks  of  severe  or  protracted 
bronchitis  or  broncho-pneumonia.  If  he  has  had  measles  or  pertussis, 
it  is  important  to  know  whether  they  were  severe,  accompanied  by  pul- 
monary complications,  or  followed  by  a  protracted  cough  or  obscure  fever. 
The  child's  general  constitution  should  be  considered,  w^hether  he  is 
delicate,  narrow-chested,  poorly  nourished,  or  anaemic. 

In  its  symptoms  and  course  it  is  with  simple  broncho-pneumonia  that 
tuberculous  disease  is  likely  to  be  confounded.  The  onset  of  simple 
pneumonia  is  usually  rapid  and  often  abrupt;  tuberculous  pneumonia 
more  frequently  develops  gradually  with  constitutional  s3anptoms  pre- 
ceding the  local  ones  by  several  days  or  even  weeks.  When  tuberculosis 
develops  rapidly,  the  pulmonary  symptoms  and  the  physical  signs  may 
be  identical  in  the  two  conditions.  One  is  often  struck  during  the  acute 
stage  with  the  disproportion  between  the  general  symptoms — loss  of 
flesh,  prostration,  and  temperature — and  the  local  evidences  of  pulmo- 
nary disease.  When  the  patient  dies  in  the  early  acute  stage  the  disease 
is  rarely  recognised,  nor,  indeed,  can  it  be  diagnosticated  with  certainty. 
Usually  it  is  not  until  the  time  for  resolution  to  occur  that  the  course 
of  the  disease  suggests  something  different  from  broncho-pneumonia. 
The  question  then  arises  whether  we  have  to  deal  with  a  case  of  per- 
sistent broncho-pneumonia  or  with  tuberculosis.  It  should  be  remem- 
bered that  it  is  not  infrequent  for  simple  broncho-pneumonia  to  resolve 
slowly  or  to  go  on  to  the  development  of  chronic  interstitial  pneumonia; 
and  that  local  conditions  as  determined  by  physical  signs,  which  in  adults 
would  be  regarded  as  certainly  tuberculous,  very  often  in  children  are 
simple  processes. 

Often  the  course  of  the  disease,  after  the  first  acute  period  has  passed, 
furnishes  further  evidence  to  clear  up  the  diagnosis;  but  not  necessarily, 
for  in  tuberculosis  it  may  be  steadily  downward,  or  it  may  be  marked  by 
periods  of  remission  and  exacerbation,  and  the  same  is  true  of  simple 
]meuraonia.  Fever  is  a  more  constant  symptom  in  tuberculosis,  and  it 
is  usually  higher  than  in  ])ersistent  broncho-pneumonia;  but  the  excep- 
tions are  so  many  and  the  variations  so  wide  that  it  is  not  safe  in  young 
children  to  lay  very  much  stress  upon  the  temperature  curve.  Anaemia 
and  wasting  are  more  marked  in  tuberculosis,  and  in  most  cases  pro- 
gressive.   A  copious  muco-purulcnt  ex]iectoration  is  seen  almost  as  fre- 


1088  THE  SPECIFIC  INFECTIOUS  DISEASES. 

quently  in  pneumonia  as  in  tuberculosis;  but  in  neither  disease  is  it 
common  under  five  years.  The  presence  of  the  bacillus  tuberculosis  in 
the  sputum  is,  of  course,  positive  evidence  of  tuberculosis. 

With  infants  and  young  children  the  only  satisfactory  method  of 
obtaining  the  sputum  for  examination  is  to  pass  the  stomach-tube  well 
into  the  oesophagus,  and  stain  the  mucous  which  adheres  to  it  when  with- 
drawn. This  procedure,  first  employed  I  think  in  the  Babies'  Hospital, 
has  been  in  constant  use  by  us  in  that  institution  for  several  years  with 
the  most  satisfactory  results. 

Simple  broncho-pneumonia  may  affect  any  part  of  the  lungs,  but  by 
preference  the  lower  lobes  posteriorly.  The  signs  of  tuberculosis  may 
likewise  be  found  anywhere,  but  most  frequently  in  the  anterior  part  of 
the  lung,  the  mammary  region,  the  axillary  margin,  or  the  apex;  if  pos- 
terior, the  signs  are  usually  at  the  apex  or  in  the  interscapular  region. 
From  the  character  of  the  physical  signs,  no  inference  can  be  drawn  un- 
less a  cavity  can  be  positively  made  out;  but  when  the  process  has 
advanced  to  that  stage,  the  diagnosis  is  generally  plain  from  the  general 
symptoms. 

Tuberculin  with  older  children  is  quite  as  useful  for  diagnosis  as  with 
adults.  With  infants  and  very  young  children,  on  account  of  the  well- 
marked  fever  which  is  usually  present,  it  is  less  frequently  applicable. 

Meningitis  developing  during  a  pulmonary  disease  of  doubtful  char- 
acter, is  generally  tuberculous,  and  its  occurrence  is  usually  to  be  inter- 
preted as  establishing  the  tuberculous  nature  of  the  process  in  the  lungs. 
The  development  of  cheesy  lymph  glands  in  the  neck,  the  groin,  or  axilla, 
or  the  presence  of  symptoms  pointing  to  enlargement  of  the  bronchial 
glands,  or  those  of  chronic  peritonitis  with  or  without  ascites,  or  intes- 
tinal haemorrhage — all  point  strongly  to  tuberculosis. 

If  the  acute  symptoms  begin  during  measles  and  persist,  they  may  be 
due  either  to  broncho-pneumonia  or  to  tuberculosis.  If,  however,  they 
begin  insidiously  during  convalescence  from  measles,  they  are  very  prob- 
ably due  to  tuberculosis.  If  the  symptoms  begin  acutely  during  per- 
tussis, they  may  be  due  to  simple  broncho-pneumonia  or  a  tuberculous 
process;  but  if  they  develop  gradually  and  insidiously  after  pertussis, 
the  disease  is  probably  tuberculosis.  It  should  not  be  forgotten,  however, 
that  it  is  not  uncommon  for  simple  broncho-pneumonia  occurring  with 
pertussis,  to  persist  two  or  three  months,  or  until  the  attack  of  pertussis 
has  subsided. 

If  the  child  was  previously  healthy  and  living  in  good  surroundings, 
and  if  the  disease  began  with  acute  s5^mptoms,  the  process  is  simple 
pneumonia  in  nine  cases  out  of  ten,  no  matter  how  irregular  its  course, 
how  prolonged  its  duration,  or  what  the  physical  signs.  Still,  after  all 
has  been  said,  the  diagnosis  is  in  all  cases  difficult,  and  in  some,  par- 
ticularly the  more  chronic  ones,  a  positive  diagnosis  is  impossible,  as 


THE   CLINICAL   FORMS   OF   TUBERCULOSIS.  l(lS9 

no  one  knows  so  well  as  he  who  has  an  opportunity  to  follow  his  cases 
to  antops}'. 

III.  Chroxic  Phthisis. — This  form  of  tuberculosis,  with  its  chronic 
hectic  fever,  slow  cavity  formation,  progressive  emaciation,  night  sweats, 
etc.,  is  very  rarely  seen  before  the  fifth  year,  and  it  is  not  at  all  frequent 
until  the  tenth  or  twelfth  year.  In  its  symptoms,  course,  termination, 
and  physical  signs,  it  resembles  the  same  disease  in  adults,  and  need  not 
be  described  at  length  here. 

IV.  Tuberculosis  of  the  Broistchial  Lymph  Nodes  (Bronchial 
Glands). — This  condition  is  usually  associated  with  some  form  of  pul- 
monary tuberculosis,  but  it  may  exist  as  the  most  important  and  some- 
times as  the  only  tuberculous  lesion. 

Its  symptoms  are  usually  associated  with  those  of  pulmonary  or  gen- 
eral tuberculosis ;  but  they  may  occur  when  the  pulmonary  changes  are 
too  few  to  be  recognised  either  by  symptoms  or  physical  signs.  From  the 
great  frequency  with  which  this  lesion  is  found  in  infants  and  young  chil- 
dren, it  might  be  expected  that  local  symptoms  would  be  common  in  such 
patients.  They  are,  however,  in  my  experience,  quite  exceptional.  Most 
of  the  cases  in  which  well-marked  symjDtoms  occur  are  in  children  over 
two  years  old,  and  it  is  between  the  third  and  tenth  years  that  they  are 
usually  seen.  In  infancy,  although  these  glands  are  almost  invariably 
affected,  death  in  the  great  majority  of  cases  occurs  from  the  pulmonary 
disease,  before  the  later  changes  in  the  glands  have  had  time  to  develop. 

General  symptoms  indicating  a  tuberculous  cachexia  may  or  may  not 
precede  the  local  ones.  The  latter  are  chiefly  mechanical,  and  depend 
upon  the  size  of  the  glands  and  upon  their  anatomical  relations,  and  very 
little  or  not  at  all  upon  the  nature  of  the  changes  in  them.  The  most 
important  relations,  so  far  as  the  production  of  symptoms  is  concerned, 
are  those  which  they  bear  to  the  pneumogastric  and  recurrent  laryngeal 
nerves,  the  superior  vena  cava,  the  trachea,  and  bronchi ;  those  less  impor- 
tant are  to  the  aorta,  pulmonary  artery,  and  oesophagus. 

Pressure  upon  or  irritation  of  the  pneumogastric  or  recurrent  nerves 
produces  cough,  dyspnoea,  and  sometimes  a  change  in  the  voice.  The  cough 
is  hoarse,  persistent,  and  teasing,  and  frequently  occurs  in  paroxysms  which 
in  many  respects  resemble  those  of  pertussis,  but  it  lacks  the  characteristic 
whoop,  and  is  not  accompanied  by  the  expectoration  of  the  mass  of  tena- 
cious mucus.  These  paroxysms  are  severe  and  often  prolonged,  but  careful 
observation  shows  distinct  differences  from  those  of  pertussis,  though  by 
an  unfamiliar  ear  the  two  are  easily  confounded.  The  dyspnoea,  like  the 
cough,  is  paroxysmal,  and  sometimes  strongly  resembles  ordinary  spas- 
modic croup ;  at  other  times  it  is  like  a  severe  attack  of  asthma.  Such 
symptoms  may  come  and  go,  but  they  are  frequently  prolonged,  and  usu- 
ally in  the  interval  between  the  severe  seizures  the  patient  is  not  wholly 
free  from  dyspnoea.     Although  the  chief  cause  of  dyspnoea  is  no  doubt 


1090  THE   SPECIFIC   INFECTIOUS   DISEASES. 

nerve  irritation,  it  may  be  due  in  part  to  pressure  upon  the  trachea  or  one 
of  the  large  bronchi.  In  dyspncea  from  pressure  on  the  tracliea  the  head 
is  usually  thrown  back,  and  the  obstruction  is  more  frequently  on  expira- 
tion than  on  inspiration. 

x\fter  such  symptoms  as  those  mentioned  have  existed  for  a  few  days 
or  weeks,  and  in  some  cases  without  any  warning,  there  may  occur  a  sud- 
den attack  of  asphyxia  which  may  prove  fatal.  This  is  generally  due  to 
ulceration  of  a  caseous  gland  into  the  trachea  or  a  large  bronchus  and  the 
escape  of  a  large  mass  into  the  air  passages,  where  it  produces  the  same 
effects  as  any  other  foreign  body. 

Loeb  has  collected  fifteen  cases  of  this  description,  a  summary  of 
which  gives  a  good  idea  of  the  circumstances  under  which  this  accident 
usually  occurs :  In  four  cases  death  took  place  in  the  first  attack  of  suffo- 
cation, the  only  previous  symptom  having  been  cough ;  in  three  there 
had  been  a  number  of  milder  attacks  extending,  in  two  of  the  cases,  over 
a  considerable  period  before  the  occurrence  of  the  fatal  one ;  in  three, 
death  occurred  in  the  first  attack,  in  children  who  had  no  previous  cough 
and  who  were  apparently  healthy  ;  in  one,  the  fatal  attack  came  on  during 
pertussis.  In  the  majority  of  the  cases,  death  followed  in  from  five  to  ten 
minutes  from  the  first  symptom ;  in  a  few  the  patients  lived  for  an  hour. 
In  rare  cases  after  ulceration  into  the  trachea,  the  patient  has  coughed  up 
a  large  quantity  of  foul  pus,  and  recovered. 

Pressure  upon  the  superior  vena  cava  is  usually  associated  with  spas- 
modic dyspnoea  and  cough,  and  causes  cyanosis  of  the  face  and  blueness 
of  the  lips.  There  is  frequently  a  puffiness  of  the  face,  and  there  may  be 
marked  oedema.  The  coexistence  of  cyanosis  with  such  oedema,  when  the 
urine  is  free  from  signs  of  renal  disease,  should  always  lead  one  to  suspect 
pressure  at  the  root  of  the  lung.  In  some  rare  cases  the  interference  with 
the  return  circulation  has  been  so  marked  that  meningeal  haemorrhage 
has  resulted.  By  a  process  of  ulceration  set  up  by  these  glands  they  may 
open,  not  only  into  the  air  passages,  but  into  the  pericardium,  the  oesopha- 
gus, or  any  of  the  large  vessels.  The  last  mentioned  is  usually  followed 
by  instant  death.  Aldibert  reports  two  cases  in  which  the  pulmonary 
artery  was  opened,  death  occurring  from  haemoptysis,  as  there  was  also  a 
communication  with  one  of  the  large  bronchi.  In  Vogel's  case  the  sub- 
clavian vein  was  perforated,  and  death  resulted  from  the  entrance  of  air. 
If  ulceration  takes  place  into  the  surrounding  connective  tissue,  a  medias- 
tinal abscess  may  result,  producing  any  of  the  pressure  symptoms  noted 
above,  and,  in  addition,  dysphagia  from  pressure  on  the  oesophagus.  Such 
an  abscess  may  point  in  the  supra-sternal  notch ;  it  may  open  through  the 
chest  anteriorly  between  the  ribs  or  at  the  xiphoid  cartilage ;  or  it  may 
burrow  along  the  oesophagus  to  the  peritoneal  cavity.  As  a  rule,  however, 
patients  die  of  general  tuberculosis  before  the  local  conditions  have  ad- 
vanced so  far. 


THE   CLINICAL   FORMS   OF   TUBERCULOSIS.  1091 

Physical  Signs. — In  order  to  produce  physical  signs,  the  mass  of  tuber- 
culous lymph  uodes  must  be  large  enough  to  form  a  mediastinal  tumour, 
or  so  situated  as  to  produce  pressure  on  the  trachea  or  bronchi.  As  a  rule, 
the  signs  are  more  characteristic  behind  than  in  front.  Percussion  may 
give  dulness  anteriorly  over  the  first  piece  of  the  sternum  or  posteriorly 
along  one  or  both  sides  of  the  spine  from  the  second  to  the  fifth  dorsal 
vertebra ;  the  dulness  is  rarely  complete.  Auscultation  posteriorly  may 
give  in  the  most  marked  cases  amphoric  or  cavernous  breathing,  or  exag- 
gerated bronchial  breathing  with  prolonged  expiration,  in  those  which 
are  less  pronounced.  Large,  moist  rdles  are  sometimes  heard.  The  aus- 
cultatory signs  are  so  like  those  of  a  cavity  that  it  is  often  difficult  to 
believe  that  a  cavity  does  not  exist.  The  sounds  heard  appear  to  be  those 
produced  in  the  trachea  and  bionchi  transmitted  to  the  ear  with  great 
exaggeration  by  the  mass  of  lymph  nodes  which  surrounds  them  and 
fills  the  space  between  them  and  the  chest  wall.  When  the  head  is  thrown 
back  a  venous  hum  may  sometimes  be  heard.  If  one  of  the  primary  bron- 
chi or  one  of  its  lobar  divisions  is  compressed,  there  may  be  very  feeble 
respiration  over  one  lung  or  one  lobe ;  if  the  pressure  is  sufficient  to  pre- 
vent the  entrance  of  air,  or  if  one  of  these  large  tubes  has  been  plugged 
by  a  caseous  mass,  there  is  an  absence  of  respiratory  murmur  over  a  single 
lobe  or  an  entire  lung.  This  sign  is  of  great  diagnostic  value,  but  it  is 
not  often  present. 

Diagnosis. — Enlargement  of  the  bronchial  glands  to  a  sufficient  degree 
to  produce  symptoms,  may  occur  in  syphilis,  in  Hodgkin's  disease,  and  in 
various  forms  of  malignant  disease  of  the  mediastinum.  A  certain  amount 
of  swelling  is  seen  in  nearly  all  cases  of  simple  bronchitis  or  jDneumonia, 
especially  in  those  running  a  subacute  or  chronic  course.  AVhether  this 
simple  hyperplasia  is  ever  sufficient  to  cause  such  symptoms  as  those  men- 
tioned is  exceedingly  doubtful.  I  have  myself  never  known  it  to  jiro- 
duce  anything  more  marked  than  a  spasmodic  cough.  The  great  infre- 
quency  of  other  forms  of  enlargement  to  a  sufficient  degree  to  be  of 
clinical  importance,  usually  warrants  us,  from  the  symptoms  mentioned, 
in  rhaking  the  diagnosis  of  tuberculosis.  The  development  in  a  child  of 
a  chronic  abscess  in  the  anterior  mediastinum,  is  almost  always  due  to 
tuberculous  glands;  and  so  is  one  in  the  posterior  mediastinum,  provided 
Pott's  disease  can  be  excluded. 

The  most  important  points  for  diagnosis  are  the  association  of  a  spas- 
modic cough  with  paroxysms  of  dyspnoea  resembling  asthma  or  croup, 
and  oedema  or  congestion  of  the  face.  More  stress  is  to  be  laid  upon 
the  symptoms  than  upon  the  physical  signs ;  the  latter  are  at  most  only 
confirmatory.  The  chief  difficulty  in  diagnosis  is  found  in  tliose  cases 
which  present  few  or  no  other  signs  of  tuberculosis,  and  which  come  first 
under  observation  with  attacks  of  dyspnoea  or  asphyxia  resembling  laiyn- 
geal  stenosis.     In  many  such  cases  tracheotomy  has  been  done  without 


1092  THE   SPECIFIC  INFECTIOUS  DISEASES. 

finding  any  cause  for  the  dyspnoea,  the  autojDsy  showing  it  to  be  due  to 
ulceration  and  impaction  of  a  caseous  gland. 

General  Prognosis  of  Tuberculosis. — The  outlook  for  a  young  child 
with  general  or  pulmonary  tuberculosis  is  always  bad.  So  long  as  the 
disease  remains  confined  to  the  lymph  nodes,  the  child  is  not  usually  in 
danger,  except  from  accidents  connected  with  their  softening  and  ulcer- 
ation, which  after  all  are  rare.  Spontaneous  cure  may  occur  in  these 
glands  in  the  same  way  as  in  others  in  the  body — viz.,  by  encapsula- 
tion, calcification,  etc.  Such  a  result  is  no  doubt  a  very  frequent  one ; 
exactly  how  often  it  occurs  it  is  impossible  to  say.  But  when  once  the 
disease  has  gained  any  headway  in  the  lung  itself,  its  steady  advance  is 
almost  certain  in  a  young  child.  In  those  who  are  older  and  have  more 
resistance  the  chances  of  an  arrest  of  the  process  are  much  greater. 

If  the  bacilli  have  gained  entrance  into  the  body  in  any  considerable 
numbers,  even  though  they  are  shut  up  in  an  encapsulated,  caseous, 
bronchial  gland,  the  patient  is  never  free  from  the  danger  of  general 
infection. 

Prophylaxis. — The  prevention  of  tuberculosis  must  have  constant  ref- 
erence to  its  cause.  The  first  essential  is  the  destruction  of  the  tubercle 
bacilli  wherever  they  exist.  Since  most  of  the  germs  existing  in  the  air 
are  derived  from  the  sputum  of  patients  affected  with  joulmonary  tuber- 
culosis, it  should  be  insisted  upon,  everywhere  and  at  all  times,  that  the 
sputum  from  such  cases  should  be  collected  in  special  cups  or  cloths  and 
destroyed  either  by  germicides  or  by  fire.  The  next  point  is  to  avoid 
needless  exposure.  A  tuberculous  mother  should  on  no  account  nurse 
her  child  nor  kiss  it  upon  the  mouth.  A  wet-nurse  likewise  should  be 
free  from  any  tuberculous  taint.  Xo  narse  or  other  care-taker  should 
ever  be  employed  about  children  who  has,  or  ever  has  had,  pulmonary 
tuberculosis.  It  is  wise  to  exclude  also  those  who  suffered  when  children 
from  tuberculosis  of  the  bones  or  the  cervical  glands,  although  the  dan- 
ger from  such  persons  is  extremely  slight.  If  active  tuberculosis  exists  in 
any  member  of  the  family,  a  young  child  should  be  kept  away  from  the 
room,  and  if  possible  should  not  reside  in  the  house.  On  no  account 
should  infected  persons  be  allowed  to  kiss  children  or  sleep  in  the  same 
bed  with  them.  The  danger  from  drinking-cups  and  other  dishes  should 
not  be  forgotten.  A  tuberculous  person  should  either  have  his  special 
dishes,  or  the  utmost  care  should  be  taken  to  boil  all  those  which  he  has 
used.  Cows  whose  milk  is  used  for  children  should  be  under  regular  veteri- 
nary inspection  and  should  have  passed  the  tuberculin  test.  In  any  case 
where  the  slightest  doubt  regarding  the  health  of  the  cows  exists,  or  where 
the  source  of  the  milk  is  unknown,  the  milk  should  be  heated  to  a  tem- 
perature of  155°  F.  for  thirty  minutes.  The  danger  of  infection  through 
the  alimentary  canal  is  very  much  less  than  through  the  respiratory  tract, 
and  consequently  the  precautions  first  mentioned  are  much  more  impor- 


THE  CLINICAL  FORMS  OF  TUBERCULOSIS.  1093 

tant  than  those  relating  to  the  food,  although  the  latter  should  on  no 
account  be  neglected. 

In  the  case  of  delicate  children  and  those  of  tuberculous  parents  or 
with  other  tuberculous  relatives,  everything  possible  should  be  done  to 
fortify  them  against  the  disease.  They  should  be  kept  under  more  or  less 
constant  medical  supervision  as  regards  their  clothing,  manner  of  life, 
etc.,  and  should  take  cod-liver  oil  every  winter.  Every  attack  of  bron- 
chitis or  broncho-pneumonia  should  be  watched  with  the  greatest  solici- 
tude. Exposure  to  measles  or  pertussis  should  especially  be  avoided.  The 
country  rather  than  the  city  should  be  chosen  for  residence,  and  the  child 
should  spend  the  winter  and  spring  in  some  warm,  dry  climate,  such  as 
that  of  southern  California,  the  interior  of  South  Carolina  or  Georgia, 
or  Lakewood,  IST.  J.  Parents  should  be  distinctly  taught  that  watchful- 
ness and  care  do  not  mean  coddling  or  the  keeping  of  children  in  the 
house  the  greater  part  of  the  time.  Such  children  should  live  as  much 
as  possible  in  the  open  air,  and  every  form  of  sport  encouraged  which 
tends  to  keep  them  there.  Overheated  houses  are  one  of  the  most  pro- 
lific agencies  in  perpetuating  a  delicate  condition  of  health.  Plenty  of 
fresh  air  in  sleeping  apartments  should  always  be  insisted  upon.  All 
catarrhal  troubles  of  the  nose  and  pharynx  should  receive  early  and 
prompt  attention,  especially  should  hypertrophied  tonsils  and  adenoid 
growths  of  the  pharynx  be  removed,  since  these  are  conditions  which 
form  a  most  favourable  nidus  for  the  growth  of  tubercle  bacilli. 

Treatment  of  General  and  Pulmonary  Tuberculosis. — If  fresh  air  and  a 
proper  climate  are  necessary  for  the  cure  of  this  disease  in  adults,  they  are 
tenfold  more  necessary  in  the  case  of  children.  Without  them  there  is 
little  hope  for  a  child  with  active  pulmonary  tuberculosis.  Nowhere  do 
these  cases  do  so  badly  as  in  a  hospital  located  in  a  city,  and  no  class  of 
hospital  cases  do  worse  than  these.  The  same  regions  that  are  beneficial 
for  adult  cases  usually  agree  with  children,  with  the  exception  that  the 
latter,  as  a  rule,  do  better  in  a  warm  than  in  a  cold  climate.  Plenty  of 
fresh  air  and  sunshine  are  essential.  A  child  must  be  where  he  can  be 
kept  in  the  open  air  for  at  least  several  hours  each  day,  in  spite  of 
fever,  cough,  or  other  acute  symptoms. 

For  the  most  acute  cases  where  the  children  are  confined  to  the  bed, 
the  largest,  best-ventilated,  and  sunniest  room  available  should  be  secured, 
and  a  window  should  be  open  the  greater  part  of  the  time.  The  general 
management  of  such  cases  is  the  same  as  for  those  with  acute  pneumonia. 

No  specific  remedy  for  tuberculosis  has  as  yet  stood  the  test  of  expe- 
rience. The  diet  is  a  matter  of  the  utmost  importance.  Tuberculous 
patients  must  be  fed  like  most  other  sick  children,  care  being  taken  not  to 
disturb  the  digestion  by  the  unnecessary  use  of  drugs.  For  a  staple  article 
of  diet,  milk  is  the  best,  and  where  this  is  not  well  borne  some  of  its  sub- 
stitutes— kumyss,  matzoon,  etc. — may  be  tried.     Cream  is  almost  as  use- 


1094  THE   SPECIFIC   INFECTIOUS   DISEASES. 

ful  as  cod-liver  oil,  and  sliould  be  given  in  one  form  or  another  whenever 
the  child  can  take  it. 

The  two  drugs  which  are  most  useful  are  creosote  and  cod-liver  oil. 
Creosote  may  be  given  both  by  the  stomach  and  by  inhalation,  as  in  cases 
of  pneumonia.  By  the  stomach  there  may  be  used  for  older  children,  the 
shellac-coated  pills  containing  one  or  two  drops  of  creosote ;  for  those 
who  are  younger,  it  may  be  given  in  combination  with  the  liquid  pepto- 
noids  or  in  an  emulsion  with  cod-liver  oil.  It  is  seldom  possible  to  give 
as  a  single  dose  more  than  half  a  drop  to  a  child  of  two  years ;  one  of 
five  years,  two  drops  may  often  be  given.  It  should  be  continued  for  a 
long  period.  Cod-liver  oil  is  usually  best  given  in  a  fresh  emulsion,  al- 
though some  children  bear  the  pure  oil  better  than  any  other  prepara- 
tion. Inunctions  of  this  or  other  oils  are  of  some  value  when  it  is  not  well 
tolerated  by  the  stomach.  Arsenic,  iron,  and  the  compound  syrup  of  the 
hypophosphites  are  all  useful  as  general  tonics,  but  as  specifics  their  ac- 
tion is  very  questionable. 

When  symptoms  jDointing  to  tuberculosis  of  the  bronchial  glands  are 
present,  the  syrup  of  the  iodide  of  iron  should  be  used  in  the  same  way  as 
in  disease  of  the  cervical  glands.  When  they  ulcerate  into  the  trachea  or 
larger  bronchi,  they  generally  cause  death,  no  matter  what  is  done.  There 
are  on  record  a  few  cases  in  which  tracheotomy  has  been  of  service  in  this 
condition,  but  in  the  great  majority  it  accomplishes  nothing. 


CHAPTEE    XI. 
SYPHILIS. 

Syphilis  is  a  communicable  disease  due  to  a  specific  poison.  Al- 
though all  indications  point  to  the  fact  that  this  is  a  micro-organism,  its 
nature  is  as  yet  unknown. 

In  infancy  and  childhood  both  the  acquired  and  the  hereditary  forms 
of  syphilis  are  seen. 

ACQUIRED  SYPHILIS. 

While  acquired  syphilis  is  very  much  less  frequent  than  the  heredi- 
tary variety,  it  is  by  no  means  a  rare  disease  in  early  life.  It  is  not  im- 
probable that  some  of  the  manifestations  of  syphilis  in  later  childhood 
which  are  usually  denominated  "  late  hereditary  syphilis,"  are  really 
due  to  the  acquired  form. 

Etiology. — An  infant  may  be  infected  by  its  mother  during  parturi- 
tion; but  this  is  extremely  rare  and  can  take  place  only  when  there 
are  lesions  upon  the  mother's  genitals.     Infection  is  more  likelv  to 


HEREDITARY  SYPHILIS.  1095 

be  from  a  mother  who  contracts  syphilis  subsequently  to  the  birth  of 
the  child,  and  may  occur  through  nursing  or  accidental  contact  by 
kissing,  etc.  In  either  of  these  ways  children  may  be  infected  by  wet- 
nurses,  or  from  a  venereal  sore  upon  the  nipple.  Whether  syphilis  can 
be  communicated  through  the  milk  when  the  nipple  is  perfectly  healthy 
and  free  from  fissures,  is  somewhat  doubtful. 

Syphilis  may  be  communicated  directly  from  a  syphilitic  child  to  one 
who  is  healthy  by  kissing,  sexual  contact,  or  indirectly  by  means  of  bot- 
tles, spoons,  cups,  clothing,  etc.  The  latter  mode  of  infection  is  most 
likely  to  occur  in  institutions.  Vaccination  was  formerly  a  not  infre- 
quent mode  of  communicating  syphilis,  but  since  the  general  introduc- 
tion of  bovine  virus  this  is  very  rarely  seen.  Cases  have  been  recorded 
by  Taylor,  Hutchinson,  and  others  where  the  disease  has  been  conveyed 
by  the  rite  of  circumcision,  either  from  the  mouth  or  the  instruments  of 
the  operator. 

The  relative  frequency  of  the  different  sources  of  infection  is  shown 
by  Fournier's  statistics  of  forty  cases  :  The  source  of  infection  was  the 
parents  in  nineteen ;  nurses,  in  eight;  servants,  in  four;  sexual  contact, 
in  four ;  vaccination,  in  two ;  other  children,  in  two  ;  a  physician,  in  one. 
The  ages  at  which  the  disease  was  acquired  in  this  series  of  cases  were  as 
follows :  during  the  first  year,  nineteen ;  during  the  second  year,  ten  ; 
during  the  third  and  fourth  years,  seven ;  from  the  fifth  to  the  fourteenth 
years,  six. 

Symptoms. — The  symptoms  of  acquired  syphilis  in  children  are  in  all 
respects  similar  to  the  same  disease  in  the  adult.  A  primary  sore  is  pres- 
ent at  the  site  of  infection,  which  is  most  frequently  the  lips,  the  mouth 
or  some  part  of  the  face ;  very  rarely  is  it  seen  on  the  genitals.  There 
are  very  few  individual  symptoms  belonging  to  hereditary  syphilis  which 
may  not  also  be  present  when  the  disease  is  acquired.  Its  course,  how- 
ever, is  very  much  milder  in  the  latter  and  a  fatal  termination  is  rare. 
Fournier  states  that  of  his  forty-two  cases  only  one  died  of  marasmus. 
This  marked  contrast  to  hereditary  syphilis  is  due  chiefly  to  the  fact  that 
in  the  acquired  variety  the  infant  is  rarely  affected  during  the  early 
months  of  life,  a  time  when  hereditary  syphilis  is  so  very  fatal. 

Tertiary  symptoms  may  appear  at  any  time  from  three  to  twenty  years 
after  the  original  infection. 

The  treatment  is  the  same  as  in  hereditary  syphilis. 

HEREDITARY   SYPHILIS. 

Etiology. — A  child  may  inherit  syphilis  from  both  parents  or  from 
either  separately.  If  both  parents  are  syphilitic,  the  child  is  usually  but 
not  invariably  so.  The  symptoms,  however,  are  not  more  severe  than 
when  the  inheritance  is  from  one  parent  only.  Tiie  likelihood  of  trans- 
mission depends  upon  the  stage  of  the  disease  in  the  parents.     If  both 


1096  THE  SPECIFIC   INFECTIOUS   DISEASES. 

are  suffering  from  secondary  symptoms,  transmission  is  almost  certain. 
If  active  treatment  has  been  employed  for  several  months,  if  the  child  is 
born  at  a  period,  when  no  active  symptoms  are  present,  or  if  the  symptoms 
are  of  a  tertiary  character,  the  offspring  will  probably  escape.  First-born 
children  are  more  likely  to  suffer  severely  from  syphilis  than  the  later 
ones,  provided  infection  of  the  parents  has  taken  place  prior  to  the  birth 
of  all  the  children. 

Infection  from  the  father .—'^y^'^ilis  may  be  inherited  from  the  father 
alone.  In  this  case  the  disease  is  probably  communicated  directly  from 
the  semen  to  the  ovum.  It  is  more  likely  to  be  transmitted  from  the 
father  than  from  the  mother,  as  the  child  is  frequently  syphilitic  when 
the  mother  has  few  or  no  active  symptoms.  Of  twenty  cases  observed  by 
Meyer  in  which  the  father  alone  was  syphilitic,  the  foetus  was  discharged 
macerated  in  eleven  cases,  and  nine  children  were  born  with  congenital 
syphilis,  all  but  one  dying  soon  after  birth.  It  is  possible,  though  rare, 
for  the  father  to  convey  syphilis  when  he  is  free  from  symptoms,  or  when 
he  is  suffering  from  tertiary  symptoms  only. 

Infection  from  the  mother. — It  is  certain  that  syphilis  may  be  trans- 
mitted when  the  mother  alone  is  diseased,  as  is  shown  by  cases  where 
women  who  have  acquired  syphilis  while  wet-nursing  infected  children, 
have  subsequently  borne  syphilitic  children,  the  father  remaining  healthy. 
If  the  mother  only  is  syphilitic  the  probabilities  of  transmission  to  the 
child  appear  to  be  considerably  less  than  if  the  father  alone  is  affected. 
If  the  mother's  symptoms  are  tertiary  the  child  will  probably  escape. 

Both  parents  healthy  at  the  time  of  conception  and  the  mother  infected 
during  pregnancy. — Under  these  conditious  the  child  may  or  may  not  be 
syphilitic.  Transmission  to  the  child  is  much  less  likely  to  occur  if  the 
mother  is  infected  during  the  last  two  months  of  her  pregnancy  than 
earlier,  although,  as  Hutchinson's  cases  conclusively  show,  there  is  no  cer- 
tainty that  the  child  will  escape.  Did  ay  states  that  if  the  mother  is  in- 
fected before  the  fourth  week  and  proper  treatment  is  instituted,  the 
child  will  usually  escape  on  account  of  the  relation  of  the  embryo  to  the 
maternal  circulation  during  this  early  period. 

Can  a  healthy  mother  hear  a  sijphilitic  child? — In  1837  Colles  enun- 
ciated the  following  proposition,  the  truth  of  which  has  been  abundantly 
verified  since  his  time  :  "  A  new-born  child  affected  with  inherited  syphi- 
lis, even  although  it  may  have  symptoms  in  the  mouth,  never  causes 
ulceration  of  the  breasts  which  it  sucks  if  it  be  the  mother  who  suckles  it, 
although  continuing  capable  of  infecting  a  strange  nurse." 

Caspary  inoculated  with  syphilis  a  woman,  apparently  healthy,  who 
had  aborted  with  a  syphilitic  child ;  the  result  was  negative.  A  similar 
experiment  was  made  by  Neumann,  with  a  like  result.  Widal  reports  a 
case  of  an  apparently  healthy  woman  who  had  a  syphilitic  child  by  an 
infected  husband;  later,  by  a  second  husband  who  was  free  from  syphilis, 


HEREDITARY  SYPHILIS.  1097 

she  had  a  syphilitic  child.  The  conclusion  seems  irresistible  that  the 
carrying  of  a  syphilitic  child  gives  immunity  to  the  mother  against  the 
disease  and  that  this  immunity  is  due  to  the  fact  that  she  herself  sufEers 
from  syphilis,  or  a  modification  of  that  disease.  According  to  Hutchin- 
son, the  modified  syphilis  acquired  by  a  woman  under  the  circumstances 
mentioned,  bears  to  syphilis  acquired  from  a  chancre  a  somewhat  similar 
relation  to  that  which  vaccinia  bears  to  smallpox.  The  mother  under 
these  circumstances  can  not  be  inoculated,  either  by  her  syphilitic  nurs- 
ing-infant or  artificially. 

The  communiccibility  of  hereditary  syphilis. — That  hereditary  syphilis 
i^^  contagious  is  conclusively  shown  by  a  number  of  recorded  instances 
in  which  a  healthy  wet-nurse  has  been  infected  by  a  syphilitic  infant. 
However,  such  examples  of  contagion  are  very  rare,  and  many  writers 
of  large  experience  state  that  they  have  never  seen  it.  It  is  certainly 
true  that  the  danger  of  spreading  infection  from  a  case  of  hereditary 
syphilis  has  been  exaggerated,  and  that  it  difliers  so  much  in  this  respect 
from  the  acquired  form  of  the  disease  that  this  peculiarity  is  of  some 
value  in  differential  diagnosis. 

Lesions. — Death  may  be  due  to  syphilis,  and  yet  the  autopsy  may  re- 
veal no  characteristic  anatomical  changes,  and  in  fact  there  may  be  no 
demonstrable  changes  in  any  of  the  organs. 

Bones. — In  the  case  of  a  syphilitic  foetus,  a  stillborn  child,  or  one 
dying  soon  after  birth,  the  changes  in  the  bones  are  more  uniformly 
present  than  are  any  other  lesions.  They  are  in  fact  rarely  wanting,  and 
it  is  by  them  usually  that  syphilis  is  recognised  post  mortem.  The  long 
bones  are  principally  affected,  the  most  important  changes  being  found 
at  the  junction  of  the  shaft  with  the  epiphyseal  cartilage.  The  lesion 
is  termed  an  epiphyseal  osteo-chondritis  or  acute  epiphysitis.  There  is 
in  the  early  stage  congestion,  swelling,  and  cell  proliferation,  which  may 
be  followed  by  separation  of  the  epiphysis,  suppuration  in  the  neighbour- 
ing joint,  osteomyelitis,  and  necrosis.  These  changes  are  more  fully 
considered  under  Diseases  of  the  Bones  (page  897). 

Liver. — This  is  probably  more  frequently  involved  in  the  foetus  and 
newly-born  infant  than  any  other  organ.  The  syphilitic  lesions  of  the 
liver  have  been  studied  very  fully  by  Hudelo.  He  describes  as  present 
in  the  youngest  infants  an  interstitial  hepatitis,  a  gummatous  hepatitis, 
and  a  combination  of  the  two  varieties. 

In  the  interstitial  form,  which  is  most  frequent  in  infancy,  there  is 
first  a  congestion  and  swelling  of  the  organ,  with  the  exudation  of  leuco- 
cytes in  groups.  The  liver  is  enlarged,  frequently  very  much  so,  but  pre- 
sents few  other  gross  changes.  Later  there  is  increased  exudation  be- 
tween the  liver  cells,  new  connective  tissue  forms,  and  atrophy  of  the  liver 
cells  takes  place,  with  obliteration  of  some  of  the  portal  and  hepatic 
vessels.    This  process  may  be  diffuse,  but  it  is  usually  in  patches.    Groups 


1098  THE   SPECIFIC   INFECTIOUS   DISEASES. 

of  miliary  syphilomata  may  also  be  found.  If  the  process  is  diffuse,  the 
liver  is  large,  firm,  and  of  a  grayish-yellow  colour.  If  it  is  localized,  the 
affected  areas  are  yellow  or  gray  and  the  other  parts  are  normal. 

The  gummatous  form  is  not  frequent  in  early  infancy,  but  belongs  to 
a  little  later  period.  In  this  there  may  be  miliary  syphilomata  with  in- 
terstitial changes,  and  in  addition  the  formation  of  small  or  large  gum- 
matous tumours,  which  may  be  softened  at  the  centre.  They  are  sur- 
rounded by  zones  of  new  connective  tissue  and  the  liver  cells  are  atro- 
phied.    Amyloid  changes  may  be  present. 

In  the  late  form  of  hereditary  syphilis,  usually  seen  in  children  over 
four  or  five  years  old,  the  liver  is  rarely  affected.  Hudelo  was  able  to 
collect  but  forty- seven  such  cases.  The  lesions  resemble  those  of  the 
congenital  variety.  There  are  found  cirrhotic  changes,  which  may  be 
diffuse  or  circumscribed,  and  gummatous  deposits,  which  vary  from  a 
minute  size  to  that  of  a  cherry ;  there  may  be  amyloid  degeneration. 

Spleen. — This  is  almost  invariably  enlarged  in  newly-born  children 
with  syphilis  and  in  syphilitic  foetuses,  but  nothing  characteristic  is  found 
under  the  microscope  (Birch-Hirschfeld).  In  older  children  the  enlarge- 
ment of  the  spleen  is  apt  to  be  greater  than  at  birth ;  the  organ  may  be 
the  seat  of  interstitial  changes,  and  sometimes  there  may  be  gummatous 
deposits.     These  changes  are  rare  in  children  under  two  years  of  age. 

Respiratory  system. — In  syphilitic  infants  which  are  stillborn  and  in 
those  which  die  soon  after  birth,  there  is  frequently  found  in  the  lungs 
what  is  known  as  "  white  pneumonia."  This  process  consists,  according 
to  Hillier,  in  fatty  changes  in  the  epithelium  of  the  air  vesicles ;  with  this 
there  is  associated  a  certain  amount  of  interstitial  pneumonia,  which  is 
chiefly  peri-bronchial.  In  older  cases  the  interstitial  pneumonia  is  ex- 
tensive, and  the  lungs  may  be  the  seat  of  gummatous  deposits,  which 
soften  and  form  small  cavities.  Accompanying  these  changes  there 
may  be  bronchiectasis,  emphysema,  and  the  usual  secondary  lesions 
which  follow  chronic  interstitial  pneumonia.  In  syphilitic  infants  there 
is  a  strong  tendency  for  all  inflammations  of  the  lungs  to  become  chronic. 

The  trachea  and  bronchi  are  in  rare  cases  the  seat  of  stenosis,  which 
results  from  cicatrization  following  the  softening  of  gummatous  deposits 
in  their  walls.  Lesions  of  the  larynx  (page  503)  are  also  infrequent. 
There  is  usually  perichondritis,  which  more  often  involves  the  epiglottis 
than  any  other  part,  and  sometimes  there  is  the  formation  of  papilloma- 
tous masses ;  but  ulceration  and  stenosis  are  both  rare. 

The  nasal  mucous  membrane  in  the  early  stage  of  the  disease  is  very 
constantly  the  seat  of  a  chronic  catarrhal  inflammation,  which  may  be 
accompanied  by  superficial  ulceration.  In  the  late  cases  there  is  deeper 
ulceration,  from  the  breaking  down  of  gummata,  with  extension  to  the 
periosteum,  cartilages,  and  bones,  causing  perforation  of  the  septum,  ne- 
crosis of  the  bones,  etc. 


HEREDITARY   SYPHILIS.  1099 

Nervous  system. — S3'philitic  lesions  of  the  brain  and  cord  are  rare  in 
children  as  compared  with  adults,  and  they  are  especially  so  in  infancy. 
The  most  characteristic  cerebral  lesion  of  the  newly-born  child  is  hydro- 
cephalus, which  may  depend  upon  ependymitis,  as  in  two  cases  reported 
by  D' Astros,  the  disease  proving  fatal  in  the  second  month.  Syphilitic 
meningitis  is  exceedingly  rare  under  two  years.  There  is  occasionally 
seen  in  young  infants  a  chronic  basilar  meningitis  (page  766)  of  syphilitic 
origin.  Chronic  pachymeningitis  associated  with  gummata  has  been  ob- 
served as  early  as  the  fourth  year.  Money  (London)  has  reported  a  case 
with  symptoms  beginning  at  eleven  months,  in  which  there  was  chronic 
meningitis  with  great  thickening  of  the  dura  mater  and  cerebral  sclero- 
sis.   A  few  other  cases  of  a  similar  nature  have  been  recorded. 

Nearly  all  the  syphilitic  lesions  of  the  nervous  system  which  are  seen 
in  adult  life  have  been  observed  in  childhood,  but  infrequently,  and  in 
young  children  they  are  extremely  rare,  although  Barlow's  patient  with 
multiple  giimmata  at  the  base  was  only  fifteen  months  old. 

Heart  and  arteries. — These  may  be  affected  even  in  young  infants. 
Adler  (ISTew  York),  of  four  cases  examined,  found  two  in  which  well- 
marked  lesions  were  present  in  infants  under  four  months.  There  was 
endarteritis  of  the  coronary  arteries  accompanied  by  the  early  changes 
belonging  to  interstitial  myocarditis.  Chiari  has  reported  syphilitic 
endarteritis  of  the  brain  at  fifteen  months,  followed  by  thrombosis  and 
softening. 

Digestive  system. — Chronic  catarrhal  pharyngitis  is  almost  a  constant 
symptom  of  the  early  cases.  Later  there  is  seen  superficial  or  deep 
ulceration  of  the  pharynx,  tonsils,  or  fauces,  which  may  lead  to  perfora- 
tion of  the  soft  palate  or  to  the  formation  of  condylomata. 

There  are  no  important  lesions  of  the  stomach  or  intestines  either 
with  early  or  late  syphilis.  The  rectum  is  occasionally  the  seat  of  ulcera- 
tion, and  condylomata  may  form  even  in  young  children. 

Organs  of  special  sense. — Otitis  is  a  frequent  accompaniment  of  the 
early  syphilitic  pharyngitis.  It  is  very  likely  to  become  chronic,  and  in 
many  cases  results  in  a  permanent  impairment  of  hearing.  Iritis  is  rela- 
tively rare  in  children,  but  it  may  occur  even  in  intra-uterine  life,  as 
shown  by  the  presence  of  adhesions  in  newly-born  children.  It  is  usually 
seen  in  infants  four  or  five  months  old,  and  is  always  serious.  Interstitial 
keratitis  occurs  frequently  as  a  late  manifestation  of  syphilis.  Choroid- 
itis and  optic  neuritis  are  both  occasionally  seen,  but  they  are  rare. 

Genito-nrinary  organs. — Xearly  all  these  may  be  affected,  but  gener- 
ally in  the  late  period  of  the  disease.  There  may  be  chronic  intersti- 
tial nephritis  and  more  rarely  gummatous  deposits  in  the  kidney,  intersti- 
tial changes  in  the  suprarenal  bodies,  and  orchitis,  which  usually  affects 
the  body  of  the  organ,  rarely  the  epididymis;  it  is  generally  an  inter- 
stitial inflammation,  witli  or  without  gummatous  deposits. 


1100  THE  SPECIFIC  INFECTIOUS  DISEASES. 

Among  the  less  frequent  visceral  lesions  may  be  mentioned,  abscesses 
of  the  thymus,  which  are  usually  small  and  multiple;  enlargement  of  the 
pancreas,  with  an  increase  of  connective  tissue  and  glandular  atrophy; 
and  chronic  peritonitis.  The  lesions  of  the  mucous  membranes  will  be 
considered  under  Symptoms. 

Symptoms. — As  the  result  of  syphilis,  abortion  may  take  place  at  any 
period  of  pregnancy,  with  the  discharge  of  a  dead  or  macerated  foetus,  or 
the  child  may  be  stillborn  at  term,  or  it  may  be  born  alive  prematurely, 
but  with  so  feeble  a  vitality  that  it  survives  but  a  few  hours.  Under 
these  circumstances  it  is  often  difficult  and  sometimes  impossible  to  decide 
positively  with  reference  to  the  existence  of  syphilis.  Maceration  of  the 
foetus  or  peeling  of  the  skin  is  no  proof,  and  even  the  examination  of  the 
internal  organs  may  not  be  conclusive.  Lomer  examined  43  foetuses,  all 
dying  before  the  thirtieth  week  of  pregnancy ;  he  found  the  spleen  and 
liver  enlarged  in  all,  and  marked  bone  changes  in  21.  Birch- Hirschf eld 
examined  108  newly-born  syphilitic  infants ;  he  found  the  spleen  invaria- 
bly enlarged ;  typical  bone  changes  were  present  in  35,  but  in  many  cases 
the  bones  were  normal.  Mervis,  from  an  examination  of  92  syphilitic 
foetuses,  states  that  no  eruption  upon  the  skin  was  found  earlier  than  the 
eighth  month. 

Symptoms  are  present  at  birth  in  only  a  small  number  of  cases.  In 
such  there  is  usually  a  very  severe  degree  of  infection,  and  the  infants 
do  not  often  live  more  than  a  few  days.  Upon  the  skin  there  may  be 
seen  an  eruption  of  pustules,  papules,  or  bullae.  The  bullae  are  usually 
upon  the  soles  and  palms,  but  may  be  found  upon  other  parts  of  the  body. 
The  name  "  syphilitic  pemphigus  "  is  often  given  to  this  condition.  Pem- 
phigus in  the  newly  born,  however,  is  not  invariably  due  to  syphilis,  but 
may  be  present  in  other  conditions  of  low  vitality.  The  bullae  are  at  first 
small,  and  then  coalesce  and  form  larger  ones  two  inches  or  more  in 
diameter.  They  contain  a  turbid  serum  which  is  sometimes  tinged 
with  blood,  and  sometimes  yellow  from  pus.  Pustules,  when  present,  are 
usually  seen  upon  the  face  or  scalp.  The  general  appearance  of  these  in- 
fants is  wretched  in  the  extreme.  The  body  is  wasted,  the  skin  wrinkled, 
and  temperature  subnormal.  The  spleen  is  usually  enlarged  and  often 
the  liver  also.  They  suck  feebly  or  not  at  all,  and  usually  die  from  inani- 
tion within  two  weeks. 

In  the  great  majority  of  cases  the  infant  appears  healthy  at  birth,  and 
continues  so  for  a  variable  time  before  the  manifestation  of  the  character- 
istic symptoms  of  syphilis.  As  a  rule,  the  more  intense  the  infection,  the 
earlier  the  symptoms  make  their  appearance.  The  earliest  symptoms  are 
generally  seen  between  the  second  and  the  sixth  weeks.  If  three  months 
pass  without  evidence  of  syphilis,  the  child  may  be  considered  safe,  the 
exceptions  to  this  rule  being  very  few.  Miller  (Moscow)  gives  the  fol- 
lowing statistics  of  the  time  of  beginning  of  symptoms  in  1,000  cases: 


HEREDITARY   SYPHILIS.  HOI 

Symptoms  appeared  during  the  first  week 85  cases. 

"                  "              "         "    second  week 138  " 

"                 "              "        "    third  week 240  " 

"                 "              "        "    fourth  week 177  " 

«                 "              "        '•    fifth  week 86  " 

"                 "              "        *'    sixth  week 54  " 

"                 "              "        "    seventh  week 50  " 

"                 "              "        '•    eighth  week 30  " 

After  the  eighth  week 140  " 

Sometimes  the  constitutional  symptoms — wasting,  cachexia,  etc. — are 
noticed  before  the  local  ones,  but  usually  this  is  not  the  case.  Generally 
the  first  symptom  is  the  coryza  or  "  snuffles,"  which  resembles  an  ordinary 
cold  in  the  head,  except  that  it  persists.  It  is  accompanied  by  a  hoarse 
cry,  indicating  that  the  larynx  participates  in  the  catarrhal  inflamma- 
tion. Soon  the  eruption  makes  its  appearance,  being  generally  first  seen 
upon  the  hands,  feet,  and  face.  Fissures  and  mucous  patches  may  be 
seen  upon  the  lips,  about  the  anus,  etc.  There  is  often  slight  fever,  from 
99°  to  101°  F.  There  may  also  be  observed  excessive  tenderness  and 
swelling  about  the  shoulders,  elbows,  wrists,  or  ankles,  due  to  acute  epi- 
physitis, which  may  cause  the  child  to  cry  from  the  slightest  amount  of 
handling,  and  the  limbs  may  be  moved  so  little  that  paralysis  is  sus- 
pected. 

In  a  severe  case,  as  these  local  symptoms  develop,  the  infant's  gen- 
eral nutrition  suffers.  It  loses  steadily  in  weight;  it  becomes  extremely 
ansemic;  it  whines  and  frets  almost  continually,  but  especially  at  night. 
The  features  have  a  pitiful,  drawn  expression;  and  the  face  is  wrinkled, 
giving  the  infant  a  very  old  appearance.  The  skin  has  a  peculiar  sal- 
low colour,  which  has  been  well  described  as  cafe  au  lait.  The  symp- 
toms may  continue  until  a  condition  of  extreme  marasmus  is  reached, 
or  death  occurs  from  some  intercurrent  affection  of  the  lungs  or  diges- 
tive organs. 

In  the  milder  forms  of  infection  the  severe  constitutional  symptoms 
described  are  not  seen,  although  the  local  evidences  of  disease  are  well 
marked.  The  severity  of  the  symptoms  is  also  much  modified  by  treat- 
ment, especially  when  this  is  begun  early. 

The  most  important  local  symptoms  are  the  coryza,  eruption,  fissures 
about  the  mouth  and  anus,  mucous  patches,  painful  swellings  at  the  ex- 
tremities of  the  long  bones,  pseudo-paralysis,  and  onychia. 

Coryza. — In  most  of  the  cases  this  is  the  first  symptom.  Beginning 
like  an  ordinary  catarrh,  it  is  distinguished  by  its  severity  and  its  per- 
sistence. There  is  a  copious  discharge  of  mucus  and  serum,  often  tinged 
with  blood.  Thick  crusts  form,  which  produce  the  usual  symptoms  of 
nasal  ol)struction;  there  is  great  difficulty  in  nursing;  the  infant  breathes 
through  the  mouth,  and  the  mucous  membrane  of  the  mouth  is  dry,  caus- 
71 


1102 


THE   SPECIFIC  INFECTIOUS   DISEASES. 


ing  great  discomfort.  If  untreated,  the  process,  which  at  first  involves 
the  mucous  membrane  only,  may  extend  to  the  submucous  tissue,  causing 
ulceration;  but  the  cartilages  and  the  bones  of  the  nasal  fossge  are  not 
involved  till  a  later  period  in  the  disease. 

The  nasal  catarrh  is  associated  with  more  or  less  laryngitis,  causing 
hoarseness  or  aphonia,  and  rarely  there  may  be  laryngeal  stenosis.  Dillon 
Brown  has  reported  one  case  in  an  infant  six  weeks  old,  which  recovered 
after  intubation. 

Eruption.— This  usually  occurs  after  the  coryza  has  lasted  about  a 
week;  but  the  two  may  come  at  the  same  time;  or  the  coryza  may  be 
absent  or  so  slight  that  the  rash  appears  to  be  the  first  symptom. 

Occasionally  there  is  seen  a  diffuse  blush  or  roseola,  but  more  fre- 
quently the  eruption  is  macular,  occurring  in  small,  dark-red  spots  about 
the  size  of  the  infant's  finger  nails,  usually  circular  and  often  slightly 

elevated;  there  is  no  surrounding  inflammation, 
and  rarely  any  itching.  It  is  usually  most 
abundant  upon  the  face,  the  neck,  and  the  ex- 
tensor surface  of  the  upper  and  lower  extremi- 
ties, especially  the  hands  and  feet,  sometimes 
extending  over  the  entire  body,  although  it  is 
generally  scanty  over  the  chest  and  abdomen. 
At  first  the  colour  is  bright,  but  gradually  be- 
comes of  a  dusky-red  or  coppery  hue.  After  a 
little  time  very  fine  scales  may  be  seen  upon 
the  surface  of  the  red  macules.  The  rash 
comes  out  slowly,  usually  requiring  from  one 
to  three  weeks  for  its  full  development.  It 
fades  gradually,  leaving  a  coppery  discoloration 
of  the  skin,  which  continues  for  a  long  time. 
The  duration  of  the  eruption  is  from  three  to 
eight  weeks;  less'  if  active  treatment  is  em- 
ployed. 

A  j)apular  eruption  is  rarely,  seen  alone,  but 
is  usually  associated  with  the  macular  variety. 
The    papules    are    of   a    brownish   colour    and 
are  hard.    They  are  seen  most  frequently  upon  the  palms  and  soles. 

A  squamous  eruption  is  frequently  seen  upon  the  palms  and  soles,  but 
very  rarely  elsewhere.  In  a  few  cases  this  scaliness  forms  the  most  dis- 
tinctive feature  of  the  cutaneous  lesion  (see  Fig.  197). 

Fissures  and  mucous  patches. — These  are  among  the  most  diagnostic 
features  of  early  hereditary  syphilis.  Fissures  are  most  frequently  seen 
on  the  lips  and  about  the  anus,  but  they  may  occur  about  the  nostrils  and 
occasionally  elsewhere.  The  fissures  of  the  lips  are  really  linear  ulcers, 
and  are  distinguished  by  their  persistence  in  spite  of  local  treatment. 


Fig.  197. — Syphilitic  scaling' 
of  the  foot.  From  an  in- 
fant eight  weeks  old. 


HEREDITARY  SYPHILIS.  1103 

They  are  multiple,  deep,  painful,  and  bleed  easily.  '  Those  at  the  angle 
of  the  mouth  are  especially  troublesome. 

Mucous  patches  may  develop  from  fissures,  but  more  frequently  from 
papules  which  are  situated  in  regions  where  they  are  exposed  to  constant 
moisture  and  friction.  Tliey  are  very  common  upon  the  muco-cutaueous 
surfaces  and  wherever  the  skin  is  especially  thin.  They  are  most  apt 
to  be  seen  about  the  lips,  anus,  scrotum,  and  vulva,  but  they  may  also  be 
found  behind  the  ears,  between  the  toes,  in  the  folds  of  the  groin,  axillae, 
or  buttocks.  They  vary  from  an  eighth  to  half  an  inch  in  diameter,  are 
whitish  in  colour,  and  are  raised  rather  than  excavated. 

Ulcers  may  be  present  upon  any  of  the  mucous  membranes,  fre- 
quently in  the  mouth  or  on  the  genitals;  they  are  seldom  symmetrical, 
and  while  they  may  be  broad  they  are  never  deep. 

Hcemorrhages. — They  are  generally  associated  with  the  lesions  of  the 
mucous  membranes,  especially  of  the  nose.  In  young  infants  with  severe 
infection,  bleeding  may  occur  from  the  bullous  eruption  upon  the  skin, 
or  from  the  fissures  at  any  of  the  orifices,  particularly  the  mouth  and 
anus.  Fischl  has  reported  seven  cases  of  multiple  haemorrhages  in  the 
newly  born,  associated  with  other  symptoms  of  congenital  syphilis. 
Mracek  noted  haemorrhages  in  thirty-three  per  cent  of  160  autopsies  on 
syphilitic  stillborn  infants  or  those  dying  soon  after  birth.  Examination 
of  the  blood-vessels  in  some  of  these  cases  showed  infiltration  of  their 
walls  and  narrowing  of  their  lumen.  The  vascular  changes  were  thought 
to  be  the  cause  of  the  bleeding. 

Nails. — The  nails  present  several  peculiarities  in  syphilitic  infants. 
There  may  be  a  disease  of  the  matrix  resulting  in  suppuration  and  exfo- 
liation of  the  nail;  frequently  the  dorsum  is  much  arched,  and  the  nail 
appears  as  if  it  had  been  pinched  by  a  pair  of  forceps — i.  e.,  claw-shaped; 
this  is  an  early  symptom  of  some  diagnostic  importance.  The  hair  and 
eyebrows  frequently  fall  out  completely.  This  symptom  is  not  usually 
present  in  very  early  infancy. 

Pseudo-paralysis. — This  is  due  to  acute  epiphysitis,  and  it  may  be 
the  first  symptom  of  hereditary  syphilis  to  attract  attention.  It  is  usu- 
ally noticed  when  the  infant  is  a  few  weeks  old  that  one  or  sometimes 
both  arms  are  not  moved,  and  that  the  parts  are  tender  when  liandliMl. 
The  arm  is  very  frequently  held  in  marked  inward  rotation  witli  the  palm 
looking  outward,  resembling  the  position  in  Erb's  palsy;  but  careful  ex- 
amination makes  it  evident  that  the  loss  of  power  is  only  a|i|);u»'ii(,  and 
that  it  is  due  either  to  the  pain  which  motion  produces  or  to  ('])ii)hyseal 
separation.  A  history  will  usually  be  obtained  that  loss  of  ])o\vcr  did 
not  exist  at  birth,  but  developed  subsequently.  The  electrical  reactions 
in  these  cases  are  normal,  and  the  rapid  imprnvcmrnt  undrr  mercurial 
treatment  is  diagnostic. 

The  only  visceral  symptoms  of  impoffaiice  relate  to  the  spleen,  which 


1104  THE  SPECIFIC  INFECTIOUS  DISEASES. 

is  almost  invariably  much  enlarged  in  the  active  stage  of  hereditary 
syphilis. 

Late  Hereditary  Syphilis. — These  symptoms  may  come  on  at  any 
period  during  childhood  or  about  the  time  of  puberty,  but  very  rarely 
at  a  later  time  than  this.  They  are  seen  both  in  those  who  have  had  the 
usual  symptoms  of  hereditary  syphilis  in  early  infancy,  and  in  others 
where  the  most  careful  examination  into  the  history  fails  to  disclose  any 
symptoms  whatever  of  early  syphilis.  It  is  fair  to  assume  in  such  cases 
either  that  early  symptoms  were  absent  or  that  they  were  of  trivial  im- 
portance. It  is  still  a  matter  of  dispute  whether  these  late  symptoms 
should  be  regarded  as  hereditary,  tertiary  syphilis,  which  has  not  pre- 
viously given  signs,  or  as  the  late  stage  of  ordinary  syphilis  in  which 
the  early  symptoms  have  been  overlooked.  It  is  certain  that  the  symp- 
toms are  quite  as  apt  to  be  severe  when  there  is  no  history  of  early, 
syphilis  as  when  this  has  been  typical.  It  is  quite  possible  that  some  of 
these  may  be  the  late  manifestations  of  the  acquired  syphilis  not  recog- 
nised in  the  early  stage. 

Late  hereditary  syphilis  shows  itself  by  symptoms  which  in  acquired 
disease  would  be  classed  as  tertiary.  The  most  characteristic  are  the 
affections  of  the  teeth,  the  bones,  gummatous  deposits  in  the  solid  vis- 
cera, the  skin,  or  mucous  membranes,  the  breaking  down  of  which  may 
lead  to  ulceration. 

Teeth. — There  are  no  peculiarities  in  the  first  teeth  of  syphilitic  chil- 
dren except  their  proneness  to  early  decay.    They  are  rather  more  likely 

to  appear  early  than  late. 

The  characteristic  teeth  of  syphilis  are  those 
of  the  second  set.     In  estimating  the  diagnostic 
value  of  these  changes,  only  the  upper  central 
Fig.  igl.— Typical "  Hutch-     incisors  are  to  be  relied  upon;  these  are  the  test 

mson's  teeth.'  (After  teeth.  Although  changes  are  frequently  seen  in 
other  teeth,  they  are  not  always  diagnostic.  Typi- 
cal syphilitic  teeth,  according  to  Hutchinson,  have  each  a  single  notch 
in  the  centre  of  the  edge  (Fig.  198).  The  notch  is  usually  shallow  and 
more  or  less  crescentic  in  shape.  The  enamel  is  generally  deficient  in 
the  centre  of  the  notch,  and  the  tooth  here  is  apt  to  be  discoloured.  The 
teeth  in  other  cases  are  variously  dwarfed  and  deformed.  (See  Fig.  199.) 
They  often  taper  regularly  from  the  base  to  the  edge,  giving  rise  to  the 
term  "  screw-driver  teeth."  The  teeth  are  not  so  flat  as  the  normal  in- 
cisors, but  often  rounded  and  peg-like.  They  are  not  properly  placed, 
but  incline  either  toward  or  away  from  each  other.  They  are  seldom 
large  enough  to  touch  the  adjacent  teeth  on  both  sides. 

Although  Hutchinson's  teeth  may  generally  be  taken  as  conclusive 
evidence  of  syphilis,  they  are  not  invariably  so,  as  Keyes  and  others  have 
shown.     It  is  to  be  remembered  in  this  connection  that  the  absence  of 


HEREDITARY  SYPHILIS. 


1105 


Fig.  199.  —  Syphilitic  teeth;  boy 
eight  years  old  ;  under  observa- 
tion several  years  with  various 
syphilitic  manifestations. 


changes  in  the  teeth  is  of  no  importance  whatever  as  evidence  that 
syphilis  is  not  present.  Hutchinson  states  that  they  are  wanting  in 
more  than  half  the  cases. 

Bones. — The  form  of  disease  which  is  usually  seen  at  this  period  is 
an  osteo-periostitis,  affecting  principally  the  shaft  of  the  long  bones  and 
the   cranium.      It   has    already   been    de- 
scribed (page  899). 

Lymph  nodes. — They  are  much  less  fre- 
quently affected  than  in  adults,  and  in 
early  infancy  they  are  seldom  involved. 
In  most  cases  after  the  first  year  there 
may  be  found  a  moderate  degree  of  en- 
largement of  the  post-cervical  and  epi- 
trochlear  glands,  swelling  of  the  latter 
having  considerable  diagnostic  value.  They 
are  situated  just  above  the  internal  condyle 
of  the  humerus,  and  under  normal  condi- 
tions can  scarcely  be  felt.  In  syphilitic 
children  they  may  be  as  large  as  a  pea  or 
a  small  bean;  sometimes  two  or  three  of 
them  can  be  distinguished.  They  are  so 
rarely  enlarged  from  other  constitutional  conditions  that,  provided  no 
local  cause  for  the  swelling  exists,  they  should  always  create  a  suspicion 
of  syphilis.  The  post-cervical  glands  are  frequently  affected,  but  are  not 
so  diagnostic.  The  degree  of  enlargement  is  rarely  great.  Occasionally 
there  are  seen  in  the  neck  large  masses  of  swollen  lymph  glands  which 
resemble  tuberculous  swellings.    They  are,  however,  very  rare. 

Special  senses. — The  most  frequent  affection  of  the  eye  in  late  syphilis 
is  interstitial  keratitis,  the  close  connection  of  which  with  hereditary 
syphilis  was  first  pointed  out  by  Hutchinson.  It  is  usually  found  asso- 
ciated with  the  typical  notched  teeth.  The  diagnostic  value  of  keratitis 
in  syphilis  is  denied  by  Fournier,  who  states  that,  while  often  syphilitic, 
it  is  not  infrequently  due  simply  to  malnutrition.  Both  eyes  are  usually 
affected,  and  in  all  degrees  of  severity,  from  a  slight  haziness  of  the 
cornea  to  complete  opacity.  However,  with  an  early  diagnosis  and  prompt 
treatment,  recovery  may  be  expected  in  most  cases. 

Chronic  otitis  may  be  a  result  of  the  acute  process  seen  in  early 
infancy.  There  is  nothing  peculiar  about  the  inflammation  in  these 
cases.  A  form  of  deafness  occurs  in  older  children,  which  Hutcliinson 
states  is  almost  invariably  due  to  syphilis.  Its  onset  is  quite  sudden, 
without  pain  and  frequently  without  discharge.  The  loss  of  hearing  is 
apt  to  be  permanent,  and  if  it  occurs  early  in  childhood  it  is  a  cause  of 
deaf-mutism. 

Skin. — The  most  important  of  the  later  manifestations  of  syphilis 


1106  THE  SPECIFIC  INFECTIOUS  DISEASES. 

consists  in  the  formation  of  subcutaneous  gummata.  In  the  early  stage 
they  are  indurated,  elastic,  of  a  grayish  colour,  with  red  borders.  Under 
treatment  they  disappear  quite  rapidly  by  absorption;  but  when  neglected 
they  break  down,  leaving  large  deep  ulcers.  These  ulcers  are  quite  char- 
acteristic in  appearance,  but  may  be  confounded  with  those  due  to  tuber- 
culosis. The  syphilitic  ulcer  has  rounded,  thickened,  indurated  borders, 
and  a  base  which  is  depressed  and  has  the  appearance  of  being  scooped 
out.  It  is  sometimes  covered  by  hard  crusts  and  is  surrounded  by  a  red 
areola.  It  leaves  a  smooth  white  scar.  The  most  frequent  situation  is 
upon  the  face  and  upper  part  of  the  legs  or  thighs.  Tuberculous  ulcers 
have  usually  soft,  flat  edges,  and  do  not  extend  so  deeply;  they  are  more 
irregular  in  outline;  the  cicatrix  left  is  of  a  purplish  colour,  which  be- 
comes red  and  slowly  fades.  Tubercle  bacilli  may  be  found.  Sometimes 
it  is  only  by  the  effect  of  treatment  that  the  diagnosis  can  be  made  be- 
tween these  two  lesions. 

Nose  and  palate. — Disease  of  these  parts  generally  begins  as  the 
breaking  down  of  gummatous  deposits  in  the  mucous  membrane.  The 
nose  may  in  consequence  be  the  seat  of  a  protracted  fetid  discharge 
(ozsena).  The  disease  may  take  on  a  destructive  form  of  ulceration  which 
is  at  times  phagedenic,  and  may  cause  rapid  destruction  of  the  nasal  car- 
tilages and  bones,  perforation  of  the  septum,  and  occasionally  of  the  floor 
of  the  nasal  fossae.  There  may  be  necrosis  of  the  turbinated  bones,  the 
vomer,  or  the  ethmoid.  In  the  most  severe  forms  the  nose  may  be  almost 
destroyed  in  the  course  of  a  few  weeks.  There  may  be  at  the  same  time 
deep  ulceration  of  the  soft  palate,  leading  to  perforation.  In  a  young 
person  this  is  almost  invariably  due  to  syphilis.  In  many  particulars 
these  ulcerations  of  the  nose  and  palate  resemble  lupus;  they  are  dis- 
tinguished by  the  rapidity  of  their  progress,  syphilis  often  doing  as 
much  damage  in  weeks  as  is  done  by  lupus  in  years  (Hutchinson). 

Other  symptoms. — Syphilitic  disease  of  the  larynx  and  bronchi  is  rare 
in  childhood.  The  former  (page  503)  may  give  rise  to  hoarseness  or 
aphonia  and  occasionally  to  stenosis;  the  latter  to  a  chronic  cough  and 
asthmatic  attacks.  There  are  no  characteristic  symptoms  belonging  to 
syphilis  of  the  lungs.  The  different  lesions  of  the  central  nervous  sys- 
tem which  may  be  due  to  syphilis  are  all  quite  rare.  The  forms  have 
already  been  mentioned,  and  their  symptomatology  is  discussed  in  Dis- 
eases of  the  Nervous  System. 

The  only  visceral  changes  which  aid  much  in  diagnosis  are  those  of 
the  liver  and  spleen.  The  liver  is  often  enlarged,  sometimes  to  a  marked 
degree,  and  occasionally  there  is  ascites,  but  very  seldom  jaundice. 

Enlargement  of  the  spleen  is  a  very  frequent  symptom — in  fact,  it  is 
almost  constant  during  active  syphilitic  disease.  I  have  several  times 
seen  it  so  swollen  as  to  form  an  abdominal  tumour  of  considerable  size. 
In  one  case,  in  a  boy  three  years  old,  the  spleen  extended  five  inches  be- 


HEREDITARY  SYPHILIS,  1107 

low  the  free  border  of  the  ribs,  quite  to  the  crest  of  the  ileum.  It  was 
associated  with  moderate  enlargement  of  the  liver,  as  is  usually  the  case. 

In  addition  to  the  local  symptoms  of  late  hereditary  syphilis  enumer- 
ated, there  are  others  of  a  general  character  which  are  quite  as  important. 
The  body  is  usually  undersized;  the  constitution  is  delicate,  and  shows 
but  little  resistance  to  all  forms  of  disease;  puberty  is  frequently  delayed, 
and  the  development  of  the  breasts  and  the  genital  organs  often  imper- 
fect; anaemia  is  usually  present,  and  the  skin  has  a  sallow  appearance. 
Mentall}',  many  of  these  children  are  somewhat  deficient,  and  in  a  few 
instances  they  become  idiotic,  epileptic,  or  the  subjects  of  dementia. 

Diagnosis. — The  diagnosis  of  early  syphilis  in  most  cases  is  not  diffi- 
cult. The  coryza,  eruption,  labial  fissures,  mucous  patches  about  the 
anus  and  genitals,  enlarged  spleen,  and  general  cachexia — all  form  a 
picture  which  it  is  difficult  to  mistake  In  irregular  cases  the  diagnosis 
is  easy  Just  in  proportion  to  the  number  of  the  foregoing  symptoms  which 
are  present.  Special  care  should  be  taken  not  to  confound  the  moist 
papules  of  simple  intertrigo  upon  the  buttocks  or  thighs  with  those  of 
syphilis. 

In  late  syphilis  the  following  symptoms  are  the  most  reliable  for  diag- 
nosis: notching  of  the  teeth,  falling  in  of  the  bridge  of  the  nose,  intersti- 
tial keratitis,  deafness  not  traceable  to  ordinary  otitis,  enlargement  of 
the  spleen  and  epitrochlear  glands,  ulceration  of  the  palate  or  nose,  the 
sabre-like  deformity  of  the  tibia,  and  nodes  upon  the  tibia  or  cranium. 

It  becomes  at  times  important  to  distinguish  hereditary  from  ac- 
quired syphilis.  While  this  is  not  always  possible,  it  is  often  so.  Visceral 
lesions  in  acquired  syphilis  are  not  common  and  belong  to  the  late  period 
of  the  disease;  in  the  hereditary  form  they  are  well-nigh  constant  and 
occur  early,  often  being  present  at  birth.  The  acute  epiphysitis,  some- 
times accompanied  by  pseudo-paralysis,  seldom  "if  ever  occurs  in  acquired 
syphilis,  though  frequent  in  the  hereditary  form.  Symptoms  due  to 
defects  in  development,  like  the  misshapen  finger-nails,  are  seen  only  in 
hereditary  syphilis.  The  early  symptoms  of  the  mucous  membranes  and 
muco-cutaneous  surfaces — coryza,  hoarseness,  haemorrhages,  labial  fis- 
sures, etc. — so  characteristic  of  hereditary  syphilis,  have  no  place  in  the 
acquired  form,  while  the  single  primary  lesion  sometimes  found  in  the 
acquired  form  does  not  exist  in  the  hereditary  disease.  Finally,  heredi- 
tary syphilis  is  very  slightly,  whereas  the  acquired  form  is  highly  con- 
tagious. 

Prognosis. — Cenerally  speaking,  the  prognosis  is  mucli  worse  in  inJ'an- 
tile  syphilis  than  in  that  of  adults.  In  infancy  it  is  much  worse  when 
hereditary  than  when  acquired,  for  the  reason  that  often  the  child  who 
is  the  subject  of  hereditary  syphilis  has  been  affected  by  the  poison  from 
the  very  beginning  of  its  existence,  and  this  has  modified  its  entire  devel- 
opment. 


1108  THE  SPECIFIC  INFECTIOUS  DISEASES. 

The  results  of  206  syphilitic  pregnancies  observed  by  Jullien  (Paris) 
were  as  follows :  abortion  occurred  in  36,  stillbirths  in  8,  and  69  children 
died  soon  after  birth,  making  a  total  mortality  of  55  per  cent ;  50  were 
living  and  syphilitic ;  only  43  living  and  in  good  health.  Still  worse  were 
the  results  in  cases  observed  by  Le  Pileur :  of  154  pregnancies  in  syphi- 
litic women,  there  were  120  abortions  or  stillbirths,  26  children  died  soon, 
after  birth,  and  only  8  survived.  The  statistics  of  the  Foundling  Asylum 
in  Moscow  for  ten  years  showed  that  of  2,038  syphilitic  infants  the  mor- 
tality was  over  70  per  cent. 

Such  a  mortality  as  that  indicated  in  the  above  statistics  is  seen  only- 
in  institutions  where  little  or  no  previous  treatment  has  been  employed. 
In  private  practice  certainly  nothing  ajoproaching  it  occurs. 

In  addition  to  those  who  die  early  as  the  result  of  syphilitic  infection, 
there  must  be  added  many  whose  constitutions  are  so  impaired  by  syphilis 
that  they  fall  an  easy  prey  in  infancy  to  pneumonia,  diarrhoea  or  other 
forms  of  acute  disease.  The  remote  effects  of  syphilis  in  infancy  it  is 
hard  to  estimate ;  it  exerts  a  modifying  influence  upon  the  constitution  in 
childhood  and  even  throughout  the  life  of  the  individual. 

The  prognosis  in  an  individual  case  depends  upon  the  age  at  which 
the  symptoms  develop,  the  time  when  treatment  is  begun,  upon  its  thor- 
oughness, and  upon  the  surroundings  and  mode  of  nourishment  of  the 
child.  The  outlook  is  better  the  longer  after  birth  the  first  symptoms 
appear ;  it  is  also  better  in  infants  who  are  nursed  than  in  those  who 
are  artificially  fed. 

As  compared  with  syphilis  of  the  adult,  relapses  are  rare,  and  when 
they  occur  early  they  are  nearly  always  the  result  of  insufficient  treatment. 
If  proper  early  treatment  is  carried  out,  the  severe  late  symptoms  are  rare ; 
patients  are  usually  free  from  all  symptoms  until  six  or  seven  years  old,  or 
until  near  the  time  of  puberty — two  periods  when  they  are  likely  to  develop. 

The  prognosis  is  better  in  the  later  children  of  syphilitic  parents  than 
in  the  earlier  ones,  provided  infection  has  preceded  the  birth  of  all  the 
children.  This  fact  illustrates  the  general  tendency  of  the  syphilitic 
poison  to  diminish  in  virulence  as  time  passes,  even  without  treatment. 
The  following  instance  cited  by  Bertin  well  illustrates  this  point : 

In  the  first  pregnancy,  the  mother  aborted  with  a  dead  child  at  the 
sixth  month;  in  the  second,  at  the  seventh  month;  in  the  third,  at  seven 
and  a  half  months;  in  the  fourth  the  child  was  born  at  term,  and  lived 
eighteen  days;  in  the  fifth  it  lived  six  weeks;  in  the  sixth  the  child  lived 
four  months,  without  treatment. 

Prophylaxis. — Xo  infected  person  should  be  allowed  to  marry  until 
at  least  two  years  have  passed  after  the  initial  sore,  steady  treatment 
being  continued  meanwhile;  nor  if  there  are  any  active  symptoms,  no 
matter  how  long  a  time  has  elapsed  since  infection.  There  is  no  cer- 
tainty in  any  case  that  the  child  will  escape. 


HEREDITARY   SYPHILIS.  1109 

The  mother  should  be  treated  duriug  her  pregnancy :  (1)  if  she  is 
syphilitic,  whether  the  disease  was  acquired  at  the  time  of  concep- 
tion or  subsequently ;  (2)  if  the  father  is  known  to  be  suffering  from 
syphilis,  whether  the  mother  has  symptoms  or  not ;  (3)  if  the  mother  has 
previously  shown  signs  of  syphilis,  but  has  had  no  active  symptoms  for 
a  considerable  period.  In  all  these  conditions  if  efficient  treatment  is 
carried  on  throughout  pregnancy  there  is  a  strong  probability,  but  in  no 
case  a  certainty,  that  the  child  will  escape.  The  third  condition  mentioned 
is  the  one  in  which  treatment  is  most  likely  to  be  neglected,  especially  if 
the  mother  has  previously  borne  a  child  who  was  not  syphilitic.  Syphilis, 
however,  shows  a  strong  tendency  to  reappear  and  become  active  during 
pregnancy,  even  though  it  has  been  long  quiescent,  as  the  following  case 
cited  by  Diday  shows : 

A  woman  who  had  lost  seven  children  from  syphilis  was  put  under 
treatment  during  the  eighth  pregnancy ;  result — child  born  healthy,  and 
continued  so.  In  the  ninth  pregnancy  treatment  was  continued  with  a 
like  result ;  in  the  tenth  pregnancy,  no  treatment,  child  syphilitic,  dying 
when  six  months  old ;  in  the  eleventh  pregnancy,  treatment  repeated, 
child  healthy. 

The  danger  of  infection  during  labour  is  slight.  If  there  are  upon 
the  genitals  of  the  mother  either  a  chancre  or  syphilitic  ulcers,  they 
should  be  thoroughly  cauterized  before  labour. 

As  the  greatest  danger  of  infecting  a  child  after  birth  is  from  its  parents 
or  a  wet-nurse,  syphilitic  parents  should  be  duly  warned  of  the  danger  to 
their  children,  and  especially  should  be  cautioned  against  kissing  them 
or  sleeping  in  the  same  bed  with  them.  The  utmost  care  should  be  ex- 
ercised to  prevent  a  healthy  child  from  being  infected  by  a  syphilitic 
nurse.  A  nurse  should  never  be  accepted  without  a  thorough  examina- 
tion, no  matter  how  clear  a  history  may  be  given.  As  a  syphilitic  child 
in  the  household  may  be  the  means  of  infecting  other  children,  the 
same  precautions  should  be  taken  as  in  the  case  of  other  contagious 
diseases.  The  chief  danger  to  other  children  comes  from  kissing  or 
from  using  bottles,  spoons,  or  cups  which  have  been  infected;  as  the 
syphilitic  infant  is  chiefly  dangerous  on  account  of  the  lesions  in  the 
mouth.  Trouble  most  frequently  occurs  because  of  ignorance  regard- 
ing the  nature  of  the  disease.  It  is  possible  for  a  syphilitic  child  to  nurse 
a  healthy  woman  without  communicating  sjrphilis,  if  the  child's  mouth 
is  treated  and  the  nipple  not  allowed  to  become  fissured  ;  but  it  is  an  ex- 
periment which  should  never  be  tried. 

Treatment. — This  should  always  be  begun  as  soon  as  the  first  positive 
symptoms  of  syphilis  appear.  Under  certain  circumstances  it  may  be 
advisable  not  to  wait  for  symptoms ;  as,  for  example,  where  both  parents 
have  recently  suffered  from  active  symptoms,  where  previous  children 
have  died  soon  after  birth,  or  where,  with  marked  symptoms  in  the  par- 


1110  THE   SPECIFIC   INFECTIOUS   DISEASES. 

ents,  the  child  exhibits  the  cachexia  of  syphilis,  but  no  definite  local 
symptoms.  Such  anticipatory  treatment  need  not  be  continued  longer 
than  six  weeks  unless  symptoms  appear. 

The  indirect  treatment,  designed  to  reach  the  child  through  the 
mother's  milk,  has  fallen  into  deserved  disuse,  as  it  is  very  uncertain  and 
altogether  unsatisfactory. 

Mercury  is  as  much  a  specific  for  hereditary  as  for  acquired  syphilis. 
There  are  many  ways  of  introducing  it  into  the  system  :  it  may  be  giyen 
by  inunctions,  by  the  mouth,  by  fumigations,  by  baths,  or  hypodermically. 
In  most  cases  inunction  is  the  manner  to  be  preferred  in  young  infants. 
Gr.x  of  mercurial  ointment,  diluted  with  the  same  amount  of  vaseline,  may 
be  rubbed  daily  into  the  palms,  soles,  axillfB,  or  the  inner  surface  of  the 
thighs.  It  is  advisable  to  change  the  place  of  inunction  from  day  to  day ; 
and  if  this  is  done,  it  is  extremely  rare  that  erythema  is  produced.  If  for 
any  reason  inunctions  are  objectionable,  as  they  may  be  where  the  family 
are  to  be  kept  in  ignorance  of  the  treatment,  either  the  gray  powder  or  the 
bichloride  may  be  given  by  the  mouth.  The  usual  dose  of  the  gray  powder 
should  be  gr.j  four  times  a  day;  that  of  the  bichloride  gr.  -^  four  times  a 
day,  always  well  diluted.  It  is  rare  that  larger  doses  are  advisable.  When 
the  symptoms  are  urgent,  it  is  often  best  to  substitute  calomel  for  a  few 
weeks,  as  the  system  can  usually  be  brought  more  rapidly  under  the  influ- 
ence of  mercury  by  this  than  by  the  other  preparations  mentioned ;  gr.  ^ 
four  times  a  day  is  the  usual  dose  required.  Other  methods  of  administra- 
tion and  other  preparations  offer  no  advantages,  and  have  some  very  ob- 
vious disadvantages. 

The  iodide  of  potassium  is  to  be  used,  either  alone  or  in  combination 
with  mercury,  whenever  such  lesions  exist  as  are  classed  among  adults  as 
tertiary.  This  includes  all  the  late  manifestations,  and  the  earlier  ones 
whenever  the  bones  or  viscera  are  affected.  The  iodide  is  usually  well 
borne  by  children,  and  may  be  given  in  almost  any  desired  dosage.  In 
infancy  it  is  rare  that  more  than  twenty  grains  daily  are  required,  but 
in  older  children  the  necessary  amount  may  be  from  one  to  two  drachms 
daily.     It  should  always  be  given  largely  diluted. 

The  duration  of  mercurial  treatment  should  be  at  least  one  year.  The 
doses  during  the  last  six  months  may  be  reduced  to  one  half  or  one  third 
those  employed  while  active  symptoms  are  present.  Treatment  should  be 
longer  than  a  year  if  symptoms  exist.  It  is  often  better  not  to  give  the 
mercury  continuously,  but  with  short  periods  of  intermission. 

The  tonic  treatment  of  syphilis  is  important  and  should  not  be  neg- 
lected. After  specific  treatment  has  been  carried  on  for  a  time,  particu- 
larly if  rapidly  pushed,  the  child  often  becomes  anemic,  and  suffers  greatly 
from  general  malnutrition.  Under  such  circumstances  also  it  is  often 
wise  to  discontinue  mercury  altogether  for  a  time,  or  at  least  to  reduce 
the  dose  very  much,  and  administer  cod-liver  oil,  iron,  wine,  and  other 


INFLUENZA.  1111 

tonics.  Such  a  change  is  frequently  found  to  act  most  beneficially,  even 
when  lesions  are  present,  which  perhaps  have  been  very  little  or  not  at  all 
affected  by  the  specific  remedies  employed.  A  judicious  combination  of 
specific  and  tonic  treatment  is  required  in  every  case,  whether  the  reme- 
dies are  given  simultaneously  or  alternately. 

Local  treatment. — Ulcerative  lesions  of  the  skin  require  cleanliness, 
dusting  with  calomel  or  iodoform,  or  bathing  with  the  black  wash.  Mu- 
cous patches  should  be  dusted  with  equal  parts  of  calomel  and  bismuth. 
Fissures  and  ulcers  of  the  mucous  membranes  should  be  treated  by  nitrate 
of  silver.  Phagedenic  ulcers  of  the  palate  or  nose  should  be  cauter- 
ized with  nitric  acid  or  the  acid  nitrate  of  mercury.  The  late  syphilitic 
ulcers  of  the  skin,  due  to  the  breaking  down  of  gummata,  should  be 
treated  with  iodoform. 


CHAPTEK    XII. 

INFLUENZA. 

Synouym :  La  grippe. 

IxFLT'EXZA  is  an  infectious,  communicable  disease,  which  is  now 
generally  admitted  to  be  due  to  the  bacillus  described  by  Pf eiffer  in  1892. 
It  is  serious  in  children  chiefly  from  its  tendency  to  complications  of 
the  respiratory  tract,  in  which  respect  it  closely  resembles  measles. 

Etiology. — The  influenza  bacillus  is  found  chiefly  in  the  sputum  and 
nasal  discharge;  it  is  also  present  in  the  lower  air-passages,  and  has  occa- 
sionally been  found  in  the  exudation  of  otitis,  empyema,  and  meningitis 
accompanying  the  disease,  but  rarely  in  the  blood.  It  is  not  easily  de- 
tected in  the  sputum,  repeated  examinations  often  being  necessary;  but 
in  typical  attacks  if  carefully  sought  it  is  found  with  great  uniformity. 
In  acute  cases  it  may  disappear  very  early;  in  protracted  cases  its  pres- 
ence is  sometimes  detected  for  weeks  or  even  months.  Besides  the  bacil- 
lus of  Pfeiffer,  there  are  frequently  found,  either  associated  or  separate- 
ly, in  the  organs  of  patients  dying  from  influenza,  the  streptococcus  and 
the  diplococcus  pneumonia?,  for  the  development  of  which  influenza 
creates  conditions  in  the  highest  degree  favourable. 

Influenza  is  highly  contagions;  the  poison  ma)'  be  carried  by  cloth- 
ing or  fomites  and  clings  for  some  time  to  infected  apartments.  The 
disease  prevails  epidemically,  and  after  epidemics  it  may  be  endemic 
for  a  number  of  years.  In  New  York  the  disease  has  probably  been 
present  for  many  years,  although  it  attracted  little  attention  under  the 
name  of  influenza  until  the  great  epidemic  of  1891.  Epidemics  prevail 
chiefly  in  winter  and  spring.     All  ages  are  liable  to  the  disease,  infants 


1112  THE  SPECIFIC  INFECTIOUS  DISEASES. 

under  one  year  least  so,  and  in  some  epidemics  they  may  escape  alto- 
gether. The  disease  has,  however,  been  observed  in  infants  only  a  few 
days  old,  where  the  mother  was  suffering  from  it  at  the  time  of  delivery. 
The  children  most  frequently  affected  are  those  from  two  to  ten  years 
of  age. 

The  period  of  incubation  is  uncertain.  It  is  usually  short,  being  gen- 
erally believed  to  be  from  one  to  seven  days.  Little  if  any  immunity 
seems  to  be  afforded  by  one  attack;  recurrences  and  second  attacks  are 
not  uncommon  in  the  same  epidemic,  and  a  patient  who  has  once  had 
influenza  seems  to  be  more  susceptible  to  the  disease  in  consequence. 

Lesions. — There  are  no  characteristic  lesions  of  influenza;  those 
which  are  most  frequently  found  are  due  to  catarrhal  inflammation  of 
the  respiratory  or  the  digestive  tract.  In  some  cases  only  the  upper 
respiratory  tract  is  involved,  in  which  case  the  disease  often  spreads  to 
the  middle  ear;  in  others,  only  the  lower  respiratory  tract,  this  in  in- 
fancy usually  spreading  rapidly  to  the  lungs,  and  resulting  in  broncho- 
pneumonia. Inflammation  of  the  stomach  and  intestines  is  much  less 
frequent  and,  as  a  rule,  less  severe.  This  will  be  considered  more  fully 
under  Complications. 

Symptoms. — The  symptoms  of  influenza  are  due  to  the  systemic  effects 
of  a  general  poison,  and  to  certain  local  congestions  and  inflammations 
which  are  regarded  as  complications.  The  two  classes  of  symptoms — the 
general  and  the  local  ones — are  found  in  all  possible  combinations. 

1.  The  mild,  uncomplicated  variety. — This  lasts  from  two  to  five  days, 
occasionally  a  week.  The  onset  is  usually  abrupt,  with  chilliness,  mus- 
cular pains,  and  sometimes  vomiting.  The  temperature  ranges  from  101° 
to  103°  F.  Even  though  the  fever  is  not  high,  the  prostration  is  consider- 
able, and  children  are  often  ill  enough  to  remain  in  bed  for  several  days. 
The  usual  general  symptoms  which  accompany  fever  are  present.  After 
the  fever  has  subsided,  the  child  is  left  weak  and  anaemic;  convalescence 
is  frequently  protracted,  and  it  may  be  three  or  four  weeks  before  the 
general  health  is  regained.  This  is  the  most  common  variety  seen,  the 
essential  symptoms  being  fever  and  prostration  without  evidences  of 
local  inflammation.  Often  there  is  in  addition  a  mild  coryza  at  the 
outset  and  a  slight  but  persistent  cough. 

2.  Uncomplicated  cases  of  the  severe  type. — These  are  not  very  frequent 
in  children.  They  are  characterized  by  high  temperature,  severe  toxic 
symptoms,  and  great  prostration.  They  often  resemble  cases  of  pneu- 
monia, except  that  the  local  symptoms  and  physical  signs  in  the  chest 
are  wanting.  The  onset  is  usually  abrupt  with  vomiting  and  headache, 
sometimes  even  with  convulsions.  The  temperature  ranges  from  100° 
to  106-5°  F.  It  seldom  remains  steadily  high,  but  often  fluctuates  widely. 
I  have  repeatedly  seen  a  temperature  over  106°  F.  in  uncomplicated 
influenza.     Marked  nervous  symptoms  are  usually  present;  there  may 


INFLUENZA. 


1113 


be  headache,  photophobia,  delirium,  stupor,  opisthtotonus,  and  convul- 
sions— all  strongly  suggesting  meningitis,  but  not  so  continuous  as  in 
that  disease.  In  other  cases  the  tongue  has  a  brown  coating,  the  lips 
are  dry  and  parched,  the  pulse  is  weak  and  rapid,  and  other  symptoms  of 
the  typhoid  condition  are  present.  The  usual  duration  of  these  severe 
attacks  is  from  two  to  five  days;  but  even  where  no  complication  devel- 


March  1:3 

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Fig.  200. — Temperature  chart  of  uncomplicated  influenza;  infant  fourteen  months  old.  No 
local  signs  of  disease;  repeated  blood  examinations  for  malaria  negative;  the  wide  fluctu- 
ations of  the  temperature  independent  of  therapeutic  measures.  Prompt  cessation  of  fever 
on  removal  from  the  city.     (Patient  seen  with  Dr.  L.  E.  La  F6tra.) 

ops  severe  symptoms  may  last  for  two  weeks  and  sometimes  longer  until 
a  change  of  climate  is  made.  (See  Fig.  200.)  Although  the  symptoms 
are  very  alarming,  except  in  young  infants,  the  attacks  are  seldom  fatal 
unless  pneumonia  develops;  but  it  may  be  a  long  time  before  the  full 
effects  of  such  an  illness  have  entirely  disappeared. 

3.  Cases  complicated  hy  catarrhal  inflammation  of  the  upper  respira- 
tory tract. — In  this  group  there  are  added  to  the  general  symptoms  of  the 
mild  uncomplicated  variety,  a  severe  coryza,  with  pharyngitis  and  often 
stomatitis.  The  catarrhal  symptoms  differ  from  ordinary  catarrh  of 
these  mucous  membranes  chiefly  in  severity.  They  are  also  likely  to  be 
more  prolonged,  and  there  is  a  greater  tendency  to  involve  the  ears  and 
the  cervical  lymph  nodes.  The  usual  symptoms  of  acute  rhino-pharyn- 
gitis are  present  with  its  serous,  sero-mucous,  or  muco-]nirulent  dis- 
charge.   The  whole  pharynx  may  be  the  seat  of  an  acute,  erythematous 


1114  THE   SPECIFIC   INFECTIOUS   DISEASES. 

blush,  or  the  mucous  membrane  may  present  a  granular  or  spongy  appear- 
ance. The  tonsils  are  red;  occasionally  there  is  follicular  tonsillitis; 
rarely  membranous  patches.  The  nostrils  and  upper  lip  are  often  ex- 
coriated from  the  nasal  discharge.  The  mouth  may  be  the  seat  of  a  sim- 
lAe  or  a  herpetic  stomatitis  with  superficial  ulceration.  These  catarrhal 
symptoms  are  usually  severe  for  three  or  four  days,  and  gradually  sub- 
side. In  infants  the  temperature  may  be  104°  or  105°  F.  at  the  outset, 
but  continues  high  only  for  a  day  or  two.  In  older  children  the  tempera- 
ture ranges  from  100°  to  102°  F. 

There  are  two  complications  which  in  infancy  are  very  frequent — 
otitis  and  cervical  adenitis.  Otitis  may  be  either  catarrhal  or  purulent. 
It  runs  the  usual  course  of  otitis  following  simple  catarrhal  processes  of 
the  pharynx,  and  usually  terminates  in  complete  recovery.  Exceptionally 
these  cases  may  go  on  to  the  development  of  chronic  otitis,  or  the  disease 
may  extend  to  the  mastoid  cells.  In  addition  to  the  severe  cases,  there 
are  frequently  seen  attacks  of  catarrhal  deafness  from  inflammation  of 
the  Eustachian  tube.  Pain  in  this  form  is  less  severe,  and  may  be  ab- 
sent; there  is  no  increased  fever.  Deafness  is  the  chief  symptom,  and 
in  most  cases  it  disappears  spontaneously. 

The  adenitis  usually  involves  either  the  lymph  nodes  situated  below 
the  ear  and  behind  the  angle  of  the  jaw,  or  those  of  the  retro-pharyngeal 
region.  The  inflammation  runs  the  usual  course  of  such  inflammations 
when  associated  with  other  diseases. 

4.  Cases  with  hroncho-pulmonary  complications. — A  moderate  amount 
of  inflammation  of  the  mucous  membrane  of  the  larynx,  trachea,  and 
large  bronchi  occurs  in  most  of  the  cases  of  influenza.  In  the  more 
severe  forms,  broncho-pneumonia  or  lobar  pneumonia  often  develops. 
Sometimes  the  pulmonary  symptoms  do  not  appear  for  two  or  three  days, 
or  even  a  week;  at  other  times  they  are  coincident  with  the  development 
of  the  fever  and  other  constitutional  symptoms,  and,  except  for  the  prev- 
alence of  influenza,  this  would  not  be  considered  a  factor  in  these  cases. 
A  striking  feature  in  these  attacks  is  that  the  temperature,  prostration, 
and  cerebral  symptoms  are  out  of  all  proportion  to  the  pulmonary  signs 
and  symptoms. 

The  broncho-pneumonia  complicating  influenza  may  not  differ  essen- 
tially from  the  ordinary  types,  except  that  the  proportion  of  cases  whicli 
do  not  go  on  to  the  development  of  areas  of  consolidation  is  larger  than 
is  seen  under  most  other  conditions.  If  lobar  pneumonia  develops,  it 
frequently  runs  its  regular  course.  But  besides  these  two  varieties  of 
pneumonia,  quite  a  large  number  of  cases  of  an  irregular  type  are  seen 
with  influenza.  These  are  often  of  short  duration,  but  accompanied  by 
extremely  high  temperature  (Fig.  201).  In  many  cases  there  is  an  ex- 
cessive amount  of  pleurisy,  so  that  the  process  is  really  a  pleuro-pneu- 
monia.     In  an  epidemic  occurring  in  the  New  York  Infant  Asylum  in 


INFLUENZA. 


1115 


the  winter  of  1801  and  1892  nearly  ever}'  pneumonia  ^vas  of  this  type, 
and  in  a  few  weeks  there  were  about  twenty  cases,  all  of  a  very  severe 
form.    This  is  often  followed  by  empyema. 

5.  Cases  ivith  ffaslro-enteric  coiit plications. — Vomiting  and  diarrhoea 
are  frequent  at  the  beginning  of  influenza,  and  in  some  cases,  especially  in 
infants,  they  may  be  the  predomi- 
nant symptoms  of  the  attack.  The 
stools  may  be  large  and  fluid,  or 
they  may  contain  mucus  and  even 
blood,  and  be  passed  with  pain  and 
tenesmus  —  the  symptoms  being 
those  of  an  acute  gastritis  or  of 
ileo-colitis  of  moderate  severity. 
The  duration  of  these  attacks  is 
usually  three  or  four  days,  and 
except  in  very  young  or  delicate 
children  they  are  rarely  fatal.  In 
older  children  there  may  be  initial 
vomiting,  abdominal  pain,  tym- 
panites, protracted  diarrhoea,  and 
other  symptoms  strongly  suggest- 
ive of  typhoid  fever. 

6.  Influenza  in  very  young  in- 
fants.— The  severe  cases  in  infants 
under  six  months  old  often  pre- 
sent peculiar  features.  The  tem- 
perature may  be  very  high,  or  it  may  be  only  two  or  three  degrees  above 
the  normal,  but  the  prostration  is  extreme.  The  eyes  are  sunken,  the 
face  is  pale,  there  is  marked  apathy,  and  food  is  often  refused  altogether. 
In  other  cases  there  is  cyanosis  and  very  rapid  respiration,  indicating 
acute  congestion  of  the  lungs,  although  no  abnormal  signs  are  present, 
except  very  feeble  breathing  sounds.  Nearly  always  tbere  is  a  disturb- 
ance of  digestion,  with  vomiting  and  undigested  stools.  Death  may 
occur  in  two  or  three  days;  sometimes  it  is  postponed  for  a  week,  the 
chief  symptoms  being  gradually  increasing  prostration,  and  finally  col- 
lapse, without  the  development  of  any  marked  local  evidences  of  dis- 
ease. The  system  seems  in  these  cases  to  be  overjiowered  by  the  intensity 
of  the  poison.  In  other  cases  pneumonia  (l('\cl(»i)s,  and  from  this  death 
occurs. 

7.  Protracted  cases. — There  has  long  seemed  to  be  sufficient  clinical 
ground  for  the  opinion  that  influenza  poisoning  may  sometimes  assume 
a  chronic  or  persistent  form,  and  Pfeifl'er  and  others  have  demonstrated 
the  presence  of  the  influenza  bacillus  for  months  in  the  secretions  of 
such  patients.     The  protracted  cases  in  my  exjierience  have  almost  in- 


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Fig.  201. — Acute  bvonclio-pneunionia,  abor- 
tive type,  complicating  influenza,  in  an 
infant  six  months  old.  The  entire  left 
lung  posteriorly,  was  involved. 


1116  THE  SPECIFIC  INFECTIOUS  DISEASES. 

variably  been  preceded  by  a  well-defined  acute  attack,  after  which  there 
is  improvement  but  not  recovery,  and  an  irregular  low  fever  follows, 
which  may  drag  on  indefinitely.  The  temperature  is  not  high,  seldom 
above  102*5°,  often  not  above  101-5°  F.  The  patients  are  not  sick 
enough  to  remain  in  bed;  there  is  in  most  cases  neither  cough  nor  other 
catarrhal  symptoms,  only  the  general  symptoms  of  a  chronic  poisoning — 
poor  appetite,  coated  tongue,  ansemia,  headache,  lassitude,  irritability, 
and  occasional  pains.  The  cases  are  often  called  malaria,  or  chronic 
intestinal  poisoning,  and  not  infrequently  tuberculosis  is  suspected. 
But  the  special  features  of  all  these  diseases  are  wanting.  In  the  cases 
I  have  seen  the  symptoms  have  been  controlled  by  change  of  climate, 
but  without  this  they  have  usually  continued  until  the  following  warm 
season. 

Complications  and  Sequelae. — The  most  frequent  ones — pneumonia, 
otitis,  acute  adenitis,  and  gastro-enteritis — have  already  been  considered. 
Cutaneous  eruptions  are  not  infrequent,  and  are  often  very  puzzling. 
There  may  be  a  general  eruption  resembling  urticaria,  or  an  erythema 
which  sometimes  simulates  measles,  but  more  frequently  scarlet  fever. 
These  eruptions  are  irregular  in  their  course  and  often  in  their  distribu- 
tion, and  are  not  followed  by  desquamation.  In  most  of  the  cases  with 
High  temperature  the  urine  contains  albumin;  although  nephritis  is  rare, 
one  should  be  on  the  watch  for  it  even  in  young  children.  I  once  saw 
acute  pyelitis  as  a  complication.  The  nervous  sequelae  of  adults — men- 
tal disturbances,  multiple  neuritis,  etc. — are  extremely  rare  in  child- 
hood, although  they  have  been  observed.  One  of  the  most  frequent  se- 
quelse  is  anaemia;  this  may  be  very  severe,  and  in  one  case  I  have  known 
it  to  continue  to  a  fatal  termination.  Following  the  inflammation  of 
the  mucous  membranes,  there  may  be  enlarged  tonsils,  adenoid  growths 
of  the  pharynx,  or  chronic  enlargement  of  the  cervical  lymph  glands. 
Attacks  of  influenza  bear  the  same  relation  to  the  development  of 
tuberculosis  as  do  those  of  measles. 

Convalescence  after  influenza  is  usually  very  slow,  and  it  is  often 
many  months  before  the  full  effects  of  a  severe  attack  have  disappeared. 
A  recurrence  of  the  symptoms  before  complete  recovery  is  not  uncom- 
mon, and  often  second  attacks  during  the  same  season  are  seen.  For  a 
long  time  the  mucous  membranes  are  in  an  extremely  sensitive  condition. 
Eelapses  are  often  brought  about  by  slight  exposure  before  the  symp- 
toms have  quite  disappeared,  and  I  have  often  seen  them  occur  simply 
from  airing  an  infant  in  the  room. 

Diagnosis. — This  is  usually  easy  when  the  disease  is  epidemic.  The 
sporadic  cases  often  present  great  difficulties,  particularly  early  in  the 
disease.  It  is  often  impossible  to  tell  for  two  or  three  days  whether  the 
case  is  one  of  pneumonia,  malaria,  or  influenza.  In  most  of  the  severe 
cases  I  have  seen,  pneumonia  has  been  the  diagnosis  first  made;  it  is 


INFLUENZA.  1117 

only  by  the  course  of  the  disease  and  the  absence  of  any  physical  signs, 
as  shown  by  careful  and  repeated  examinations,  that  influenza  can  be 
distinguished  from  pneumonia.  From  malaria,  influenza  is  differentiated 
by  the  fact  that  the  fever  is  not  materially  affected  by  quinine,  there 
are  no  organisms  in  the  blood,  and  the  spleen  is  not  usually  enlarged. 

The  cerebral  symptoms  are  less  continuous  than  in  meningitis  and 
are  usually  in  direct  proportion  to  the  fever.  In  the  protracted  cases,  the 
temperature  may  bear  some  resemblance  to  typhoid,  but  the  other  char- 
acteristic symptoms  of  that  disease  are  wanting.  Measles  is  distin- 
guished by  Koplik's  spots.  In  its  mode  of  onset,  and  sometimes  in  its 
eruption,  influenza  often  resembles  scarlet  fever,  but  the  course  of  the 
symptoms  usually  clears  up  the  doubt.  In  general,  influenza  is  charac- 
terized by  severe  constitutional  symptoms  without  evidence  of  local  dis- 
ease of  sufficient  importance  to  explain  the  temperature. 

From  ordinary  catarrh,  influenza  differs  only  in  its  high  communica- 
bility,  its  severity,  and  the  frequency  with  which  it  is  complicated  by 
otitis,  adenitis,  and  pneumonia.  Mild  cases  when  not  epidemic  can  not 
be  distinguished  from  simple  catarrh  of  the  respiratory  tract. 

Although  in  most  cases  the  bacilli  may  be  found  by  staining  the 
sputum  or  nasal  discharge,  or  may  be  cultivated  from  either  of  these, 
the  difficulties  in  the  way  are  such  that  this  method  of  diagnosis  has  been 
as  yet  but  little  employed.  In  many  cases  the  bacilli  disappear  early, 
and  in  others  careful  and  repeated  examinations  are  necessary  to  dis- 
cover them.  In  general,  therefore,  the  other  symptoms  of  influenza  must 
be  relied  upon  for  diagnosis.  Since  none  of  these  is  wholly  characteris- 
tic, exact  diagnosis  is  by  no  means  easy,  and  in  some  cases  it  may  be 
impossible.  A  probable  diagnosis  is  made  by  excluding  the  other  dis- 
eases mentioned;  the  probability  is  greatly  increased  if  influenza  is  prev- 
alent, especially  if  there  are  other  cases  in  the  same  house.  The  tend- 
ency in  practice  is  to  call  a  great  many  other  kinds  of  infection  by  the 
name  of  influenza,  particularly  when  the  disease  is  epidemic. 

Prognosis. — As  a  rule,  the  type  of  influenza  seen  in  children  is  milder 
than  that  which  occurs  in  adults.  In  the  case  of  children  previously 
healthy,  few  die  except  from  pulmonary  complications,  while  the  great 
majority  of  attacks  are  mild  and  recovery  is  prompt.  In  infants  the 
tendency  to  pulmonary  complications  is  much  greater  than  in  older  chil- 
dren. Uncomplicated  cases  are  seldom  fatal,  except  in  infants  under  six 
months  old;  and  even  though  the  temperature  is  very  high  and  the  symp- 
toms severe,  recovery  may  usually  be  predicted  as  long  as  there  is  no 
evidence  of  serious  complications.  The  prognosis  of  the  pneumonia  of 
influenza  is  rather  worse  than  that  of  simple  broncho-pneumonia,  and 
depends  chiefly  upon  the  age  of  the  patients  affected.  In  a  word,  in- 
fluenza is  ])articularly  serious  in  the  very  young,  or  when  there  are  pul- 
monary coini)lications,  but  rarely  otherwise.  In  infants  the  constitu- 
72 


1118  THE   SPECIFIC  INFECTIOUS  DISEASES. 

tional  depression  which  results  may  be  the  beginning  of  a  condition  of 
malnutrition  which  goes  on  to  the  development  of  marasmus;  or  a  child 
falls  an  easy  victim  to  some  other  form  of  acute  disease.  The  remote 
effects  of  influenza  may  therefore  be  serious,  even  though  the  attack 
itself  is  not  especially  severe. 

Treatment. — The  communicability  of  the  disease  makes  it  desirable 
that  cases  of  influenza  should  be  isolated  whenever  practicable,  and  par- 
ticularly that  delicate  children,  or  those  prone  to  pulmonary  disease, 
should  not  be  exposed.  The  fumigation  of  apartments  after  attacks 
should  be  regularly  practised,  preferably  with  formalin  gas;  this  with 
isolation  will  do  much  to  control  house  epidemics. 

The  disease  usually  runs  its  course,  when  uncomplicated,  in  from 
three  to  seven  days.  As  there  is  no  specific  for  influenza,  the  indications 
are  to  sustain  the  patient,  to  make  him  comfortable  during  the  attack, 
and  to  prevent  so  far  as  possible  the  occurrence  of  complications.  Every 
child  witli  influenza  should  be  put  to  bed  and  kept  there  during  acute 
symptoms.  At  the  outset  the  bowels  should  be  opened  by  castor-oil  or 
calomel,  and  free  perspiration  induced  by  the  use  of  hot  drinks,  the  hot 
pack,  or  small  doses  of  Dover's  powder  in  combination  with  phenacetine. 
A  very  high  temperature  should  be  relieved  by  cold  sponging  or  the  cold 
pack,  precisely  as  in  pneumonia,  but  large  doses  of  antipyretic  drugs  are 
to  be  avoided.  The  nervous  symptoms — restlessness,  pain,  headache,  and 
other  disturbances — are  best  controlled  by  phenacetine  in  combination 
with  codeine — e.  g.,  to  a  child  of  one  year,  phenacetine  gr.  j,  codeine  gr. 
3V5  every  three  or  four  hours.  Double  the  dose  may  be  given  to  a  child 
of  four  years.  Alcoholic  stimulants  are  required  whenever  the  pulse 
shows  signs  of  weakness,  as  it  does  in  most  of  the  severe  cases,  and  in 
most  young  infants.  They  should  be  given  according  to  the  same  rule& 
as  in  pneumonia.  Next  to  alcohol,  strychnine  is  the  most  valuable  heart 
stimulant. 

In  older  children  there  is  a  decided  advantage  in  the  use  of  moder- 
ately large  doses  of  quinine — e.  g.,  gr.  ij,  four  or  five  times  a  day,  to  a 
child  five  years  old;  but  in  infants  this  should  be  omitted,  on  account 
of  its  tendency  to  upset  the  stomach.  The  cough  which  so  often  persists 
after  influenza  is  best  controlled  by  cod-liver  oil  and  creosote,  used  as 
after  acute  bronchitis.  With  persistent  bronchitis  which  resists  ordinary 
remedies,  a  patient  should  be  sent  to  a  warm,  dry  climate.  The  compli- 
cations of  influenza  are  to  be  treated  as  they  arise,  in  the  same  manner 
as  when  they  occur  under  other  conditions.  In  all  cases  careful  feeding 
in  accordance  with  the  general  rules  laid  down  for  feeding  in  acute  dis- 
eases, good  nursing,  and  care  to  avoid  exposure  during  convalescence, 
are  essentials  in  treatment.  One  should  be  particularly  anxious  about 
patients  who  have  a  strong  tendency  to  tuberculosis,  and  such  cases 
should  be  watched  with  the  greatest  solicitude. 


MALARIA.  1119 

In  prolonged  or  constantly  recurring  attacks  nothing  is  of  much 
avail  except  a  change  of  air.  If  this  is  impossible,  a  child  should  be  fre- 
quently removed  from  one  apartment  to  another,  as  re-infection  often 
appears  to  take  place  from  the  sick-room. 


CHAPTEE    XIII. 
MALARIA. 

Malaeia  is  a  general  infectious  disease  due  to  the  presence  in  the 
blood  of  a  specific  organism  often  called  the  pJasmodium,  but  more  ex- 
actly the  hcematocytozoon  malarice.  It  manifests  itself  in  children  by  the 
ordinary  acute  febrile  attacks  which  are  seen  in  adults  and  by  chronic 
malarial  poisoning.  Both  of  these  forms  may  present  certain  peculiar 
symptoms  dependent  upon  the  age  of  the  patient. 

Etiology. — The  malarial  organism  was  discovered  by  Laveran  in  1881; 
it  is  a  parasite  of  the  blood  and  belongs  to  the  group  of  protozoa.  It  is 
now  well  established  that  the  parasite  enters  the  blood  through  the  bite 
of  certain  forms  of  mosquito,  those  belonging  to  the  genus  Anopheles, 
and  probably  in  no  other  way.  For  this  knowledge  we  are  indebted 
chiefly  to  the  work  of  Eonald  Koss,  in  India,  in  1897.  For  a  general 
discussion  of  the  malarial  parasite,  its  methods  of  staining,  etc.,  the 
reader  is  referred  to  works  on  clinical  medicine. 

Malaria  affects  all  ages,  even  the  newly-born  infant.  We  must  accept 
with  some  allowance  the  statements  made  by  the  older  writers  upon  the 
subject  of  intra-uterine  infection,  but  in  the  following  case  occurring  in 
the  practice  of  my  former  associate,  Dr.  Crandall,  there  seems  little 
doubt  that  the  disease  was  contracted  in  utero:  For  ten  days  before  de- 
livery the  mother  had  suffered  from  a  tertian  intermittent  of  moderate 
severity.  Eighteen  hours  after  birth  the  child  was  noticed  to  have  cold 
hands  and  feet,  blue  lips  and  nails,  and  a  pinched  face.  These  symptoms 
lasted  about  half  an  hour  and  were  followed  by  a  distinct  fever.  Upon 
the  following  day  the  paroxysm  was  repeated.  Examination  of  the  blood 
of  both  mother  and  child  was  made  by  Dr.  Walter  James,  who  found  the 
malarial  organisms  in  both  cases. 

Malaria  is  more  frequently  overlooked  in  young  children  than  in  later 
life,  from  the  fact  that  its  forms  are  more  irregular,  and  this  has  led  to 
the  belief  that  young  children  are  less  liable  than  adults  to  the  disease. 
I  believe,  however,  the  opposite  to  be  the  case.  In  a  large  number  of  in- 
stances where  families  have  been  exposed  to  malarial  poisoning  I  have 
noted  that  the  young  children  were  frec{uently  the  first  to  show  the 
symptoms  of  the  disease. 


1120  THE   SPECIFIC  INFECTIOUS  DISEASES. 

Malaria  is  an  endemic  disease  prevailing  in  certain  localities.  Exact 
knowledge  regarding  the  mode  of  infection  has  cleared  up  many  obscure 
points  in  the  etiology  of  this  disease.  The  role  of  the  mosquito  explains 
the  greater  liability  to  contract  malaria  after  sunset  and  during  the 
night,  the  danger  from  stagnant  ponds  and  pools  of  water,  the  peculiar 
susceptibility  of  infants  and  young  children,  and  the  greater  frequency 
of  the  disease  in  the  spring  and  summer.  Malarial  attacks  may,  however, 
occur  at  any  season,  since  the  poison  may  be  latent  in  the  body  for  an 
indefinite  time;  how  long  it  is  impossible  to  say,  but  there  seems  to  be 
conclusive  proof  that  it  may  be  for  many  months.  Attacks  of  malaria 
very  often  occur  when  the  general  health  has  been  reduced  by  some  other 
caiise,  particularly  by  disturbances  of  digestion. 

Lesions. — Opportunities  for  a  study  of  the  peculiarities  of  the  lesions 
of  malaria  in  children  are  infrequent,  especially  in  ISTew  York,  as  fatal 
cases  are  extremely  rare.  I  have  myself  seen  but  two.  As  observed  by 
others,  the  lesions  do  not  differ  in  any  marked  way  from  the  adult  form 
of  the  disease.  The  most  important  changes  are  the  destruction  of  the 
red  corpuscles  of  the  blood,  enlargement,  and  in  chronic  cases  hyper- 
plasia with  pigmentation  of  the  spleen;  less  frequently  pigmentation  of 
the  liver,  kidneys,  and  brain.  Pneumonia  and  gastro-enteritis  are  occa- 
sional complications. 

Symptoms. — The  clinical  forms  of  malarial  fever  in  children  from  six 
to  ten  years  old,  do  not  differ  essentially  from  the  same  disease  in  adults. 
Both  intermittent  and  remittent  forms  occur,  the  former  being  the  type 
usually  seen.  Of  the  different  varieties  of  intermittent  fever,  the  quo- 
tidian (Fig.  202)  is  the  most  common,  although  the  tertian  (Fig.  203)  is 
fairly  frequent,  but  in  this  locality  the  quartan  is  extremely  rare.  The 
stages  of  the  paroxysm  are  generally  well  marked.  The  cold  stage  begins 
with  a  chill  or  vomiting,  with  headache,  lassitude,  and  general  pains. 
The  hot  stage  is  usually  characterized  by  a  higher  temperature  than  in 
adults,  and  this  is  followed  by  the  sweating  stage,  which  is  generally 
marked.  The  paroxysm  may  be  repeated  every  day  or  every  other  day 
until  controlled  by  quinine,  or  the  stages  may  become  less  and  less  dis- 
tinct as  the  disease  progresses  until  a  more  or  less  remittent  tjqoe  of  fever 
develops.  Less  frequently  the  fever  is  remittent  from  the  beginning  and 
the  constitutional  symptoms  are  of  greater  severity.  In  this  form  there 
is  marked  prostration,  the  tongue  is  thickly  coated,  there  are  often  ten- 
derness and  pain  in  the  region  of  the  liver,  and  occasionally  there  is 
slight  jaundice. 

In  infants  and  very  young  children  peculiar  types  of  malaria  are 
seen.  A  well-marked  intermittent  fever  with  distinct  stages  is  often 
absent,  many  cases  assuming  more  of  a  remittent  type  or  an  irregular 
form  of  intermittent  (Fig.  204).  The  onset  is  usually  abrupt  with  vomit- 
ing, a  well-marked  chill  beins^  rare.    Malarial  chills  are  not  often  wit- 


MALARIA. 


1121 


nessed  in  children  under  five  years  old.  They  are  replaced  in  infants  by 
cold  hands  and  feet,  blue  lips  and  nails,  sometimes  slight  general  cyano- 
sis, pallor,  drowsiness,  and  prostration.  A'omiting  has  been  present  in 
two  thii'ds  of  my  own  cases.  Several  times  have  I  seen  a  malarial  attack 
ushered  in  by  convulsions. 

The  fever  is  relatively  higher  than  in  adults,  rising  rapidly  to  104°  or 
105°  F.,  occasionally  to  106°  or  106-5°  F.  This  continues  from  four  to 
twelve  hours  and  gradually  falls,  usually  to  normal.  The  other  constitu- 
tional symptoms  of  the  febrile  stage  are  much  less  severe  than  in  most 


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Fig.  202.— Typical  malarial  temperature,  quotidian  type,  in  a  boy  six  years  old.  Each  paroxysm 
preceded  oy  a  chill.  It  will  be  noticed  that  the  temperature  rose  higlier  with  each  suc- 
ceeding paroxysm  :  x  uiarks  the  time  when  quinine  was  begun. 


diseases  with  the  same  elevation  of  temperature.  The  sweating  stage 
is  only  slightly  marked  and  is  often  absent  altogether.  With  the  fall 
in  the  temperature  there  is  a  gradual  subsidence  of  all  the  other  symp- 
toms of  the  febrile  stage. 

After  the  first  paroxysm  the  patient  may  be  quite  well  for  several 


1122 


THE  SPECIFIC  INFECTIOUS   DISEASES. 


hours  or  even  for  a  day,  when  the  second  paroxysm  occurs.  This  is  gen- 
erally not  so  well  marked  as  the  first  one,  the  third  may  be  even  less  so, 
and  the  case  may  resemble  more  and  more  one  of  continuous  fever  with 
wide  oscillations  in  the  temperature.    In  some  cases  it  is  remittent  at  first 


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Fig.  203. — Typical  malarial  temperature,  tertian  type,  in  a  boy  five  years  old.  Onset  with 
vomiting  and  drowsiness,  but  no  chill.  This  was  an  anticipating  intermittent,  the  first 
paroxysm  occurring  at  3  p.  m.,  the  second  at  12  m.,  the  third  at  10  a.  m.  ;  x  marks  the  time 
when  quinine  was  begun. 

and  later  becomes  intermittent,  but  it  is  very  rare  under  any  circum- 
stances that  the  temperature  does  not  touch  the  normal  point  at  some 
time  in  the  twenty-four  hours.  In  infants  the  quotidian  has  been  in  my 
experience  very  much  more  frequent  than  any  other  type,  the  tertian 
being  rare  and  the  quartan  almost  unknown. 

Enlargement  of  the  spleen  is  present  in  the  great  majority  of  cases, 
and  usually  to  a  sufficient  degree  to  be  readily  appreciated  by  examina- 
tion. The  most  satisfactory  method  of  examination  is  by  palpation  (page 
8T8).  A  spleen  which  can  be  easily  felt  below  the  ribs  (except  in  the 
rare  cases  in  which  the  organ  is  displaced  downward  by  some  condition 
in  the  thorax)  is  enlarged.     When  it  is  not  sufficiently  enlarged  to  be 


MALARIA. 


1123 


readily  felt  Id}'  a  practised  observer  under  favourable  conditions  for  ex- 
amination, it  is  not  large  enough  to  be  of  any  diagnostic  importance. 
Kone  of  the  other  symptoms  occurring  in  malarial  fever  are  character- 
istic; they  are  quite  similar  to  those  which  are  seen  in  almost  all  febrile 
attacks.    They  are  anorexia,  coated  tongue,  constipation,  and  restlessness. 

Masked  or  Irregular  Forms  of  Malaria. — These  are  quite  frequent  in 
3'ouug  children,  and  are  due  to  the  presence  of  certain  special  or  uncom- 
mon symptoms  which  may  readily  lead  to  a  mistake  in  diagnosis.  They 
are  more  often  seen  than  cases  of  true  malarial  cachexia. 

Among  the  most  frequent  of  the  irregular  forms  are  those  relating 
to  the  nervous  system.  Headache  is  exceedingly  common  and  is  usually 
frontal.  AVhen  severe  and  associated  with  continuous  drowsiness,  vomit- 
ing, and  constipation,  it  may  lead  to  a  strong  suspicion  of  tuberculous 
meningitis.    Vertigo  is  not  a  frequent  symptom,  but  it  is  sometimes  very 


DAY                         1 

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Fig.  204. — An  irregular  malarial  temperature  in  a  child  nine  months  old.  The  paroxysm  on  the 
fourth  day  was  accompanied  by  an  attack  of  acute  pulmonary  confrestion  which  came  near 
being  fatal ;  x  marks  the  time  when  quinine  was  besTun.  Although  the  course  of  the  tem- 
perature is  irregular,  it  touched  the  normal  line  both  on  the  second  and  fourth  days. 


prominent.  Pains  in  various  parts  of  the  body  are  very  common.  A 
sharp  severe  pain  at  the  epigastrium  is  frequent  at  the  beginning  of  a 
paroxysm.  It  is  often  associated  with  tenderness,  but  has  no  relation  to 
meals.     Less  frequcMitly,  pain  is  localized  in  tlie  region  of  the  spleen 


1124  THE  SPECIFIC  INFECTIOUS  DISEASES. 

or  liver.  Trifacial  neuralgia  of  malarial  origin  is  rare  in  childhood. 
Aching  or  dragging  pains  in  the  muscles  of  the  lower  extremities  are 
frequent  symptoms  during  acute  attacks,  but  they  are  of  short  duration, 
disappearing  with  the  fever.  They  are  to  be  distinguished  from  the 
acute  lancinating  pains  of  multiple  neuritis,  which  is  occasionally  seen 
as  a  result  of  malarial  poisoning.  I  have  seen  the  latter  in  young  chil- 
dren in  three  cases,  and  it  has  been  observed  by  others.  The  pain  is 
accompanied  by  tenderness  of  the  muscles  and  nerve  trunks,  and  by  loss 
of  power,  which  is  usually  partial. 

Spasmodic  torticollis  (page  727)  I  have  seen  in  eight  cases,  in  which 
the  condition  seemed  very  clearly  to  depend  upon  malaria.  This  was 
shown  by  the  fact  that  the  spasm  was  intermittent,  coming  on  every  after- 
noon, but  being  absent  in  the  morning;  that  it  was  accompanied  by  a 
slight  rise  in  temperature,  and  usually  by  enlargement  of  the  spleen;  and 
that  it  was  immediately  controlled  by  cj[uinine.  This  combination  of 
symptoms  seemed  to  be  conclusive  evidence  of  the  malarial  origin  of  the 
affection,  although  these  cases  were  observed  before  the  time  when  blood 
examinations  were  made. 

Accompanying  the  paroxysm  of  malaria  there  is  occasionally  seen, 
more  often  in  infants  than  in  older  children,  acute  pulmonary  congestion 
(Fig.  204),  which  may  give  rise  to  obscure  and  often  very  alarming 
symptoms.  There  is  an  acute  onset  with  vomiting  and  prostration,  high 
temperature,  cough,  rapid  respiration,  and  often  slight  cyanosis.  On  ex- 
amination of  the  chest  there  is  found  feeble  or  rude  respiration  over  one 
lung,  or  over  both  lungs  behind,  and  sometimes  coarse  moist  rales;  these 
signs  and  symptoms  may  disappear  in  the  course  of  a  few  hours  with  the 
fall  in  temperature,  to  return  with  the  next  paroxysm,  or  if  quinine  is 
given  they  may  disappear  entirely.*  This  group  of  symptoms  has  often 
led  to  the  mistaken  opinion  that  the  disease  was  pneumonia,  which  had 
been  aborted  by  the  administration  of  quinine. 

*  The  following  case  is  a  good  example  of  this  condition  in  its  more  severe  form, 
and  illustrates  the  difficulties  in  the  diagnosis  of  malaria  in  infancy :  A  fairly  nour- 
ished child,  nine  months  old,  who  had  been  under  observation  in  an  institution  for 
two  weeks,  was  suddenly  taken  with  vomiting  and  fever  (Fig.  204).  A  cathartic  was 
followed  by  a  large  undigested  stool,  and  as  the  temperature  then  fell  to  normal,  the 
attack  was  regarded  as  one  of  indigestion.  On  the  third  day  the  temperature  was 
again  high  and  accompanied  by  cough ;  coarse  rales  were  found  throughout  the  chest, 
and  fine  rales  at  the  right  base  ;  it  was  then  thought  that  pneumonia  was  developing. 
On  the  fourth  day  all  the  symptoms  were  so  much  improved  that  the  infant  was  regarded 
as  convalescent.  At  6  p.  m.  the  temperature  was  normal,  and  the  infant  went  to  sleep 
quietly.  At  9.30  p.  m.  he  awoke  with  a  temperature  of  104°,  extreme  restlessness,  and 
marked  dyspnoea.  In  half  an  hour  his  symptoms  had  increased  to  a  point  where  he 
seemed  likely  to  die.  He  became  cyanotic,  the  respirations  were  of  a  panting  char- 
acter and  rose  nearly  to  one  hundred  a  minute,  and  he  coughed  with  almost  every 
breath ;  the  pulse  was  scarcely  perceptible.    The  severe  symptoms  continued  for  about 


MALARIA.  1125 

Subacute  or  Chronic  Forms  of  Malaria. — The  most  constant  symptoms 
are  antemia,  enlargement  of  the  spleen,  and  slight  fever.  The  anaemia  is 
usually  marked,  often  being  extreme.  The  enlargement  of  the  spleen  is 
distinct,  easily  made  out  by  palpation,  and  sometimes  is  very  great. 
The  fever  is  often  so  slight  as  to  be  discovered  only  when  the  tempera- 
ture is  taken  five  or  six  times  in  the  twenty-four  hours.  The  other 
symptoms  are  of  a  very  indefinite  character;  there  may  be  slight  oedema 
of  the  lower  extremities,  general  muscular  weakness,  so  that  the  child 
is  easily  fatigued,  loss  of  appetite,  coated  tongue,  constipation,  headache, 
muscular  pains,  and  often  cough  from  a  slight  bronchitis.  These  symp- 
toms may  depend  upon  many  conditions  other  than  malaria,  even  when 
they  are  seen  in  a  malarial  district.  The  only  positive  evidence  of  mala- 
ria in  such  cases  is  the  presence  of  the  malarial  organisms  in  the  blood. 
Even  the  swollen  spleen,  ana?mia,  and  slight  fever,  which  are  often  looked 
upon  as  diagnostic,  may  be  present  in  cases  of  anaemia  with  which  mala- 
ria has  nothing  whatever  to  do. 

Diagnosis. — The  positive  diagnosis  of  malaria  rests  upon  the  demon- 
stration of  the  malarial  organisms  in  the  blood.  They  will  be  found  in 
nearly  all  the  cases  provided  a  careful  examination  is  made  during  the 
paroxysm,  and  also  that  no  quinine  has  been  administered.  When  their 
number  is  small  they  may  be  missed  at  the  height  of  the  fever,  although 
they  may  readily  be  found  just  before  the  temperature  begins  to  rise. 
Blood  from  the  spleen  is  more  certain  to  show  the  organisms  than  that 
from  the  finger;  and  if  possible  the  examination  should  be  of  fresh  blood 
as  well  as  of  stained  specimens.  While  a  positive  result  is  conclusive,  a 
negative  one  is  not  always  so  because  of  the  impossibility  of  fulfilling  all 
the  above  conditions.  This  fact  and  lack  of  experience  in  blood  examina- 
tions make  it  necessary  for  a  large  part  of  the  profession  to  make  the 
diagnosis  by  the  other  symptoms.  These,  in  order  of  their  importance, 
I  would  place  as  follows:  Prompt  curability  (especially  in  cases  of  fever) 
by  quinine;  distinct  periodicity  in  the  symptoms;  enlargement  of  the 
spleen;  and  a  history  of  an  exposure  in  a  district  known  to  be  malarial. 
Particular  importance  is  to  be  attached  to  the  therapeutic  test.  Recent 
experience  emphasizes  more  and  more  strongly  the  fact  that  quinine  has 
very  little  influence  upon  fevers  which  are  not  malarial,  and,  conversely, 
that  a  fever  immediately  and  permanently  controlled  by  quinine  is  pretty 
certain  to  be  malarial.    The  combination  of  all  the  above  symptoms,  even 

an  hour,  then  passed  away  gradually,  and  at  the  end  of  two  and  a  half  hours  they 
had  completely  disappeared,  and  the  child  was  in  a  quiet  sleep  which  continued  until 
morning.  Malaria  was  now  suspected,  and  the  diagnosis  established  by  the  discovery 
of  the  Plasmodium  in  the  blood.  The  spleen  was  at  this  time  much  enlarged ;  the 
signs  in  the  chest  were  those  only  of  bronchitis  of  the  large  tubes.  Quinine  was  now 
begun  in  full  doses,  and  immediately  controlled  the  temi)erature  and  the  pulmonary 
symptoms. 


1126  THE   SPECIFIC  INFECTIOUS  DISEASES. 

in  the  absence  of  an  examination  of  the  blood,  may  be  regarded  as  sufB.- 
cient  to  establish  the  diagnosis  of  malaria. 

The  cachexia  and  course  of  the  temperature  in  septicsemia,  pysemia, 
broncho-pneumonia,  tuberculosis,  and  empyema,  may  easily  cause  them 
to  be  mistaken  for  malaria.  The  fever  and  recurring  chills  of  pyelitis 
are  often  attributed  to  malaria;  as  are  also  the  heaviness,  lethargy,  head- 
ache, coated  tongue,  and  slight  fever  of  chronic  intestinal  indigestion. 
Many  conditions  accompanied  by  an  enlarged  spleen  may  be  confounded 
with  malaria,  especially  simple  angemia,  leuksemia,  rickets,  and  syphilis. 
While  malaria  may  be  multiform  in  its  manifestations,  the  physician  can 
fall  into  no  more  serious  error  than  to  regard  all  ailments  with  obscure 
or  indefinite  symptoms  as  malarial,  neglecting  careful  physical  and  blood 
examinations,  by  which  means  alone  an  accurate  diagnosis  is  reached. 

Prognosis. — Although  it  is  seldom  fatal  in  itself,  an  attack  of  malaria 
in  an  infant  may  so  undermine  the  constitution  that  the  child  may  suc- 
cumb to  some  other  acute  disease,  usually  of  the  lungs  or  intestines. 
Cases  are  often  difficult  to  cure  while  the  patient  remains  in  the  malarial 
districts,  and  while  a  constant  absorption  of  the  poison  continues.  Under 
other  circumstances  the  prognosis  of  malaria  is  good. 

Treatment. — Prophylaxis. — More  exact  knowledge  regarding  the  eti- 
ology of  malaria  makes  it  possible  for  much  to  be  done  in  the  way  of 
prevention.  Besides  the  general  measures  proposed  for  the  extermination 
of  the  mosquitoes  concerned,  emphasis  should  be  laid  upon  the  necessity, 
in  the  case  of  young  children,  of  protecting  them  against  the  bites  of 
mosquitoes  in  localities  which  are  or  which  may  possibly  be  malarial. 
This  can  be  done  by  a  more  thorough  use  of  mosquito  netting  and  by  using 
upon  exposed  parts  of  the  body  lotions  or  ointments  containing  menthol, 
pennyro3^al,  turpentine,  or  other  substances  which  keep  these  pests  away. 
The  general  treatment  is  symptomatic,  and  is  to  be  conducted  as  in  all 
acute  febrile  diseases.  In  the  cold  stage,  stimulants  or  a  hot  bath  may 
be  required;  in  the  hot  stage,  ice  to  the  head  and  frequent  sponging. 
The  bow^els  in  all  cases  should  be  freely  opened,  preferably  by  calomel. 

Methods  of  administration  of  quinine. — For  infants  my  own  prefer- 
ence is  to  give  the  bisulphate  in  an  aqueous  solution,  one  or  two  grains 
to  the  teaspoonful,  according  to  the  age  of  the  patient.  Most  infants 
take  such  a  solution  with  less  difficulty  and  vomit  it  less  frequently  than 
the  combinations  with  the  various  vehicles  supposed  to  cover  its  taste. 
In  the  event  of  failure  by  this  method, the  same  solution  may  be  given  per 
rectum  through  a  catheter.  It  should  then  be  more  largely  diluted  with 
some  bland  fluid  such  as  gruel,  and  in  double  the  dose.  This  is  necessary, 
not  only  because  absorption  is  less  certain  and  complete,  but  also  be- 
cause a  rectal  dose  can  seldom  be  repeated  oftener  than  every  five  or 
six  hours.  There  is  sometimes  an  advantage  in  giving  part  of  the  quinine 
by  the  mouth  and  part  of  it  by  the  rectum;  should  lioth  fail  it  may  be 


MALARIA.  1127 

given  hypodermically.  For  this  purpose  the  bimuriate  of  quinine  and 
urea,  the  hydrochlorosulphate,  the  hydrobromate,  or  the  bisulphate  may 
be  used.  The  salts  first  mentioned  have  the  advantage  of  greater  solu- 
bility. But  all  are  more  or  less  irritating  and  there  usually  follows  some 
induration  at  the  site  of  the  injection,  which  may  last  a  long  time.  While 
the  hypodermic  use  of  quinine  is  sometimes  invaluable  it  should  not  be 
employed  in  infants  except  in  serious  attacks  and  when  we  are  tolerably 
certain  of  our  diagnosis.  In  a  number  of  instances  both  in  hospitals  and 
private  practice  I  have  seen  ugly  sloughing  follow  the  use  of  nearly  all 
the  preparations  generally  employed.  The  occurrence  of  abscess  points 
to  infection  at  the  time  of  injection;  but  necrosis  I  believe  may  be  due 
simply  to  the  irritation  of  the  quinine  upon  tissues  having  a  lowered 
vitality,  as  in  the  case  of  young  or  delicate  infants.  I  have  seen  this 
happen  when  the  strictest  precautions  against  infection  were  observed. 
The  frequent  repetition  of  the  hypodermic  injections  should  be  avoided; 
in  most  cases,  one  or  two  good  doses  are  sufficient,  the  effect  being  con- 
tinued by  quinine  given  by  other  methods. 

For  children  from  two  to  seven  years  old  the  taste  of  quinine  must 
be  concealed.  An  aqueous  solution  of  the  bisulphate  may  be  mixed  with 
the  syrup  of  sarsaparilla,  orange,  or  yerba  santa;  or  the  sulphate  may  be 
given  in  suspension  in  the  same  vehicle,  the  mixture  being  made  just 
before  the  dose  is  taken;  otherwise  the  partial  solution  of  the  drug  will 
render  the  whole  dose  exceedingly  bitter.  When  the  dose  required  is  not 
large,  as  in  the  milder  cases,  the  lozenges  of  the  tannate  of  quinine  com- 
bined with  chocolate  answer  the  purpose  admirably,  for  these  are  so 
nearly  tasteless  that  children  w^ill  take  them  wdthout  difficulty.  Each 
lozenge  usually  contains  one  grain  of  the  tannate,  which  is  equivalent  to 
about  one  third  of  a  grain  of  the  sulphate  of  quinine.  A  similar  lozenge 
containing  one  grain  of  the  sulphate  may  be  made,  which  is  often  taken 
by  children  without  the  slightest  objection.  The  bisulphate  may  be  given 
in  solution  by  the  rectum,  or,  better,  at  this  age,  in  the  form  of  supposi- 
tories; but,  as  in  infancy,  with  very  urgent  symptoms,  it  is  better  to  resort 
at  once  to  the  hypodermic  method  in  case  of  failure  by  the  stomach. 

For  children  over  seven  years  old,  the  same  methods  of  administra- 
tion may  usually  be  employed  as  in  adults.  It  is  always  preferable  to 
give  quinine  in  solution,  or  if  not  so,  in  capsule,  but  never  in  pill  form. 

In  a  case  with  well-marked  paroxysms  the  quinine  should  if  possible 
be  given  in  the  interval,  with  the  largest  dose  about  four  hours  before 
the  expected  paroxysm.  With  infants  this  plan  is  sometimes  imprac- 
ticable, as  frequent  small  doses  are  usually  better  borne  by  the  stom- 
ach than  a  few  large  ones.  In  them  also  vomiting  seems  less  likely 
to  occur  when  it  is  given  on  an  empty  stomach.  For  this  reason  it 
is  advantageous  to  give  the  drug  at  regular  two-  or  three-hour  intervals 
durin^r  the  nif^ht,  and  omit  all  medication  durin;?  tlie  dav.    I  have  never 


1128  THE  SPECIFIC  INFECTIOUS  DISEASES. 

succeeded  in  getting  the  physiological  effects  of  quinine  by  inunction, 
though  there  are  good  observers  who  claim  this  result.  It  is  certainly  a 
very  uncertain  way  of  introducing  quinine  into  the  system. 

Dosage. — Relatively  much  larger  doses  of  quinine  are  required  for 
young  children  than  for  adults.  Except  for  its  tendency  to  disturb  the 
stomach,  quinine  is  borne  remarkably  well  by  little  patients.  Generally 
too  small  doses  are  given.  An  infant  of  a  year  with  a  sharp  attack  of 
malarial  fever  will  usually  require  from  eight  to  twelve  grains  of  the 
sulphate  (ten  to  fourteen  grains  of  the  bisulphate)  daily.  Occasionally 
I  have  found  it  necessary  to  give  double  the  quantity  referred  to,  and  I 
have  seen  no  unpleasant  cerebral  symptoms.  It  is  useless  to  expect  to 
control  an  acute  attack  of  malaria  by  such  doses  as  one  grain  three  or 
four  times  a  day.  Children  from  five  to  ten  years  old  require  almost  as 
large  doses  as  do  adults.  ISTone  of  the  substitutes  for  quinine  are  to  be 
relied  upon  in  acute  cases. 

In  chronic  cases,  arsenic  and  iron  are  usually  required  in  combination 
with  smaller  doses  of  the  quinine  than  those  mentioned.  For  children 
over  seven  years  old,  Warburg's  tincture  may  be  employed.  In  most 
chronic  cases  a  cure  can  be  effected  only  by  a  change  of  climate. 

The  marked  and  irregular  manifestations  of  malaria  are  to  be  treated 
in  the  same  manner  as  cases  of  malarial  fever. 


SECTION  X. 
OTHER  GENERAL  DISEASES. 

CHAPTEK   I. 
RHEUMATISM. 

The  rheumatic  diathesis  manifests  itself  in  children  by  quite  a  differ- 
ent group  of  symptoms  from  those  seen  in  adults ;  for  this  reason  the 
disease  was  formerly  supposed  to  be  a  rare  one  in  early  life.  It  is  only 
within  recent  years  that  its  frequency  and  its  peculiarities  have  come  to 
be  appreciated.  For  our  present  understanding  of  the  subject  we  are  in- 
debted largely  to  the  work  of  English  physicians,  especially  Oheadle,* 
who  has  brought  out  more  fully  than  anyone  else  the  close  connection  ex- 
isting between  many  conditions  formerly  not  regarded  as  rheumatic.  One 
who  has  in  mind  only  the  adult  types  of  articular  rheumatism,  and  regards 
arthritis  as  a  necessary  symptom  for  a  diagnosis,  will  overlook  in  early  life 
many  manifestations  which  are  clearly  the  result  of  the  rheumatic  poi- 
son. There  is  seen  at  this  period  a  group  of  clinical  phenomena,  which 
often  occur  in  combination  or  in  succession,  whose  association  was  not 
understood  until  they  were  all  discovered  to  be  related  to  rheumatism. 
Sometimes  one  member  of  the  group  and  sometimes  another  is  first  seen, 
but  when  one  has  appeared  others  are  likely  soon  to  follow. 

Rheumatism  in  childhood,  then,  is  manifested  not  alone  by  arthritis 
with  acute  or  subacute  symptoms,  but  by  a  large  number  of  other  condi- 
tions which  are  not  to  be  regarded  in  the  light  of  complications,  but  rather 
as  forms  of  the  disease. 

Etiology. — It  is  not  in  the  province  of  this  work  to  discuss  the  various 
theories  regarding  the  nature  of  rheumatism  and  its  exciting  cause.  The 
drift  of  medical  opinion  to-day  is  strongly  toward  the  view  that  acute 
rheumatism  is  an  infectious  disease,  probably  o"*^  microbic  origin.  Al- 
though the  character  of  the  micro-organism  is  not  yet  determined,  the 
latest  observations  of  Poynton  and  Paine  f  point  to  a  diplococcus.  The 
excessive  formation  of  acids  in  the  system  may  be  regarded  as  a  result 
of  the  infection,  or  possibly  as  a  condition  necessary  for  the  activity  of 
the  specific  poison.  Under  five  years  of  age  articular  rheumatism  is  not 
common,  and  in  infancy  it  is  extremely  rare.  I  once  saw,  however,  in 
a  nursing  infant,  a  typical  attack  of  rheumatic  fever  with  multiple  joint 

*  See  the  Ilarveian  Lectures,  1889.  f  Lancet,  May  4,  1901. 

1129 


1130  OTHER  GENERAL  DISEASES. 

lesions;  and  undoubted  cases  have  been  reported  at  as  earl}'  an  age  as 
two  months.  In  1899  Miller  (Philadelphia)  could  find  in  medical  litera- 
ture but  nineteen  cases  under  one  year.  The  condition  is  therefore  so 
exceptional  that  one  should  be  cautious  in  making  the  diagnosis  of  rheu- 
matism in  infancy.  Most  of  the  cases  so  regarded  are  examples  of  scurvy. 
After  the  fifth  year  both  the  articular  and  the  other  manifestations  of 
rheumatism  become  very  common,  and  occur  with  increasing  frequency 
up  to  the  time  of  puberty. 

Heredity  is  a  very  important  etiological  factor,  and  in  fully  two 
thirds  of  the  cases  that  have  come  under  my  care,  a  rheumatic  family 
history  was  obtained.  Of  the  other  important  causes,  the  most  frequent 
are  living  in  damp  dwellings,  direct  exposure  to  cold  and  wet,  poor 
hygienic  surroundings,  and  insufficient  food.  While  seen  among  all 
classes,  rheumatism  is  more  common  among  those  who  are  badly  housed. 
Attacks  of  rheumatism  occur  at  all  seasons,  but  are  much  more  frequent 
in  the  spring  months.  One  attack  strongly  predisposes  to  a  second,  and 
in  most  cases  there  is  a  history  of  a  large  number  of  attacks  of  greater 
or  less  severity.  Among  my  own  patients,  girls  have  been  affected  with 
greater  frequency  than  boys. 

Symptoms. —  The  general  and  articular  manifestations. — The  clinical 
types  of  rheumatism  in  children  present  very  notable  contrasts  to  those 
seen  in  adults.  A  typical  attack  of  acute  articular  rheumatism  such  as  is 
seen  in  adult  life,  with  a  sudden  onset,  high  temperature,  severe  inflam- 
mation of  several  joints,  profuse  acid  perspiration,  and  occasional  delir- 
ium, is  rarely  seen  in  a  child  under  eight  or  ten  years  old.  In  most  of 
the  attacks  in  childhood  the  onset  is  not  very  acute,  the  temperature  is 
but  slightly  elevated — only  100°  or  101-5°  F. — the  swelling  and  pain  are 
moderate,  and  the  redness  is  often  absent.  The  number  of  joints  involved 
is  generally  small,  those  most  frequently  affected  being  the  ankles,  the 
knees,  the  small  joints  of  the  foot,  the  wrists,  or  the  elbows.  These  symp- 
toms are  often  not  severe  enough  to  keep  the  patient  in  bed,  and  only  the 
pain  in  the  joints  of  the  lower  extremities  prevents  him  from  walking. 
The  duration  of  these  attacks  is  from  one  to  three  weeks,  and  in  the 
course  of  a  month  most  of  them  recover  even  without  treatment. 

Not  infrequently  the  symptoms  are  limited  to  a  single  joint,  usually  the 
hip,  knee,  or  ankle.  Possibly  the  joints  of  the  upper  extremity  are  affected 
oftener  than  would  appear,  but  disease  here  is  much  more  likely  to  be 
overlooked  than  when  lameness  is  present.  The  swelling  is  moderate  and 
may  not  be  evident  except  on  a  close  examination ;  in  some  cases  there  is 
none.  There  is  stiffness  of  the  joint,  as  shown  by  lameness,  and  there  may 
be  so  much  pain  and  soreness  that  the  child  refuses  to  walk  altogether. 
Muscular  spasm  about  the  affected  joint  is  often  marked,  and  may  be  the 
most  striking  objective  symptom.  The  tenderness  is  sometimes  local- 
ized, but  it  may  affect  the  ligaments,  tendons,  and  even  the  muscles. 
These   symptoms   may  persist  for   two  or  three  weeks   and  lead  to  the 


RHEUMATISM.  1131 

suspicion  of  incipient  tuberculous  disease  of  the  joint.  Eheumatisni  is 
distinguished  by  its  more  acute  onset  and  usually  by  the  presence  of 
slight  fever ;  some  elevation  of  temperature  being  the  rule,  though  it  is 
not  often  much  over  100°  F.  A  family  history  of  rheumatism,  or  a  his- 
tory of  previous  similar  attacks  in  the  patient  affecting  the  same  or  other 
joints,  or  other  manifestations  of  rheumatism,  are  also  of  assistance  in  the 
diagnosis.  Occasionally  all  doubt  is  removed  by  the  disease  extending  to 
other  joints,  or  by  the  development  of  endocarditis.  In  some  cases  the 
symptoms  are  less  in  the  articulation  than  in  the  muscles,  and  they  are 
dismissed  as  simply  "  growing  pains,"  having  nothing  characteristic  about 
them  except  their  occurrence  in  damp  weather. 

Cardiac  manifestations. — These  may  occur  where  the  articular  symp- 
toms are  very  mild,  and  in  some  cases  where  they  are  entirely  absent. 
The  most  frequent  is  endocarditis.  This  is  much  more  often  seen  in  the 
acute  rheumatism  of  children  than  of  adults,  and  probably  occurs  in  the 
majority  of  all  severe  cases ;  if  it  does  not  come  in  the  first  attack,  it  is 
likely  to  be  seen  in  the  later  ones.  It  frequently  occurs  with  a  mild  rheu- 
matic arthritis,  often  being  unnoticed  until  valvular  disease  of  considerable 
severity  has  developed.  Sometimes  there  is  only  high  fever  with  severe 
constitutional  symptoms  of  an  indefinite  character,  but  no  arthritis,  and 
no  suspicion  that  the  attack  is  rheumatic  until  endocarditis  is  discovered. 
Such  cases  are  not  infrequent.  If  the  patients  are  kept  under  observation, 
articular  symptoms  are  almost  certain  to  develop  later,  and  often  there  are 
other  manifestations  of  rheumatism,  especially  chorea. 

Pericarditis  is  less  frequent  than  endocarditis,  and  usually  occurs  in 
children  over  seven  years  old.  It  is  often  associated  with  endocarditis. 
The  most  characteristic  form  of  infiammation  in  early  life  is  a  subacute, 
dry,  fibrous  form,  often  resulting  in  great  thickening  with  extensive  adhe- 
sions, and  frequently  in  obliteration  of  the  pericardial  sac.  When  once 
started  it  shows  a  strong  tendency  to  recurrence  and  persistence. 

The  heart  is  so  frequently  affected  in  the  rheumatism  of  childhood 
that  it  should  be  closely  watched  whenever  articular  symptoms  are  present, 
no  matter  how  mild  they  may  be  ;  and  not  only  in  these  cases,  but  in  all 
the  conditions  hereafter  enumerated  with  which  rheumatism  is  likely  to  be 
associated. 

Inflammations  of  other  serous  membranes — the  pleura,  peritonaeum, 
and  pia  mater — were  much  more  frequently  ascribed  to  rheumatism  in  the 
past  than  now.  There  is  little  doubt  that  on  rare  occasions  any  one  of 
these  may  be  due  to  rheumatism.  The  pleura  is  most  often  involved,  but 
even  this  is  rare  in  young  children. 

Torticollis  when  it  occurs  acutely  is  frequently  rheumatic.  This  form 
is  characterized  by  its  sudden  development,  continuous  spasm,  the  great 
amount  of  muscular  soreness,  the  moderate  pain,  and  the  fact  that  it  usu- 
ally disappears  spontaneously  after  a  few  days.     It  is  often  seen  in  con- 


;[132  OTHER  GEKERAL  DISEASES. 

nection  with,  a  rheumatic  sore  throat.  Other  manifestations  of  muscular 
rheumatism  are  less  characteristic  and  usually  affect  the  muscles  of  the 
extremities. 

Ancemia  is  almost  invarialDly  seen  in  rheumatic  patients,  both  during 
and  between  the  attacks.  The  effect  of  the  rheumatic  poison  upon  the 
blood  resembles  that  of  malaria.  The  presence  of  ansemia  is  so  evident 
and  its  degree  often  so  marked,  that  one  may  have  great  difficulty  in  dis- 
tinguishing cardiac  murmurs  which  are  lisemic  from  those  due  to  endo- 
carditis. 

Cliorea. — In  the  article  upon  Chorea  I  have  already  discussed  the  asso- 
ciation of  that  disease  with  rheumatism  and  expressed  my  own  belief  in 
a  very  close  relationship  existing  between  them.  Xot  very  infrequently 
chorea  is  the  first  manifestation  of  the  rheumatic  diathesis,  to  be  followed 
soon  by  articular  symptoms  or  by  endocarditis  without  such  symptoms. 
In  other  cases  chorea  and  acute  endocarditis  occur  together  without 
articular  symptoms,  or  all  three  may  be  associated.  Whichever  of  the 
three  conditions  is  first  seen,  the  physician  should  always  be  on  the  look- 
out for  the  others.  The  frequency  of  rheumatism  in  choreic  patients  has 
been  variously  estimated  by  different  observers:  in  my  own  cases  over 
fifty-six  per  cent  gave  unmistakable  evidence  of  the  rheumatic  diathesis. 

Tonsillitis. — The  association  of  tonsillitis  and  ]Dharyngitis  with  rheu- 
matism appears  in  many  cases  to  be  a  close  one.  Children  who  are  the 
subjects  of  frequent  attacks  should  be  regarded  as  possibly  rheumatic, 
and  closely  watched  for  other  signs  of  that  disease.  Acute  tonsillitis 
often  ushers  in  an  attack  of  rheumatic  arthritis,  and  occasionally  acute 
endocarditis  without  articular  symptoms.  Eheumatism  may  be  associated 
with  any  form  of  tonsillitis,  but  its  connection  with  quinsy  seems  closest. 
The  nature  of  the  relationship  is  not  yet  fully  explained;  by  many  the 
tonsils  are  regarded  as  the  structures  through  which  the  rheumatic 
poison  is  absorbed.  Packard  (Philadelphia),  however,  regards  the  ton- 
.sillitis  as  non-rheumatic,  and  the  endocarditis  as  of  septic  origin. 

Subcutaneous  tendinous  nodules. — General  attention  was  first  drawn 
to  these  as  a  manifestation  of  rheumatism  by  Barlow  and  Warner,  in 
1881,  who  described  them  as  "  oval,  semi-transparent,  fibrous  bodies  like 
boiled  sago  grains."  They  are  most  frequently  found  at  the  back  of  the 
elbow,  over  the  malleoli,  at  the  margin  of  the  patella;  occasionally  on 
the  extensor  tendons  of  the  hands,  fingers,  or  toes,  or  over  the  spinous 
processes  of  the  vertebrae  or  the  scapulae.  They  are  composed  of  fibrin, 
cells,  and  fibrous  tissue,  and  vary  in  size  from  a  large  pin's  head  to  a 
small  bean,  sometimes  being  as  large  as  an  almond.  The  nodules  may 
come  in  crops,  lasting  for  a  few  weeks  and  then  disappearing,  or  they 
may  last  for  months.  An  eruption  of  nodules  is  usually  coincident  with 
other  rheumatic  manifestations.  These  nodules  are  better  felt  than  seen, 
although,  as  Cheadle  observes,  they  are  visible  if  the  skin  is  tightly 
drawn.    They  are  certainly  not  common  in  this  country;  and  although  I 


RHEUMATISM.  II33 

have  made  it  a  rule  to  examine  rheumatic  patients  for  them,  I  have  seen 
them  but  seldom,  and  they  have  been  prominent  in  only  two  or  three 
cases.  This,  I  think,  has  also  been  the  experience  of  most  observers  in 
Kew  York.  From  published  reports,  however,  they  appear  to  be  much 
more  frequent  in  England.  There  can  be  no  doubt  regarding  the  con- 
nection of  these  nodules  with  rheumatism. 

Erythema. — The  connection  between  rheumatism  and  the  various 
forms  of  erythema — marginatum,  papulatum,  and  nodosum — has  been 
very  clearly  shown  by  Cheadle.  None  of  these  are  frequent  conditions  in 
childhood,  but  when  seen  they  should  always  suggest  rheumatism. 

Purpura. — The  association  of  purpura  with  rheumatism  is  so  often 
seen  that  there  can  be  little  doubt  of  the  close  connection  between  the 
two  conditions.  Rheumatic  purpura,  however,  is  quite  distinct  from  the 
other  forms  of  purpura,  and  is  a  much  less  frequent  disease. 

Diagnosis. — In  order  to  recognise  rheumatism  in  a  child,  one  must 
free  his  mind  from  preconceived  notions  of  the  disease  drawn  from  its 
manifestations  in  adults,  as  very  few  cases  correspond  to  the  adult  type  of 
acute  rheumatism.  In  early  life  the  disease  is  recognised  not  by  any  one 
or  two  special  symptoms,  but  by  the  association  or  combination  of  a  num- 
ber of  conditions  which  may  appear  unrelated.  In  determining  whether 
or  not  any  given  set  of  symptoms  is  due  to  rheumatism,  one  should  con- 
sider :  (1)  The  family  history,  since  in  early  life  heredity  is  so  important 
an  etiological  factor;  (2)  the  previous  history  of  the  patient,  not  only  as 
regards  articular  pains  and  swelling,  the  slight  joint-stiffness  without 
swelling,  the  indefinite  wandering  pains  of  damp  weather,  and  the  so-called 
growing  pains,  but  also  the  previous  existence  of  chorea,  frequent  attacks 
of  tonsillitis,  torticollis,  or  erythema ;  (3)  the  examination  of  the  patient, 
which  should  include  a  careful  search  for  tendinous  nodules,  as  well  as  a 
thorough  examination  of  the  heart  for  signs  of  endocarditis  or  pericar- 
ditis, and,  in  cases  which  are  at  all  acute,  the  temperature.  In  doubtful 
cases  with  mon-articular  symptoms  much  importance  is  to  be  attached 
to  the  presence  of  slight  fever,  the  abrupt  onset,  and  tenderness  of  the 
neighbouring  muscles  and  tendons, — all  occurring  without  a  history  of 
traumatism.  Eheumatism  is  more  often  overlooked  than  confounded 
with  other  diseases  ;  although  in  childhood  multiple  neuritis  and  tubercu- 
lous and  syphilitic  bone  disease  are  often  mistaken  for  it,  and  in  infancy 
the  same  is  true  of  scurvy.  The  extreme  infrequeucy  of  rheumatism 
during  the  first  two  years  of  life  should  always  make  one  skeptical  regard- 
ing it.  In  an  infant,  when  the  symptoms  are  confined  to  the  legs  and 
are  not  accompanied  by  fever,  they  are  almost  certain  to  be  due  to  scurvy 
even  though  the  gums  are  normal  and  ecchymoses  have  not  yet  ajipeared 
(page  244). 

Prognosis. — Rheumatism  in  a  child  is  in  itself  seldom  if  ever  danger- 
ous to  life.  In  the  great  majority  of  cases  the  articular  symi)toms  soon 
73 


1134  OTHER  GENERAL  DISEASES. 

disappear,  even  without  special  treatment.  The  danger  from  the  disease 
consists  in  its  cardiac  complications.  One  attack  of  rheumatism  is  almost 
certain  to  be  followed  by  others,  and  when  once  the  heart  has  been  af- 
fected its  lesions  are  likely  to  increase  with  each  recurrence  of  the  disease. 

Treatment. — Eheumatism  in  children  derives  its  chief  importance 
from  its  relation  to  cardiac  disease.  Cardiac  complications  are  so  fre- 
quent and  so  serious  that  everything  possible  should  be  done  to  avert 
rheumatism  from  those  who  by  inheritance  are  especially  predisposed  to 
it,  to  prevent  its  recurrence  in  a  child  who  has  once  had  the  disease,  and 
during  an  attack  to  prevent  the  heart  from  becoming  involved.  The  rela- 
tion of  diet  to  rheumatism  is  very  imperfectly  understood;  but  it  is  cer- 
tainly a  fact  that  rheumatic  children  do  much  better  upon  a  diet  com- 
posed largely  of  nitrogenous  food,  where  starches  are  restricted  in 
amount,  than  the  reverse.  Milk  should  be  freely  given  in  all  cases.  The 
underclothing  should  be  of  flannel  during  the  entire  year,  in  summer  the 
lightest  weight  being  worn.  The  feet  should  be  carefully  protected,  and 
exposure  in  damp  weather  avoided.  In-door  occupations  should  be 
chosen  for  rheumatic  boys. 

The  tendency  to  recurrence  is  so  strong  in  this  disease  that  a  child  of 
rheumatic  antecedents,  who  has  shown  in  the  various  ways  mentioned  a 
marked  predisposition  to  rheumatism,  and  who  has  had  an  attack,  even 
though  a  mild  one,  should,  if  possible,  spend  the  winter  and  spring  in 
some  warm,  dry  climate,  or  even  remain  there  permanently.  Otherwise  in 
most  such  children,  it  is  only  a  question  of  time  when,  with  the  repeated 
attacks,  the  heart  will  become  involved. 

To  avert  the  danger  of  cardiac  complications  during  an  attack  of  rheu- 
matism, or  to  limit  their  extent,  there  are  two  things  which  should  invari- 
ably be  insisted  on  :  first,  to  confine  to  the  house  and  in  a  warm  room  every 
child  with  rheumatic  pains,  no  matter  how  mild  ;  secondly,  if  fever  is  also 
present,  to  keep  the  child  in  bed  while  it  continues,  even  though  it  may 
never  be  above  100°  F.  Absolute  rest  and  the  equable  temperature  thus 
secured  are  unquestionably  of  more  importance  than  anything  else  in  pro- 
tecting the  heart  during  a  rheumatic  attack.  With  these  precautions  must 
be  combined  an  early  diagnosis.  In  very  many,  perhaps  in  most  cases,  the 
harm  is  done  before  the  true  nature  of  the  disease  is  suspected,  the  symp- 
toms being  dismissed  as  of  slight  importance  because  the  articular  mani- 
festations are  not  very  severe.  Children  who  have  once  had  rheumatism 
should  be  closely  watched  during  chorea  and  other  diseases  related  to 
rheumatism,  the  heart  should  be  frequently  examined,  and  the  physician 
should  be  on  the  alert  for  the  first  articular  symptoms. 

Aside  from  the  measures  just  mentioned,  the  treatment  of  rheumatism 
in  childhood  is  to  be  conducted  very  much  like  that  of  adult  life.  In  the 
most  acute  attacks  either  salicylate  of  soda,  oil  of  wintergreen,  or  salicin 
should  be  given ;  as  the  majority  of  cases  are  not  very  acute,  marked  im- 
provement is  by  no  means  always  obtained  by  these  drugs.      Alkalies 


DIABETES  MELLITUS.  1135 

should  be  given  in  all  cases,  but  particularly  in  those  in  which  there  is 
hyperacidity  of  the  urine.  Either  the  acetate  or  citrate  of  potassium  or 
the  bicarbonate  of  sodium  may  be  used,  a  sufficient  quantity  being  admin- 
istered to  render  the  urine  alkaline. 

Quite  as  important  as  these  drugs  is  the  use  of  general  tonics,  particu- 
larly iron  and  cod-liver  oil.  These  should  be  given  not  only  between 
attacks  to  fortify  patients  against  their  recurrence,  but  also  in  subacute 
cases  which  are  sometimes  influenced  very  little  or  not  at  all  either  by 
salicylates  or  alkalies. 


CHAPTER   II. 
DIABETES  MELLITUS. 

In  this  chajjter  will  be  attempted  only  a  description  of  the  peculiar 
features  which  diabetes  presents  when  affecting  young  patients.  It  is  a 
very  infrequent  disease  in  children.  Of  1,360  cases  of  diabetes  collected 
by  Pavy,  only  eight  were  under  ten  years  of  age.  In  a  series  of  700  cases 
collected  by  Prout,  only  one  case  was  under  ten  years.  In  a  series  of  380 
cases  collected  by  Meyer,  only  one  case  was  under  ten  years  of  age. 

Etiology. — Stern,  in  a  series  of  117  collected  cases  of  diabetes  in  chil- 
dren, states  that  47  were  females  and  31  males,  the  sex  in  the  other  cases 
not  being  given.  Although  extremely  rare,  cases  have  been  observed 
during  the  first  two  years,  and  even  during  the  first  year  of  life.  Sta- 
tistics on  this  point  are  not  altogether  trustworthy,  since  some  cases  of 
temporary  glycosuria  have  certainly  been  included. 

Among  the  etiological  factors,  heredity  is  one  of  the  most  important. 
Pavy  reports  the  case  of  a  child  dying  of  diabetes  at  two  years  in  whose 
family  the  disease  had  existed  for  three  generations.  Inherited  gout, 
insanity,  and  nervous  diseases  generally,  may  be  looked  upon  as  factors  in 
the  production  of  diabetes.  Several  of  the  cases  reported  in  children 
have  been  preceded  by  injuries  received  upon  the  head.  In  a  few  cases 
the  disease  has  followed  the  consumption  of  large  quantities  of  sugar  for 
a  long  time.     In  very  many  cases  no  adequate  cause  can  be  found. 

Symptoms. — The  most  important  early  symptoms  are  thirst,  polyuria, 
and  wasting ;  their  development  is  often  quite  rapid.  The  thirst  is  in- 
tense, often  leading  children  to  drink  four  or  five  pints  of  fluid  a  day. 
The  amount  of  urine  passed  varies  from  one  to  eight  quarts  daily.  Tlie 
specific  gravity  is  from  1,026  to  1,040,  and  the  amount  of  sugar  is  from 
iive  to  ten  per  cent,  rarely  more.  Albumin  is  not  infrequently  present. 
Incontinence  of  urine  is  an  important  symptom,  and  often  one  of  the 
earliest  to  be  noticed.  The  wasting  is  usually  quite  rapid,  so  that  a  child 
may  lose  as  much  as  six  or  eight  pounds  in  a  month.      It  is  generally  ac- 


1136  OTHER  GENERAL  DISEASES. 

companied  by  ansemia.  The  appetite  may  be  poor ;  at  times,  however,  it 
is  voracious.  Other  symptoms  of  less  importance  are  a  dry  mouth,  scanty 
perspiration,  irregular  sleep,  occasional  epistaxis,  furuncles  and  abscesses, 
decayed  teeth,  and  genital  irritation. 

The  course  of  the  disease  is  much  more  rapid  in  children  than  in 
adults,  and,  as  a  rule,  the  younger  the  child  the  more  rapid  its  progress. 
The  majority  of  cases  prove  fatal  in  from  two  to  four  months  from  the 
time  the  symptoms  are  sufficiently  marked  to  make  the  diagnosis  possiblco 
Very  few  last  more  than  six  months ;  occasionally,  however,  one  of  the 
milder  type  may  be  prolonged  from  one  to  two  years. 

The  progress  of  the  disease  is  marked  by  continuous  wasting,  which 
may  result  in  a  marked  degree  of  marasmus,  and  prove  fatal.  Some  are 
carried  off  by  intercurrent  pneumonia  or  tuberculosis,  but  the  majority 
die  comatose.  When  coma  develops,  the  case  may  be  considered  hopeless, 
and  death  is  likely  to  be  postponed  but  a  few  days.  The  cause  of  diabetic 
coma  has  not  yet  been  satisfactorily  explained,  but  it  is  usually  believed  to 
be  due  to  acetonsemia. 

Diagnosis. — Diabetes  is  apt  to  be  overlooked,  because  of  the  common 
neglect  of  urinary  examinations  in  children.  The  prominent  symptoms — 
thirst,  polyuria,  and  wasting — when  associated,  should  always  attract  at- 
tention. Incontinence  of  urine,  accompanied  by  marked  wasting,  is  always 
suspicious.  In  some  cases  genital  irritation  may  be  the  most  prominent 
early  symptom.  A  positive  diagnosis  is  made  only  by  an  examination  of 
the  urine. 

Prognosis. — In  few  diseases  is  the  prognosis  so  bad  as  in  diabetes  in 
children.  So  high  an  authority  as  Senator  declares  that  diabetes  in  chil- 
dren is  hopeless  and  all  treatment  is  useless.  From  a  study  of  seventy- 
seven  cases,  Stern  reaches  the  same  conclusion.  There  are,  however, 
cases  on  record  in  which  recovery  is  believed  to  have  taken  place.  The 
cases  which  I  have  seen  have  all  terminated  unfavourably.  In  a  given 
case  the  prognosis,  as  to  the  duration  of  the  disease,  is  rendered  much 
worse  by  the  presence  in  the  urine  of  diacetic  and  oxybutyric  acids. 
This  condition  is  even  more  serious  than  is  a  high  percentage  of  sugar; 
that  the  patient  will  then  live  more  than  three  months  is  highly  im- 
probable. 

Treatment. — The  indications  for  treatment  are  the  same  in  children 
as  in  adults:  first,  diet;  secondly,  general  hygienic  measures;  and,  finally, 
the  use  of  drugs,  of  which  at  the  present  time  the  favourites  are  codeine, 
salicylate  of  soda,  and  the  bromide  of  arsenic. 


INDEX 


Abdomen,  examination  of,  37 ;  growth  of,  24 ; 
in  rickets,  263. 

Abscess,  alveolar,  277  :  cerebral,  769 ;  etiology, 
769;  lesions,  769;  symptoms,  770;  diagnosis, 
771 ;  from  meningitis,  771 ;  prognosis,  771 ; 
treatment,  771;  cerebral,  in  acute  otitis,  930; 
ischio-rectal,  453  ;  mammary,  115  ;  hepatic, 
45fi ;  peritoneal,  463 ;  peritonsillar,  308 ;  peri- 
typhlitic  (see  Appendicitis),  435;  psoas,  in 
spinal  caries,  888 ;  retro-cesophageal,  314 ; 
etiology,  314 ;  symptoms,  315 ;  diagnosis,  315  ; 
prognosis,  316  ;  treatment,  316 ;  retro-pharyn- 
geal,  in  Pott's  disease,  296, 888 ;  retro-pharyn- 
geal,  of  infancy,  293 ;  etiology,  293 ;  symp- 
toms, 294 ;  prognosis,  295  ;  diagnosis,  295 ; 
treatment,  296 ;  subphrenic,  473. 

Abscesses,  multiple,  in  malignant  endocarditis, 
622  ;  multiple,  in  newly  born,  83. 

Acetonsemia  in  diabetes  mellitus,  1136. 

Acetonuria,  647. 

Acid,  hydrochloric,  increased  by  lavage,  339 ; 
hydrochloric,  in  gastro-enteric  intoxication, 
374 ;  hydrochloric,  in  stomach  digestion,  318 ; 
lactic,  in  stomach  digestion,  318. 

Adenie  (see  Hodgkin's  Disease),  877. 

Adenitis,  acute    non-suppurative,  868 ;    acute 
simple,  with  otitis  media,  867 ;  acute  suppu- 
rative, axillary,  867 :  acute  suppurative,  cer- 
vical, 867  ;  acute  suppurative,  inguinal,  867 
cervical,  in   diphtheria,  1010;   in   influenza 
1113;  in  measles,  969 ;  retro-oesophageal,314 
retro-pharyngeal,    293;    simple    acute,   865 
etiology,  866 ;  lesions,  866 ;  symptoms,  866 
diagnosis,  868  ;  treatment,  868  ;  simple  chron- 
ic,  868;    syphilitic,   869;    tuberculous,   870; 
etiology,  870 ;  lesions,  870 ;  symptoms,  873 ; 
prognosis,    875 ;    diagnosis,    875 ;    treatment, 
875;  treatment,  surgical,  876. 

Adenoid  vegetations  of  pharynx,  297,  477 ; 
etiology,  298 ;  symptoms,  299 ;  diagnosis, 
301 ;  treatment,  301 ;  asthma  from,  520 ;  cause 
of  acute  otitis,  932 ;  causing  acute  nasal  ca- 


tarrh, 476 ;  chronic  laryngitis  with,  502 ;  in 
rickets,  264 ;  removal  advised  in  tuberculous 
adenitis,  876 ;  with  adenitis,  869. 

Adenoma  of  umbilicus,  112. 

Agenesis,  cortical,  785. 

Airing,  when  allowed  out  of  doors,  8. 

Air-space  required  by  infants,  10. 

Alalia,  736. 

Albinism,  stigma  of  degeneration,  803. 

Albumin  water,  preparation  of,  332- 

Albuminuria,  functional  or  cyclic,  640;  in 
chronic  cardiac  disease,  626 ;  in  chronic  ne- 
phritis, 665;  in  influenza,  1116;  in  measles, 
969 ;  in  pertussis,  991 ;  in  scarlet  fever,  949  ; 
in  typhoid  fever,  1054. 

Alcohol,  as  stimulant,  49;  as  tonic,  50;  effect 
on  breast  milk,  171 ;  use  of,  in  diet  of  nurse, 
135. 

Amaurotic,  family  idiocy,  795. 

Amyloid  degeneration,  in  chronic  bone  disease, 
838 ;  of  the  intestines,  406  ;  of  the  liver,  406  ; 
of  the  spleen,  406. 

Ansemia,  cardiac  murmurs  in,  633 ;  following 
diphtheria,  1020;  pernicious,  850;  etiology, 
850 ;  lesions,  851 ;  symptoms,  851 ;  blood, 
851 ;  treatment,  852 :  pseudo-leukaemic,  of 
infancy,  848  ;  etiology,  849 ;  lesions,  849 ; 
symptoms,  849  ;  blood,  849 ;  prognosis,  850  ; 
treatment,  852  ;  simple,  845 ;  etiology,  845  ; 
symptoms,  846 ;  prognosis,  847 ;  treatment, 
852  ;  splenic  (see  A.  Pseudo-leuk^emic),  848 ; 
with  adenoids,  300 ;  in  malaria,  1125;  in  mal- 
nutrition, 230;  in  marasmus,  239  ;  in  rheuma- 
tism, 1132;  in  rickets,  264;  in  scurvy,  246; 
in  tuberculosis,  1084;  preceding  tuberculosis, 
1077. 

Aiuesthesia,  partial,  in  multiple  neuritis,  834. 

Anasarca,  general,  in  acute  dift'use  nephritis, 
660  ;  in  chronic  cardiac  disease,  626. 

Aneurism,  635. 

Angina,  catarrhal,  in  measles,  967;  in  scarlet 
fever,  946. 


1137 


1138 


INDEX. 


Anglo-Swiss  food,  162. 

Ankle,  enlarged  epiphyses  in  rickets,  2fi2. 

Anodynes,  51. 

Anorexia,  hysterical,  732. 

Antipyretic  drugs,  48. 

Antipyretics,  46  ;  in  acute  broncho-pneumonia, 
555. 

Antipyrine,  in  chorea,  723  ;  in  catarrhal  croup, 
487;  in  pertussis,  995;  scarlatiniform  rash 
from,  952. 

Antitoxin,  in  the  treatment  of  tetanus,  90 ; 
eliminated  by  human  milk,  137  ;  results  with- 
out, in  membranous  laryngitis,  495 ;  with, 
1040  (see  Diphtheeia  Antitoxin)  ;  strepto- 
coccus, 1050. 

Anuria,  648. 

Anus,  fissure  of  the,  450  ;  imperforate,  116. 

Aorta,  abnormal  origin  of,  608 ;  aneurism  of, 
636  ;  atheroma  of,  636  ;  congenital  narrowing 
of,  in  chlorosis,  847 ;  hypoplasia  of,  635 ; 
thrombosis  of,  637. 

Aortic  insufficiency,  629  ;  stenosis,  628. 

Aphasia,  functional,  736 ;  in  acquired  cerebral 
paralysis,  791 ;  after  typhoid  fever,  1055  ;  mo- 
tor, in  cerebral  tumour,  774,  775. 

Aphonia,  hysterical,  731 ;  in  diphtheritic  pa- 
ralysis, 837. 

Appendicitis,  434;  etiology,  434;  lesions,  434; 
catarrhal  form,  435;  suppurative  form,  435; 
gangrenous  form,  435 ;    symptoms,  436 ;  ca- 
tarrhal  form,   436;    suppurative   form,   436; 
gangrenous  form,  437 ;  course  and  termina- 
tion, 438 ;    prognosis,   439 ;    diagnosis,    439 
from  colic,  439 ;  from  acute  indigestion,  439 
from  intussusception,  440  ;  from  psoitis,  440 
leucocyte  count  an  aid,  440  ;  treatment,  440. 

Arm,  paralysis  of,  at  birth,  110. 

Arnold  sterilizer,  152. 

Arsenic,  as  a  tonic,  50 ;  dosage  in  chorea, 
723. 

Arteries,  hypogastric,  in  foetal  circulation,  602 ; 
hypoplasia  of,  635 ;  umbilical,  in  foetal  circu- 
lation, 602. 

Arthritis,  acute,  of  infants,  881 ;  etiology,  881 ; 
symptoms,  881 ;  diagnosis,  882 ;  treatment, 
882 ;  acute  suppurative,  syphilitic,  898  ;  gon- 
orrhoea!, 682,  686;  rheumatic,  1130. 

Arthrogryposis  (see  Tetany),  712. 

Artificial  feeding,  circumstances  favouring,  165  ; 
versus  wet-nursing,  166. 

Ascaris  lumbricoides  (see  Worms,  Intestinal), 
444. 

Ascites,  472;  causes,  472;  detection  of,  472; 
chylous,  472 ;  in  acute  diffuse  nephritis,  660  ; 
in  cirrhosis  of  liver,  458;  rare  with  amyloid 
liver,  459 ;  with  chronic  peritonitis,  465 ; 
with  tuberculosis  of  the  peritonfeuin,  467. 


Asphyxia,  death  from,  in  young  children,  44 ; 
from  overlying,  42;  froni  aspiration  of  food, 
43  ;  from  enlarged  thymus,  43 ;  in  convul- 
sions, 700 ;  in  retro-pharyngeal  abscess,  294 ; 
in  the  newly-born,  67  :  etiology,  67  ;  lesions, 
67  ;  symptoms,  68  ;  diagnosis,  69  ;  prognosis, 
69  ;  treatment,  69  ;  from  tuberculous  bronchial 
lymph  nodes,  1090  ;  methods  of  resuscitation, 
71 ;  sudden,  from  tongue-swallowing,  276 ; 
sudden,  in  retro-oesophageal  abscess,  315. 

Aspiration  of  chest  in  empyema,  598. 

Asthma,  519  ;  etiology,  520 ;  symptoms,  520  ; 
symptoms  of  attacks  resembling  capillary 
bronchitis,  520  ;  symptoms  following  attacks 
of  bronchitis,  521 ;  symptoms  of  hay  fever, 
521 ;  symptoms  of  adult  type,  522  ;  diagnosis, 
522  ;  prognosis,  522 ;  treatment,  522 ;  catar- 
rhal, 521 ;  with  adenoids,  300 ;  long  uvula, 
cause  of,  293  ;  simulated  by  tuberculous  bron- 
chial glands,  1089. 

Astigmatism,  stigma  of  degeneration,  804. 

Ataxia,  Friedreich's  826 ;  in  multiple  neuritis, 
834. 

Atelectasis,  acquired,  583 ;  from  compression, 
583;  from  obstruction.  584;  in  delicate  in- 
fants, 584 ;  causing  sudden  death,  43  ;  con- 
genital, 72;  lesions,  72;  symptoms,  73;  diag- 
nosis, 74 ;  treatment,  75 ;  in  marasmus,  237. 

Atheroma,  685. 

Athetoid  movements,  724  ;  in  acquired  cerebral 
paralysis,  792  ;  in  birth  paralysis,  789. 

Athetosis,  724. 

Athrepsia   (see  Marasmus),  236. 

Atomizer,  55 ;  steam,  59. 

Atresia  ani,  347. 

Atrophy,  infantile  (see  Marasmus),  236  ;  mus- 
cular, facial  type,  831 ;  in  multiple  neuritis, 
834;  juvenile  form,  831;  progressive  mus- 
cular, hand  type,  828  ;  peroneal  type,  829. 

Atropine,  hypodermically  in  cholera  infantum, 
380. 

Aura  of  epilepsy,  706. 

Autopsies,  principal  lesions  found  in,  39. 

Babcock's  centrifugal  machine,  133, 140. 

Bacillus  of  diphtheria,  1001,  1024;  distribution 
in  the  body,  1005;  in  milk,  139;  in  healthy 
throats,  1026 ;  in  laryngeal  diphtheria,  491 ; 
non-virulent,  1025 ;  of  Eberth,  in  typhoid 
fever,  1050  ;  of  Friedlander,  in  acute  broncho- 
pneumonia, 528  ;  Klebs-Loeffler  (seeB.  Diph- 
theri.e),  1001;  lactis  aerogenes,  320;  of 
Pfeifter,  in  iufiuenza,  1111 ;  pseudo-diphthe- 
ria, 1026  ;  of  tuberculosis,  1058  :  in  acute  bron- 
cho-pneumonia, 529  ;  inempyema,  593 ;  paths 
of  infection,  1062. 

Backwardness,  730. 


INDEX. 


1139 


Bacteria,  in  etiology  of  diarrhoea,  359 ;  in  hu- 
man milk,  \36 ;  in  cow's  milk,  138-142,  150, 
154;  means  of  excluding  from  cow's  milk, 
142 ;  intestinal,  320. 

Bacterium  coli  commune,  320  ;  in  appendicitis, 
434 ;  in  gastro-enteric  intoxication,  364 ;  in 
peritonitis,  462. 

Bacterium  lactis  aerogene,  320. 

Balanitis,  682. 

Band,  abdominal,  1,  3. 

Barley  water,  directions  for  making,  1 61 ;  use 
during  first  year,  202. 

Barlow's  disease  (see  Scorbutus),  242. 

Bath,  at  birth,  1,  2  ;  cold,  48  ;  in  acute  broncho- 
pneumonia, 555  ;  in  asphyxia  of  newly  born, 
TO ;  evaporation,  48  ;  hot,  54  ;  hot  air,  54 ;  va- 
pour, 54 ;  mustard,  54  •,  bran,  55  ;  tepid,  55  ; 
shower,  55 ;  cold  sponge,  55  ;  hot,  in  asphyxia 
of  newly-born,  70  ;  in  typhoid  fever,  1058. 

Bed-wetting,  688. 

Beef,  broth,  161 ;  extracts,  160  ;  juice,  expressed, 
159 ;  juice,  without  cooking,  160 ;  prepara- 
tions of,  159  ;  raw  scraped,  161. 

Belladonna,  51 ;  elimination  of,  in  milk,  136 ; 
scarlatiniform  rash,  952. 

Bile,  physiological  action  of,  319. 

Bile-ducts,  congenital  malformations  of,  75. 

Birth  paralyses,  105  ;  cerebral,  105  ;  spinal,  105  ; 
peripheral,  105. 

Bladder,  contraction  of,  causing  enuresis,  689 ; 
control  acquired,  689 ;  exstrophy  of,  681 ; 
hffimorrhage  from,  in  newly-born,  104 ;  stone 
in,  694 ;  training  to  control,  4. 

Bleeders,  855. 

Blindness,  hysterical,  730 ;  stigma  of  degenera- 
tion, 804;  transient,  in  pertussis,  991. 

Blisters,  52. 

Blood,  circulation  of,  in  early  life,  602 ;  cor- 
puscles, red,  841  ;  corpuscles,  white,  842  ;  dis- 
eases of,  841 ;  haemoglobin,  841 ;  in  chlorosis, 
848;  in  diphtheria,  1012;  in  leukemia,  854; 
in  pernicious  anaemia,  851 ;  in  pseudo-leu kse- 
mic  anaemia,  849 ;  in  simple  anaemia,  845 ; 
leucocytes  of,  varieties  of,  842 ;  leucocytosis, 
843;  Plasmodium  malaria  in,  1002,  1125; 
specific  gravity,  841. 

Blood-serum,  LoefBer's,  1002. 

Blc^od-vessels,  diseases  of,  635 ;  aneurism,  635  ; 
arterial  hypoplasia,  635 ;  atheroma,  635  ;  em- 
bolism, 636 :  thrombosis.  636. 

Boat-belly  in  tuberculous  meningitis,  762. 

Boll  (see  Fukunculosis),  917. 

Bone-marrow  in  leukaemia,  853. 

Bones,  diseases  of,  881 ;  in  hereditary  .syphilis, 
1097;  in  late  syphilis,  1105;  lesions  of,  in 
rickets,  252;  microscopical  changes  of,  in 
rickets,  253 ;  syphilitic  diseases  of,  897 ;  tu- 


berculous diseases  of,  832 ;  etiology,  883 ; 
lesions,  883. 

Bothriocephalus  latus,  443. 

Bottles,  nursing,  choice  and  care  of,  199. 

Bowels,  haemorrhages  from  (see  Hemorrhage, 
Intestinal)  ;  movements  of,  irregularity  in 
times  for,  420 ;  training  to  control  move- 
ments, 4. 

Bow-legs  in  rickets,  261. 

Bradycardia,  634. 

Brain,  diseases  of,  743  ;  abscess  of,  769  ;  atrophy 
and  sclerosis  of,  786 ;  atrophy  and  sclerosis 
of,  in  acquired  cerebral  paralysis,  790 :  cysts 
of,  in  infantile  cerebral  paralysis,  784 ;  mal- 
formations of,  743 ;  tuberculosis  of,  1073 ; 
tumour  of,  772 ;  water  on  the,  759 ;  weight 
of,  695. 

Bran  bath,  55. 

Breast,  abscess  of,  in  newly-born,  115. 

Breasts,  care  of,  during  lactation,  167  ;  secretion 
of,  in  newly-born,  114. 

Breast-feeding,  167  ;  schedule  for,  169. 

Breast  milk  (see  Milk,  Woman's). 

Breath,  offensive,  in  ulcerative  stomatitis,  282. 

Breathing,  noisy,  with  adenoids,  299 ;  stridu- 
lous,  in  diseases  of  the  larynx,  486,  489,  492  ; 
in  retro-oesophageal  abscess,  315. 

Bright's  disease  (see  Nephritis),  659. 

Bromides,  elimination  of,  in  milk,  136. 

Bronchi,  catarrhal  spasm  of,  521 ;  diphtheria 
of,  1009;  foreign  bodies  in,  504;  lesions  of,  in 
acute  broncho-pneumonia,  529  ;  lymph  nodes 
of,  in  tuberculosis,  1062,  1070 ;  tube  casts  of, 
517. 

Bronchial  glands  (see  also  Lymph  Nodes,  Bron- 
chial), enlarged,  cause  of  asthma,  520 ;  in 
acute  broncho-pneumonia,  536  ;  reflex  cough 
from,  519. 

Bronchitis,  acute  catarrhal,  508 ;  etiology,  508 : 
lesions,  509 ;  symptoms  in  infants,  509  ; 
symptoms  in  older  children,  511  ;  diagnosis 
from  broncho-pneumonia,  511 ;  treatment, 
512;  abortive  measures,  513;  attacks  of  suf- 
focation, 515  ;  cardiac  stimulants,  514  :  coun- 
ter-irritation, 513;  emetics,  514;  expectorants, 
514;  general  management,  513;  inhalations, 
514;  in  infants,  mild  cases,  514;  in  infants, 
severe  cases,  515;  in  older  children,  515; 
local  applications,  513 ;  opium,  514 ;  prophy- 
laxis, 512;  protracted  cough  in  convales- 
cence, 516;  respiratory  stimulants,  514;  re- 
spiratory failure,  515 ;  a^ithma  following,  521 ; 
capillary  (see  Broncho-pneumonia,  Acute), 
527,  538 ;  attacks  of  asthma  resembling, 
520;  chronic,  517:  etiology,  517;  symptoms, 
517  ;  diagnosis,  518 ;  treatment,  518 ;  chronic, 
bronchiectasis  in,  518;   chronic,  in  rickets, 


1140 


INDEX. 


256 ;    diphtheritic,    broncho-pneumonia    in, 
549;  fibrinous,  516;  treatment,  517;  in  per- 
tussis,  990 ;    in   typhoid   fever,   1054 ;    spas- 
modic (see  Asthma),  521. 
Bronchiectasis   in   chronic   bronchitis,  518;  in 

broncho  pneumonia,  chronic,.  578. 
Broncho-pneumonia,  acute,  527 ;  bacteriolog'y, 
528 ;  complications,  549 :  cyanosis  in,  538, 
540;  complicating  influenza,  1114;  diph- 
theria, 1011 ;  measles,  966  ;  pertussis,  990  ; 
pseudo-diphtheria,  1048  ;  rickets,  256 ;  diag- 
nosis, 550 ;  from  congenital  atelectasis,  550 ; 
from  severe  bronchitis,  550 ;  from  lobar 
pneumonia,  551 ;  from  malarial  fever,  551 ; 
etiology,  527 ;  age,  527 ;  previous  condition, 
527  ;  previous  disease,  527 ;  season,  527 ;  sex, 
527  ;  duration  of,  543  ;  lesions,  529  ;  in  acute 
congestive  form  (acute  red  pneumonia),  531 ; 
in  mottled  red  and  gray  pneumonia,  533 ;  in 
gray  pneumonia  (persistent  broncho-pneu- 
monia), 585 ;  associated,  in  the  lung,  536  ;  ab- 
scesses of  lung,  537 ;  bronchial  glands,  536 ; 
emphysema,  537 ;  gangrene,  537 ;  pleurisy, 
536 ;  intra-alveolar  haemorrhage,  532 ;  pul- 
monary collapse,  530 ;  seat  of  the  disease, 
531 ;  physical  signs,  chart  of,  544 ;  without 
consolidation,  543  ;  with  areas  of  partial  con- 
solidation, 543 ;  with  areas  of  consolidation 
more  or  less  complete,  545 ;  day  of  appear- 
ance, 546 ;  protracted  or  persistent  form,  546 ; 
secondary  pneumonia  with  measles,  548 ;  ileo- 
colitis, 549 ;  influenza,  549  ;  pertussis,  548  ; 
diphtheria,  548 ;  prognosis,  551 ;  mortality 
tables,  552 ;  protracted  cases,  546 ;  pathologi- 
cal difl'erentiation  from  lobar  form,  523  ;  rela- 
tive frequency  of,  525;  respiration  in,  538, 
540 ;  symptoms,  537 ;  acute  congestive  type, 
537;  acute  disseminated  type,  538;  common 
type,  539 ;  temperature  charts  of,  541 ;  tem- 
perature in,  537,  538,  539  ;  terminations,  535 ; 
treatment,  553 ;  by  antipyretics,  555 ;  cold, 
555 ;  emetics,  554 ;  hygiene,  554  ;  inhalations, 
556;  stimulants,  554;  of  attacks  of  collapse, 
556;  of  nervous  symptoms,  556  ;  of  protracted 
cases,  556 ;  prophylaxis,  553 ;  summary  of,  557. 

Broncho-pneumonia,  chronic,  578 ;  etiology, 
578  ;  lesions,  579  ;  symptoms,  579  ;  physical 
signs,  580 ;  course,  580 ;  prognosis.  580 ;  diag- 
nosis, 580 ;  from  tuberculosis,  580 ;  treatment, 
581. 

Broncho-pneumonia,  tuberculous,  1065,  1078  ; 
rapid  cases,  1079  ;  protracted  cases,  1080  (see 
also  TuBEEOULous  Pneumonia). 

Broths,  directions  for  making,  161. 

Bubo,  with  gonorrhceal  urethritis,  682;  vulvo- 
vaginitis, 686. 

Buhl's  disease,  91. 


Calamine  lotion,  915. 

Calculi,  biliary,  460 ;  renal,  673  ;  pyelitis  with^ 

674 ;  vesical,  694. 
Calomel  fumigations,  493. 
Calomel,  how  best  given,  46. 
Cancrum   oris  (see   Stomatitis,  G-angrengus), 

288. 
Carbohydrates,  function  of,  in  diet,  125. 
Carcinoma  of  brain,  772 ;  of  kidney.  667 ;  of 

stomach,  345. 
Cardiac  cough,  519. 
Carnrick's  soluble  food,  163. 
Casein,  146,  150, 181 ;  in  the  faeces,  321;  stools 

in  difficult  digestion  of,  411. 
Caseinogen,  146. 

Casts  in  urine  of  chronic  nephritis,  665. 
Catarrh,  Eustachian,  in  hypertrophy  of  tonsils,. 
310 ;    foetid   (see  Ehinitis,   Ateophic),  481 ; 
gastric,    338 ;    gastro-intestinal,    857 ;    nasal 
acute,   474 ;   etiology,  474 ;    symptoms,   475 ;. 
diagnosis,  475 ;  treatment,  475 ;  prophylaxis, 
476;  chronic,  477;  with  adenoid  growths,  300,. 
477 ;  foreign  bodies  in  nose,  477 ;  nasal  polypi,. 
478  ;  rhinitis,  simple  chronic,  478  ;  hypertro- 
phic,   480  ;    atrophic,    481 ;    syphilitic,   481  ;■ 
rhino-pharyngeal,  with  adenoids,  299. 
Catheters,  sizes  required  for  infants,  638. 
Cellulitis  of  abdominal  wall  with  peritonitis,. 

462;  of  neck,  in  scarlet  fever,  948. 
Centrifugal  machine,  133,  144. 
Cephalhsematoma,  external,   95 ;  internal,  96 ;. 

symptoms,  96 ;  diagnosis,  96  ;  treatment,  97. 
Cereals,  161 ;  allowed  from  third  to  sixth  year, 

220. 
Cerebellum,  abscess  of,  769  ;  tumours,  776. 
Cerebral  paralysis,  784 ;  from  haemorrhage,  105;. 
etiology,  105 ;  lesions,  106  ;  symptoms,  107 ; 
prognosis,  108  ;  treatment,  108. 
Cerebrum,  abscess  of,  769  ;  tumour,  772. 
Chest,  circumference  of,  20 ;  development  of,. 
24;   "funnel"  chest,   24;    in    rickets,    259; 
lateral  depressions  of,  in  adenoids,  299 ;  lat- 
eral furrowing  of,  in  rickets,  256. 
Cheyne-Stokes  respiration  in  acute,  meningitis,. 

755  ;  in  tuberculous  meningitis,  762. 
Chicken-pox  (see  Varicella),  977. 
Chloral,  dosage  and  administration,  57. 
Chlorosis,    847 ;    etiology,  847 ;    lesions,    847 ;. 
symptoms,   848 ;    blood   in,   848 ;    prognosis, 
848  ;  diagnosis,  848  ;  treatment,  852. 
Cholera  infantum,  357  (see  also  Intoxication, 

Acute  Gastro-enteric),  376. 
Chorea,  717  ;  acute  endocarditis  in,  620  ;  course 
and  duration,  721  ;  diagnosis,  721 ;  endocar- 
ditis in,  721 ;  etiology,  717 ;  following  birth 
paralysis,  789  ;  typhoid  fever,  1055;  habit, 
723  ;   heart  murmurs  in,  721  ;  prognosis  of. 


INDEX. 


lUl 


722 ;  hysterical,  731  ;  with  adenoids,  301 ;  in 
rheumatism,  1132 ;  pathology,  719  :  post- 
hemiplegic, 725  ;  in  cerebral  palsy,  792  ;  prog- 
nosis,722 ;  relation  to  rheumatism,  718 ;  speech 
in,  721,  736;  symptoms,  720:  treatment,  722; 
urine  in,  721. 

Circulation,  changes  in,  at  birth,  602;  foetal. 
602 ;  in  early  life,  602. 

Circulatory  system,  diseases  of  the,  602. 

Claw-hand,  828. 

Cleft  palate,  272. 

Clothing  at  birth,  2 ;  in  summer,  3 ;  at  night, 
3 ;  in  summer  diarrhoea,  369. 

Club-foot  with  spina  bifida,  807. 

Codeine,  doses  of,  51. 

Cod-liver  oil  as  tonic,  50. 

Cold,  as  an  antipyretic,  47 ;  ice  cap,  47  ;  spong- 
ing, 47  ;  pack,  47  ;  bath,  48  ;  irrigation  of  the 
colon,  48 ;  in  the  head,  with  adenoids,  298 ; 
therapeutics  of,  53. 

Cold  sores,  273. 

Colic,  habitual,  from  excessive  proteids,  198 ; 
intestinal,  416;  renal,  674. 

Colitis,  acute  (see  Ileo-colitis,  Acute),  381 ; 
amcebic,  405 ;  membranous,  394 ;  membranous 
gastritis  with,  334. 

Collapse,  in  acute  broncho-pneumonia,  treat- 
ment of,  556  ;  in  acute  peritonitis,  464 ;  in  ap- 
pendicitis, 438 ;  in  corrosive  gastritis,  336  ;  in 
ulcer  of  stomach,  345. 

Collapse,  pulmonary  (see  Atelectasis,  Ac- 
quired), 583. 

Colles's  law,  1096. 

Colon,  abnormal  position  of,  348 ;  congenital 
atresia  of,  115;  cysts  of  mucosa,  401 ;  dilata- 
tion of,  424 ;  in  rickets,  263 ;  follicular  ulcers 
of,  385 ;  hypertrophy  of,  424 ;  irrigation  of,  48, 
63 ;  in  gastro-enteric  into.xication,  372 ;  in  in- 
testinal indigestion,  415;  membranous  in- 
tianimation  of,  390  ;  transverse,  dilatation  of, 
iu  chronic  ileo-colitis,  403. 

Colostrum,  127 ;  corpuscles  of,  127 ;  composi- 
tion of,  128. 

Coma,  in  tuberculous  meningitis,  762 ;  in  dia- 
betes niellitus,  1136. 

Compression-myelitis  (sec  Myelitis),  814. 

Condensed  milk,  cause  of  rickets,  249 ;  compo- 
sition of,  156;  dilution  of,  for  infants,  156; 
fresh,  156. 

Congenital,  ichthyosis,  905;  myotonia,  726; 
rickets,  256  ;  syphilis,  1100  ;  tuberculosis,  1060. 

Conjunctiva,  catarrhal  inflanmiatioa  in  measles, 
963;  ha3morrhage  from,  in  newly  born,  104. 

Constipation,  a  cause  of  chlorosis,  847  ;  causes 
of,  in  rickets,  263;  chronic,  418;  etiology, 
418;  symptoms,  419;  diagnosis,  420;  treat- 
ment, 420 ;   food,    420 ;  massage,  421 ;   sup- 


positories, 422;  enemata,  422;  medicinal, 
423;  dilatation  of  colon  in,  424;  from  anal 
fissure,  450;  early  symptom  of  rickets,  257 ; 
from  deficient  fat  in  food,  198;  in  appendi- 
citis, 436;  in  intestinal  indigestion,  chronic,. 
410,  412;  in  intussusception,  430. 

Contractures,  hysterical,  731. 

Convulsions,  697 ;  etiology,  697 ;  pathology,. 
699 ;  symptoms,  699 ;  diagnosis,  700 ;  in 
acute  disease,  701 ;  in  brain  disease,  701 ;  in 
epilepsy,  701 ;  in  gastro-intestinal  disease, 
701 ;  prognosis,  702 ;  treatment,  702 ;  at- 
tributed to  dentition,  278;  causing  death 
without  other  symptoms,  44;  chloral  in,. 
703  :  epileptic,  706 ;  hysterical,  732 ;  in  ac- 
quired cerebral  paralysis,  791 ;  in  cerebral 
haemorrhages,  107 ;  in  congenital  atelectasis, 
73 ;  in  pertussis,  991 ;  in  rickets,  265 ;  mor- 
phine in,  703. 

Cooley  creamer,  149. 

Cord,  spinal,  diseases  of,  805  ;  malformations  of, 
805;  position  of,  811  ;  meningitis,  811  ;  mye- 
litis, 812;  pressure-paralysis  of,  814;  tu- 
mours of,  824 ;  weight  of,  695. 

Cord,  umbilical,  care  of,  1  ;  separation  of,  2. 

Cornea,  ulcers  of,  in  chronic  ileo-colitis,  403. 

Corpuscles  of  blood,  841. 

Coryza,  474 ;  early  symptoms  of  measles,  961 ;. 
syphilitic,  481,  1101. 

Cough,  hysterical,  731 ;  reflex,  518 ;  from  pha- 
ryngeal irritation,  518 ;  from  elongated  uvula,. 
518 ;  from  pharyngeal  mucus,  518 ;  from 
aural  irritation,  518;  from  cardiac  disease,. 
519 ;  of  puberty,  519 ;  periodical,  at  night,. 
519;  from  Pott's  disease,  519;  symptoms 
519 ;  diagnosis,  519  ;  treatment,  519  ;  spas- 
modic, in  retro-cesophageal  abscess,  315 ;  in 
tuberculous  bronchial  glands,  1089  ;  whoop- 
ing (see  Pertussis),  985. 

Counter-irritants,  52. 

Cow's  milk  (see  Milk). 

Cranio-tabes,  early  symptoms  in  rickets,  257. 

Cranium,  syphilitic  nodes  on,  902. 

Cream,  147  ;  to  secure  difterent  percentages  of, 
148,  149. 

Cream-gauge,  132,  145. 

Credo's  method  of  preventing  ophthalmia  ne- 
onatorum, 1  ;  treatment  of  ophthalmia,  86. 

Cretinism,  sporadic,  798  ;  etiology,  798  ;  symp- 
toms, 798;  diagnosis,  800;  prognosis  and 
treatment,  800. 

Croup,  bronchial,  516;  catarrhal,  485;  kettle, 
58  ;  membranous,  491  ;  membranous,  in  scar- 
let fever,  947  ;  spasmodic,  485  ;  true,  491. 

Cry,  causes  and  varieties  of,  33  ;  in  disease,  34  ; 
in  colic,  417  ;  in  rctro-pliaryngeal  abscess, 
294 ;  from  insufficient  food,  170. 


1142 


INDEX. 


Cryptorchidism,  681. 

Cups,  dry,  indications  for,  53 ;  wet,  condemned, 
54. 

■Curds  and  whey,  159. 

Cyanosis,  in  acute  broncho-pneumonia,  538, 
540 ;  in  acute  inanition,  226 ;  in  chronic 
cardiac  disease,  626 ;  in  congenital  atelectasis, 
73 ;  in  congenital  disease  of  heart,  609 ;  in 
diphtheritic  paralysis,  887;  in  malaria,  1121, 
1124;  of  face,  from  pressure  at  root  of  lung, 
1090. 

Cyclic  vomiting,  326. 

Cyst,  of  brain,  772 ;  of  brain  in  infantile  cere- 
bral paralysis,  784;  of  intestinal  mucosa,  401. 

Cysticercus,  442. 

Dactylitis,  scrofulous,  895 ;  syphilitic,  903  ; 
tuberculous,  895 ;  symptoms,  896  ;  diagnosis, 
897 ;  treatment,  897. 

Deaf-mutism,  804  ;  stigma  of  degeneration,  804. 

Deafness  following  mumps,  999  ;  with  adenoids, 
299  ;  with  hypertrophy  of  tonsils,  310  ;  sud- 
den, in  late  syphilis,  1105. 

Death,  most  frequent  causes  of,  at  diflerent 
ages,  41 ;  sudden,  causes  of,  42. 

Deformities,  hysterical,  731 ;  in  rickets,  257. 

Degeneration,  stigmata  of,  803. 

Deltoid,  paralysis  of,  at  birth,  109. 

Dentition,  27  ;  eruption  of  first  teeth,  28  ;  erup- 
tion of  permanent  teeth,  29  ;  delayed,  28  ; 
before  birth,  28;  difficult,  277;  symptoms, 
278  ;  treatment,  279  ;  in  rickets,  264  ;  in  the 
etiology  of  diarrhoea,  850 ;  often  delayed  in 
malnutrition,  230. 

Dermatitis,  exfoliativ^e,  of  newly  born,  904 ; 
gangrenous,  918;  treatment,  919. 

Development,  conditions  interfering  with,  30  ; 
muscular,  25  ;  of  body,  15. 

Dew's  method  of  inducing  artificial  respiration, 
70. 

Dextro-cardia,  609. 

Diabetes  insipidus,  648 ;  symptoms,  649 ;  di- 
agnosis, 650 ;  treatment,  650. 

Diabetes  mellitus,  1185;  symptoms,  1135  ;  prog- 
nosis, 1186  ;  treatment,  1186. 

Diacetonuria,  647. 

Diagnosis,  general  considerations  in,  31. 

Diapers,  3. 

Diaphragm,  hernia  through,  116. 

Diarrhoea,  acute,  eliminative,  352;  from  drugs, 
352 ;  from  intestinal  indigestion,  353 ;  from 
nervous  influences,  852 ;  mechanical,  351  ; 
of  infectious  origin,  358 ;  varieties  of,  351 ; 
etiological  factors  in,  349  ;  inflammatory  (see 
Ileo-oolitis,  Acute),  881 ;  in  chronic  intes- 
tinal indigestion,  410;  in  intestinal  tuber- 
culosis, 408  ;  mycotic,  857  ;  summer,  357. 


Diastatic  ferment  of  pancreas,  319;  of  bile, 
819. 

Diathesis,  lymphatic,  with  adenoids,  298. 

Diet  (see  also  Feeding),  as  cause  of  chronic 
constipation,  419;  cause  of  rickets,  249;  in 
acute  gastro-enteric  infection,  368;  in  acute 
gastric  indigestion,  332  ;  in  chronic  constipa- 
tion, 420 ;  in  chronic  gastric  indigestion,  341 ; 
in  cyclic  vomiting,  329  ;  in  eczema,  918 ;  in 
intestinal  indigestion,  414;  in  malnutrition, 
233;  in  rickets,  269  ;  in  scurvy,  249 ;  of  nurse, 
efl'ect  on  milk,  135. 

Dietary  of  the  infant,  126. 

Digestion,  gastric,  817  ;  duration  of,  818  ;  in 
infancy,  316;  intestinal.  319. 

Digestive  system,  diseases  of  the,  272. 

Digitalis,  dosage  for  infant,  ^79. 

Dilatation  of  the  stomach,  342. 

Diphtheria,  1000 ;  bacillus  (see  Bacillus  of 
Diphtheria),  1001 ;  broncho-pneumonia  in, 
548,  1011,  1019  ;  blood  in,  1012;  cardiac  fail- 
ure in,  1017  ;  cardiac  thrombi  in,  1011 ;  ca- 
tarrhal, 1006,  1013;  cervical  lymph  nodes  in, 
1010  ;  complications  and  sequelae,  1019  ;  con- 
valescence, 1048 ;  croupous  bronchitis  in,  516  ; 
diagnosis,  1020  ;  bacteriological,  1024  ;  tech- 
nique of,  1024 ;  reliability  of,  1025 ;  clinical, 
1021 ;  from  pseudo-diphtheria,  1023 ;  disin- 
fection after,  1029  ;  distribution  and  mode  of 
communication,  1002;  embolism  in,  1019; 
entero-colitis  in,  1020 ;  etiology,  1001 ;  hsem- 
on-hages,  1020  ;  immunization.  1030 ;  incu- 
bation, 1004;  lesions,  1004;  membrane,  1006  ; 
membrane,  seat  and  distribution  of,  1007  ; 
membranous  gastritis  in,  334;  proctitis  in, 
451 ;  myocarditis  in,  632, 1018;  nasal  syringing 
in,  1034;  nephritis  in,  1011, 1020;  of  oesoph- 
agus, 318;  otitis  in,  1019;  paralysis  after, 
1011 ;  paralysis  in,  836;  predisposing  causes, 
1003  ;  prognosis,  1027  ;  prophylaxis,  1029  ; 
quarantine,  1029;  septicaemia  in,  1018;  sick- 
room in,  1082  ;  simulated  after  tonsillotomy, 
312;  sloughing  in,  1019;  spleen  in,  1010; 
symptoms,  1012 ;  symptoms,  without  mem- 
brane, 1018  ;  symptoms,  with  limited  mem- 
brane (tonsillar),  1014 ;  symptoms,  severe 
cases,  1015;  symptoms,  mixed  infection  (sep- 
tic), 1016  ;  thrombosis  in,  1019 ;  toxceraia, 
1017  ;  toxins  of,  1005  ;  treatment,  1033  ;  gen- 
eral, 1033;  stimulants,  1033;  local,  1034; 
serum,  1085  ;  of  children  exposed,  1030 ;  of  sus- 
pected cases,  1080  ;  supplementary  to  antitox- 
ine,  1044 ;  virulent  bacilli  in  healthy  throats, 
1026  ;  visceral  lesions,  1010  ;  false  (see 
Pseudo-Diphtheria),  1044  ;  laryngeal,  491, 
1016;  nasal.  518.  1013,  1015;  pseudo  (see 
Pseudo-Diphtheria),  1001, 1044;  scarlatinal 


INDEX. 


1143 


(see  PsEUDO-DiPHTHEBiA  I,  1044  ;  scarlatinal, 
947  ;  scarlatinitbnii  erytheiua  in,  952  ;  strep- 
tococcus (see  rsKiuo-DiiMiTiiEUiA),  1044; 
tonsillar,  1014. 

Diphtheria  antito.xin,  dosage  of,  1036 ;  effect 
on  membrane,  1038  ;  history  of,  1035  ;  immu- 
nizing close  of,  1031  ;  intiuence  on  mortality 
of  cities,  1042;  limitations  of,  1038;  local  and 
general  effects  of,  1038  ;  other  treatment  with, 
1033,  1044 ;  production  of,  1036 ;  real  and 
alleged  dangers  from,  1039 ;  results  in  hospital 
practice,  1040 ;  results  in  laryngeal  cases, 
1041 ;  results  in  private  practice,  1040  ;  mod- 
ified by  time  of  injection  and  age  of  patient, 
1027, 1037  ;  of  intubation  with  and  without, 
1041 ;  strength  of,  1036  ;  syringe  for,  1036  ; 
time  of  administration,  1037. 

Diplegia,  in  birth  paralysis,  786  ;  in  meningeal 
haemorrhage,  107  ;  spastic,  784. 

Disease,  peculiarities  of,  in  children,  30;  eti- 
ology, 30 ;  syiuptomatology  and  diagnosis, 
31 ;  pathology,  38  ;  prognosis,  40  ;  prophy- 
laxis, 44 ;  therapeutics,  45. 

Diverticulum,  Meckel's,  112,  349. 

Dobell's  solution,  56. 

Dover's  powder,  dosage  of,  51. 

Dropsy  (see  also  CEdema)  ;  in  acute  diffuse  ne- 
phritis, 660 ;  in  chronic  cardiac  disease,  626  ; 
in  chronic  nephritis,  665 ;  iu  newly  born,  118 ; 
in  tuberculosis,  1083;  without  renal  disease, 
678. 

Drugs,  administration  of,  46 ;  elimination  of,  in 
breast  milk,  136 ;  well  borne.  52 ;  not  well 
borne,  52. 

Duct,  omphalo-mesenteric,  112,  116. 

Ductus  arteriosus,  closure  of,  602 ;  in  foetal  cir- 
culation, 602 ;  patent,  608 ;  venosus.  closure 
of,  002 ;  in  foetal  circulation,  602. 

Duodenum,  catarrhal  infiammation  of,  336 ; 
congenital  atresia  of,  115. 

Dura  mater,  hsematoma  of,  747;  thrombosis  of 
the  sinuses  of,  767. 

Dysentery  (see  Ileo-colitis,  Acute),  381. 

Dysphagia,  hysterical,  731 ;  in  retro-pharyngeal 
abscess,  295. 

Dyspnoea,  evidences  of,  33;  from  tuberculous 
bronchial  lymph  nodes,  1090;  in  acute  ca- 
tarrhal laryngitis,  489  ;  in  catarrhal  spasm  of 
larynx,  440  ;  in  membranous  laryngitis,  492 ; 
in  chronic  cardiac  di.sease,  625 ;  in  retro- 
pharyngeal abscess,  294 ;  inspiratory,  in 
retro-cesophageal  abscess,  315  ;  pressure  of 
abscess  on  pneumogastric,  31 5 ;  spasmodic, 
in  asthma,  519. 

Ear,  anomalies  of,  as  stigmata  of  degeneration, 
803;  hsemorrhage  from,  in  newly  born,  104; 


middle,  inflammation  of  (see  Otitis),  925  ;  in 
measles,  968 ;  in  scarlet  fever,  948. 

Ears,  development  of  hearing,  26. 

Ebcrth's  bacillus  of  typhoid  fever,  1050. 

Ecchymoses  in  purpura,  857 ;  in  scurvy,  243 ; 
in  leukaemia,  854. 

Echinococcus  of  liver,  460. 

Eclampsia  (see  Convulsions),  697. 

Ecthyma  gangrenosa,  918. 

Ectocardia,  609. 

Eczema,  908 ;  etiology,  908 ;  varieties,  910 ; 
diagnosis,  912 ;  prognosis,  912 ;  treatment, 
913  ;  dietetic,  913  ;  of  kidneys,  914;  of  bowels, 
914;  general,  914;  local,  915;  exacerbations 
during  dentition,  278  ;  intertrigo,  911 ;  pu.stu- 
lar,  of  scalp,  911 ;  rubrun),  910  ;  seborrhoeic, 
908,  911 ;  .simple  chronic,  910. 

Emboli,  infectious,  in  malignant  endocarditis, 
622. 

Embolism,  636  ;  in  diphtheria,  1019. 

Emphysema,  585  ;  etiology,  585  ;  lesions,  586  ; 
in  acute  vesicular,  586  ;  in  interstitial,  inter- 
lobular, 586  ;  symptoms,  587  ;  acute,  in  bron- 
chitis of  infants,  511 ;  in  acute  broncho-pneu- 
monia, 537  ;  in  pertussis,  990. 

Empyema,  592 ;  bacteriology,  592  ;  lesions,  593  ; 
symptoms,  595  ;  diagnosis,  596;  by  exploratory 
puncture,  596  ;  from  unresolved  pneumonia, 
596 ;  from  pleuro-pneumonia,  596  :  from  tuber- 
culosis, 596  ;  prognosis,  597  ;  acute  peritonitis 
complicating,  462:  following  pleuro-pneu- 
monia, 576  ;  spontaneous  cure,  598 ;  treatment, 
598  ;  by  aspiration,  598  ;  simple  incision  and 
drainage,  598;  resection  of  a  rib,  600;  meth- 
ods of  expanding  lung  after,  601 ;  tuberculous, 
1065  ;  acute  broncho-pneumonia,  536. 

Encephalocele,  743  ;  symptoms,  744 ;  treatment, 
745. 

Endarteritis,  syphilitic,  of  brain,  1099 ;  tuber- 
culous, 759. 

Endocarditis,  acute  simple,  618  ;  etiology,  618  ; 
lesions,  619  ;  symptoms,  620  ;  diagnosis,  620  ; 
prognosis,  621 ;  treatment,  621 ;  acute  simple, 
in  chorea,  620 ;  chronic  (see  also  Heart, 
Valvular  Disease),  623 ;  foetal,  606 :  in 
chorea,  721;  in  rheumatism,  1131;  malignant, 
622  ;  etiology,  622  ;  lesions,  622  ;  symptoms. 
622  ;  diagnosis,  623  ;  treatment,  623. 

Enemata,  65  ;  nutrient,  65  ;  drugs  by,  65 ;  as- 
tringent, in  chronic  ileo-colitis,  404 ;  iu 
chronic  constipation,  422  ;  in  colic,  418  ;  ice- 
water  in  cholera  infantum,  380  ;  injuries  to 
rectum  from,  450. 

Enteritis  follicularis  (see  Ileo-colitls,  Acute), 
381. 

Entero-colitis,  in  diphtheria,  1020  (.see  Ileo- 
colitis,. Acute),  381. 


1144 


INDEX. 


Enuresis,  688  ;  etiology,  689  ;  symptoms,  690  ; 
prognosis,  690 ;  treatment,  690 ;  stigma  of 
degeneration,  804. 

Ependymitis,  acute,  in  hydrocephalus,  780 ;  fol- 
lowing spina  bifida,  810. 

Epidemic,  hsemoglobinuria,  90 ;  meningitis  (see 
Meningitis,  Acute). 

Epidermis,  exfoliation  of,  in  congenital  ichthy- 
osis, 912;  exfoliation  of,  in  newly  born,  904. 

Epilepsy,  704 ;  aura  in,  706  ;  course,  708 ;  diag- 
nosis, 709  ;  etiology  of,  704  ;  hysterical,  731 ; 
idiopathic,  704 ;  in  acquired  cerebral  paraly- 
sis, 792  ;  in  birth  paralysis,  789  ;  insanity  fol- 
lowing, 802 ;  intestinal  putrefaction  in,  705  ; 
Jacksonian,  in  cerebral  tumour,  774 ;  men- 
tal condition  in,  708  ;  pathology,  705  ;  prog- 
nosis, 709  ;  status  epilepticus,  709  ;  stigma  of 
degeneration,  804  ;  symptomatic,  708  ;  symp- 
toms, 706  ;  grand  mal,  706  ;  petit  mal,  707  ; 
treatment,  general,  710 ;  during  an  attack,  712. 

Epiphyseal  separation  in  acute  arthritis,  881 ; 
in  scurvy,  246  ;  in  syphilis,  897. 

Epiphyses,  enlargement  of,  in  rickets,  261 ;  in 
syphilis,  898,  903. 

Epiphysitis,  acute  (see  Arthritis,  Acute),  881 ; 
syphilitic,  897,  1103. 

Epispadias,  680. 

Epistaxis,  483 ;  in  anaemia,  846 ;  in  pertussis, 
988  ;  in  purpura,  860 ;  in  scurvy,  245. 

Epitrochlear  lymph  nodes  in  syphilis,  1105. 

Erb's  paralysis,  110. 

Erysipelas  in  newly  born,  83. 

Erythema,  following  diphtheria  antitoxin, 
1038  ;  in  influenza,  1116  ;  intertrigo,  911 ;  in 
intestinal  indigestion,  413 :  in  rheumatism, 
1133 ;  of  the  buttocks  in  marasmus,  239 ; 
scarlatiniform,  causes,  952. 

Erythroblasts,  849. 

Estlander's  operation,  601. 

Eustachian  tube  in  acute  otitis,  925 ;  inflamma- 
tion of,  in  influenza,  1114  ;  obstruction  of,  in 
hypertrophy  of  tonsils,  310. 

Exercise,  importance  of,  7 ;  caution  regarding, 
in  heart  disease,  631 ;  in  anaemia,  853. 

Expectorants  in  bronchitis,  514. 

Exstrophy  of  bladder,  681. 

Extubation,  499. 

Eye,  anomalies  of,  as  stigmata  of  degeneration, 
803 ;  keratitis,  interstitial,  in  syphilis,  1105 ; 
care  of,  at  birth,  1,3;  diphtheritic  paralysis 
of,  836  ;  early  use,  25  ;  ectropion  of,  in  con- 
genital ichthyosis,  905  ;  inflammation  of,  in 
newly  born,  85 ;  in  measles,  969 ;  nystagmus, 
725. 

Face,  asymmetry  of,  as  stigma  of  degeneration, 
803 ;  expression  of,  in  disease,  33 ;  cyanosis 


and  oedema  of,  from  pressure  at  root  of  lung-^ 
1090. 

Facial  paralysis,  at  birth,  108 ;  acquired,  periph- 
eral, 838;  in  otitis,  931. 

Faeces,  321 ;  of  milk  diet,  321 ;  of  mixed  diet,. 
322 ;  incontinence  of,  453. 

Fat,  determination  of,  in  milk,  133 ;  in  the 
faeces,  322 ;  test  for,  355 ;  lack  of,  a  cause  of 
rickets,  249 ;  lack  of,  causing  constipation, 
419;  in  woman's  milk,  131;  percentages  of, 
in  modification  of  cow's  milk,  180, 187  ;  symp- 
toms from  deficiency  of,  in  food,  198  ;  symp- 
toms from  excess  in  food,  197,  199 ;  fimction 
of,  in  diet,  124. 

Fatty  degeneration  of  the  newly  born,  91. 

Fauces,  syphilitic,  ulceration  of,  1099. 

Feeble-mindedness,  794. 

Feeding,  artificial,  fundamental  principles  of,. 
177 ;  rules  for,  192,  201 ;  schedule  for  first 
year,  202;  number  of  feedings,  twenty-four 
hours,  202 ;  intervals  by  day,  202 ;  night 
feedings,  202  ;  quantity  for  one  feeding,  202 ; 
quantity  for  twenty-four  hours,  202 ;  versus- 
wet-nursing,  166;  breast,  schedule  for,  169. 
other  than  milk,  first  year,  202;  difficult 
cases,  first  year,  203;  summary  of  infant 
feeding,  212  ;  in  institutions,  213  ;  on  jour- 
neys, 214 ;  daily  dietary  at  eighteen  months, 
218;  for  healthy  infants,  second  year,  216; 
difficult  cases,  second  year,  218  ;  from  third 
to  sixth  year,  220  ;  articles  allowed,  220 ;  arti- 
cles forbidden,  221 ;  dietary,  from  third  to- 
sixth  years,  222 ;  during  acute  illness,  222 ; 
in  infants,  222 ;  older  children,  223  ;  during- 
very  hot  days,  368 ;  by  gavage,  in  acute  ill- 
ness, 223  ;  nasal,  63  ;  in  acute  gastro-enteric- 
intoxication,  370 ;  in  acute  intestinal  indi- 
gestion, 356  ;  methods  of,  in  etiology  of  diar- 
rhoea, 350 ;  mixed,  indications  for,  177 ;  sim- 
ple rules  in,  222. 

Feet,  anomalies  of,  as  stigmata  of  degeneration,. 
803. 

Feser's  lactoscope,  145. 

Fever,  puerperal,  of  the  child,  79  ;  from  insuffi- 
cient nourishment,  170  ;  inanition,  118 ;  toxic, 
in  intestinal  indigestion,  413  (see  also  Tem- 
perature). 

Finger  (see  Dactylitis). 

Fingers,  clubbing  of,  in  chronic  cardiac  dis- 
ease, 626  ;  in  congenital  heart  disease,  610. 

Fissure  of  the  anus,  450. 

Fistula,  congenital,  of  the  neck,  312. 

Flatulence,  cause  of  colic,  417  ;  in  intestinal  in- 
digestion, 412. 

Foetal  circulation,  602  ;  endocarditis,  606. 

Foetus,  evidences  of  syphilis  in,  1100. 

Follicles,  solitary  (see  Lymph  Nodules)  ;  soli- 


INDEX. 


1145 


tary,  of  intestine,  often  enlarged  in  marasmus, 
237. 

Follicular  ulceration  of  intestine,  385. 

Fomentations,  hot,  53. 

Fontanel,  bulging,  in  acute  meningitis,  755 ; 
bulging  of,  in  meningeal  hemorrhage,  107  ; 
bulging  of,  in  tuberculous  meningitis,  759 ; 
in  hydrocephalus,  781 ;  closure  of,  'l-i  ;  in  cre- 
tinism, 800  ;  in  rickets,  256. 

Food,  constituents,  123  ;  proteids,  123;  fats,  124; 
carbohydrates,  125;  mineral  salts,  126;  water, 
126 ;  farinaceous,  a  cause  of  eczema,  909 ;  in 
chronic  indigestion,  341 ;  second  year,  216 ; 
improper,  in  etiology  of  diarrhoea,  350 ;  re- 
gurgitation of,  causes  and  treatment,  197. 

Food-listula  between  oesophagus  and  larynx, 
314. 

Food-diseases,  242. 

Foods,  infant,  162;  milk,  162;  malted,  163; 
farinaceous,  163;  predigested,  danger  of 
long  use,  123;  proprietary,  dangers  of,  122; 
cause  of  rickets,  249 ;  cause  of  scurvy,  242 ; 
faults  of,  125. 

Foramen  ovale,  closure  of,  603 ;  function  of,  in 
foetal  life,  602 ;  patent,  608. 

Fractures,  green-stick,  in  rickets,  253,  261. 

Franco-Swiss  food,  163. 

Freeman's  pasteurizer,  153. 

Friedliinder's  bacillus  in  acute  broncho-pneu- 
monia, 528. 

Friedreich's  ataxia,  826. 

Fruit,  best  time  for  giving,  218  ;  during  second 
year,  218 ;  allowed  during  third  to  sixth  year, 
221 ;  forbidden  during  third  to  sixth  year, 
221. 

Fumigations  of  calomel,  493. 

Furunculosis,  917 ;  treatment,  917 ;  in  diabetes 
mellitus,  1136. 

Gangrene,  of  the  face,  288 ;  of  intestine,  in  in- 
tussusception, 427 ;  of  lung,  581 ;  in  acute 
broncho-pneumonia,  537 ;  in  lobar  pneu- 
monia, 560 ;  in  scarlet  fever,  951 ;  in  measles, 
968. 

Gastralgia,  329;  in  malaria,  1123;  in  spinal 
caries,  886. 

Gastritis,  acute,  332;  etiology,  332;  lesions, 
333 ;  catarrhal,  333 ;  gastro-malacia,  333 ; 
ulcerative,  333 ;  membranous,  334 ;  corrosive, 
334;  symptoms,  335;  catarrhal,  335;  ulcera- 
tive, 335 ;  membranous,  336 ;  corrosive,  336 ; 
treatment,  336 ;  chronic,  338  ;  ulcers  in,  344 ; 
toxic  (see  Gastritis,  Corrosive),  334. 

Gastro-duodenitis,  336;  etiology,  337;  symp- 
toms, 337 ;  treatment,  337. 

Gastro-enteric  infection  or  intoxication  (see 
Intoxication,  Acute  Gastro-enteric),  357. 


Gastro-enteritis  (see  Intoxication,  Acute  Gas- 
tro-enteric), 357 ;  in  newly  born,  82. 

Gavage,  62;  in  acute  illness,  223;  in  acute  in- 
anition, 228 ;  in  diphtheria,  1033 ;  in  prema- 
ture infants,  14;  iu  thrush,  287. 

Genital  irritation,  693. 

Genital  organs,  diseases  of,  679 ;  anomalies  of, 
as  stigmata  of  degeneration,  803 ;  care  of,  in 
newly  born,  4 ;  malformations  of,  679 ;  fe- 
male, gangrene  of,  288;  female,  diseases  of, 
684 ;  haemorrhage  from,  in  newly  born,  104 ; 
males,  diseases  of,  682. 

Gerber's  food,  156. 

Gingivitis,  hemorrhagic,  in  scurvy,  244,  245. 

Glands,  bronchial  (see  Lymph  Nodes,  Bron- 
chial). 

Glands,  lymphatic  (see  Lymph  Nodes),  862. 

Glioma  of  brain,  772  ;  of  spinal  cord,  824. 

Glio-sarcoma  of  brain,  772. 

Glossitis,  275. 

Glottis,  oedema  of  the,  501 ;  spasm  of,  idiopathic, 
715. 

Glycosuria,  643. 

Gonococcus,  ditferentiation  of,  686;  in  gonor- 
rhoea! stomatitis,  287 ;  in  specific  urethritis, 
682 ;  in  vulvo-vaginitis,  686. 

Gout,  eczema  in  children,  909 ;  uric-acid  de- 
posits in  urine,  646. 

Granuloma  of  umbilicus.  111. 

Grippe  (see  Influenza),  1111. 

Growing  pains,  rheumatic,  1131. 

Growth,  conditions  interfering  with,  30 ;  of 
body,  15  ;  extremities,  21 ;  trunk,  21. 

Gumma,  8yj)hilitic  (see  Syphilis  Lesions;, 
1097 ;  in  syphilitic  bone  disease,  901 ;  of 
brain,  772. 

Gums,  abscess  of,  277 ;  bleeding  in  ulcerative 
stomatitis,  283 ;  inspection  of,  35 ;  lancing, 
279 ;  spongy  and  bleeding,  in  scurvj',  244, 246 ; 
in  ulcerative  stomatitis,  283. 

Habit-chorea,  723. 

Habit-spasm,  723. 

Habits,  injurious,  739. 

HEematemesis,  345. 

Htematoma  of  the  sterno-mastoid,  94. 

HematocytozoOn  malaria?,  1119. 

Hematuria,  642 ;  in  newly  born,  103 ;  in  pur- 
pura, 858 ;  in  pyelitis,  672 ;  in  scurvy,  246 ; 
in  tumours  of  kidney,  668. 

Hemoglobin,  841. 

Hemofflobinuria,  643;  epidemic,  90;  paro.xys- 
mal,  643. 

Hemophilia,  855. 

Hemoptysis  in  tuberculosis,  1083. 

Hemorrhage,  from  stomach,  345 ;  in  hemo- 
philia, 856 ;  intra-alveolar,  in  acute  broncho- 


1146 


INDEX. 


pneumonia,  532 ;  internal,  causing  sudden 
death,  42 ;  intestinal,  from  tuberculous  ulcer, 
408  :  in  typhoid  fever,  1054 ;  meningeal,  caus- 
ing birth  paralysis,  785  ;  in  acquired  cerebral 
paralysis,  790 ;  in  acute  broncho-pneumonia, 
549  ;  in  convulsions,  700 ;  meningeal,  in  per- 
tussis, 990 ;  meningeal,  in  purpura,  858 ;  nasal, 
in  diphtheria,  1020 ;  pulmonary,  in  cardiac 
cases,626 ;  rectal,  from  ulcer, 452 ;  in  leukaemia, 
854 ;  in  measles,  969 ;  in  pertussis,  989 ;  in 
pernicious  ansemia,  851 ;  in  purpura,  858 ;  in 
the  newly  born,  93 ;  hsematoma  of  the  sterno- 
mastoid,  94;  cephalhsematoma,  95;  visceral, 
97 ;  in  scurvy,  243,  247 ;  subperiosteal,  in 
scurvy,  243  ;  in  syphilis,  1103. 

Hemorrhagic  disease  of  the  newly  born,  98  ; 
etiology,  99  ;  lesions,  101 ;  symptoms,  102  ; 
diagnosis,  104;  prognosis,  104;  treatment, 
104  ;  Gaertner's  bacillus  in,  100. 

Haemorrhoids,  453 ;  in  chronic  constipation, 
419. 

Hair,  anomalies,  stigmata  of  degeneration,  803. 

Hand,  progressive  muscular  atrophy  of,  828. 

Hands,  anomalies,  stigmata  of  degeneration, 
803. 

Harelip,  272. 

Hawley's  food,  163. 

Hay  fever,  521. 

Head,  circumference  of,  20  ;  closure  of  sutures, 
22 ;  closure  of  fontanels,  22 ;  shape  of,  23  ; 
in  rickets,  257  ;  examination  of,  37  ;  hydro- 
cephalic, characteristics  of,  781 ;  rotary  and 
nodding  spasm  of,  725  ;  sweating  of,  in  rick- 
ets, 257. 

Headache,  frequent,  with  adenoids,  300 ;  vai'ie- 
ties,  733 ;  diagnosis,  734 ;  treatment,  734. 

Hearing,  when  developed,  26. 

Heart,  diseases  of,  602  ;  aneurism  of,  633  ;  aortic 
disease,  congenital,  608 ;  area  of  absolute 
cardiac  dulness,  605 :  of  relative  dulness, 
604 ;  auscultation  of,  37 ;  dilatation  of,  in 
valvular  disease,  624 ;  diphtheritic  paralysis 
of,  836,  837 ;  examination  of,  604  ;  hyper- 
trophy of,  in  congenital  disease,  611  ;  hyper- 
trophy of,  in  valvular  disease,  624 ;  in  mea- 
sles, 969  ;  in  scarlet  fever,  950  ;  malformations 
of,  606 ;  peculiarities  of,  in  early  life,  602 ; 
persistent  foetal  conditions,  606  ;  position  of 
apex  beat,  604 ;  in  infancy,  604 ;  size  and 
growth  of,  603 ;  sounds  of,  reduplication, 
606;  relative  intensity,  605 ;  sudden  failure 
of,  in  diphtheria,  1017  ;  thrombus  of,  ante- 
mortem,  636  ;  transposition  of,  609  ;  congen- 
ital anomalies  of,  etiology,  606 ;  diagnosis, 
610  ;  from  acquired  disease,  612 ;  from 
antemic  murmurs,  612 ;  lesions,  606 ;  fre- 
quency of,  606 ;   secondary,  609  ;  prognosis, 


612  ;  symptoms,  609  ;  treatment,  613  ;  func- 
tional disorders  of,  634 ;  symptoms,  634 ; 
diagnosis,  635 ;  prognosis,  635 ;  treatment,  635 ; 
murmurs  of,  627 ;  anaemic,  633 ;  in  congen- 
ital disease,  610 ;  in  chorea,  721 ;  in  marasmus, 
239  ;  prognosis  of,  630  ;  valves,  aortic  insuffi- 
ciency, 629  ;  murmur  of,  629  ;  aortic  stenosis, 
628 ;  murmur  of,  628  ;  mitral  insufficiency, 
627  ;  murmur  of,  627  ;  mitral  stenosis,  628 ; 
murmur  of,  628 ;  congenital  absence  of 
valves,  609 ;  tricuspid  insufficiency,  629 : 
murmur  of,  629 ;  valvular  disease  of  (see 
also  Endocakditis),  618  ;  chronic  valvular 
disease  of,  623  ;  lesions,  623  ;  etiology,  624  ; 
symptoms,  625 ;  clinical  varieties,  627  ;  prog- 
nosis, 630  ;  diagnosis,  631 ;  treatment,  631 ; 
ventricle,  left,  signs  of  dilatation,  628  ;  signs 
of  hypertrophy,  627  ;  right,  signs  of  hyper- 
trophy, 611. 

Hectic  fever  in  tuberculosis,  1082. 

Height,  21 ;  from  birth  to  sixteenth  year,  20. 

Hemianopsia  in  cerebral  tumour,  775. 

Hemichorea,  720. 

Hemiplegia  in  acquired  cerebral  paralysis,  791 ; 
in  birth  paralysis,  786  ;  in  meningeal  haemor- 
rhage, 107  ;  in  cerebral  tumour,  775  ;  spastic, 
784. 

Hermaphroditism,  false,  680. 

Hernia,  cerebri,  744  ;  diaphragmatic,  116  ;  um- 
bilical, 113. 

Herpes,  labialis,  273  ;  of  the  vulva,  687. 

Herpetic  stomatitis,  280. 

Hiccough,  726  ;  in  acute  peritonitis,  463  ;  in  ap- 
pendicitis, 438. 

Hip,  articular  ostitis  of,  889  ;  symptoms  and 
stages,  890  ;  physical  examination,  890  ;  diag- 
nosis, 892  ;  prognosis,  893  ;  treatment,  893. 

Hip-joint  disease  (see  Hip,  Aeticulah  Ostitis 
or),  889. 

History-taking,  32. 

Hives  (see  Urticaria),  920. 

Hoarseness  with  adenoids,  299 ;  in  catarrhal 
spasm  of  larynx,  486  ;  in  syphilis,  1102. 

Hodgkin's  disease,  877. 

Home  modification  of  milk  (see  Milk,  Modifi- 
cation AT  Home),  186. 

Horlick's  food,  163. 

Hubbell's  pi-epared  wheat,  163. 

Hutchinson's  teeth  in  late  hereditary  syphilis, 
1104. 

Hydatids  of  liver,  460. 

Hydrencephalocele,  743  ;  symptoms,  744 ;  treat- 
ment, 745. 

Hydrencephaloid,  378  ;  treatment,  380. 

Hydrocele,  683  ;  treatment  of,  684. 

Hydrocephalus,  778  ;  in  clironic  basilar  menin- 
gitis, 766;  with  .spina  bifida,  780,  807*;  acute, 


INDEX. 


1147 


778  (see  Meningitis,  Tuberculous),  75'J  ; 
chronic,  external,  778;  internal,  778;  eti- 
ology, 77S  ;  lesions,  779  ;  symptoms,  780  ; 
prognosis,  783 ;  diagnosis,  783  ;  treatment, 
784 ;  shape  of  head,  781 ;  congenital,  74C ; 
intra-uterine,  744  ;  spurious,  378 ;  treatment, 
380 ;  syphilitic,  1099. 

Hydronephrosis,  651 ;  traumatic,  675 ;  with 
malforiuations  of  kidney,  653 ;  with  renal 
calculi,  674. 

Hydromyelus,  825. 

Hygiene  of  infancy,  1. 

Hypersesthesia,  general,  in  acute  meningitis, 
754;  in  infantile  spinal  paralysis,  819  ;  hys- 
terical, 730 ;  in  multiple  neuritis,  834 ;  in 
scurvy,  245  ;  in  spinal  meningitis,  812. 

Hypermetropia,  stigma  of  degeneration,  804. 

Hypertrophy,  of  the  tonsils,  310 ;  muscular 
pseudo,  829. 

Hypodermic  medication,  66. 

Hypospadias,  080. 

Hysteria,  729 ;  etiology,  729 ;  symptoms,  730 
psychical,  730 ;  sensory,  730 ;  joint,  730 
motor  and  convulsive,  731 ;  diagnosis,  732 
prognosis,  732  ;  treatment,  732. 

Hystero-epilepsy,  731 ;  treatment  of  attack, 
733. 

Ice,  bag,  54 :  cap,  47,  54 ;  coil,  54. 

Ichthyosis,  congenital,  905 ;  symptoms,  905 ; 
treatment,  906. 

Icterus,  455  ;  in  epidemic  haemoglobinuria,  96  ; 
in  gastro-duodenitis,  337  ;  varieties  in  newly 
born,  75  ;  in  malformation  of  the  bile  ducts, 
75  :  physiological  or  idiopathic,  76. 

Idiocy,  794 ;  Mongolian,  794 ;  amaurotic  fam- 
ily, 795  ;  cretinoid,  798. 

Ileo-colitis,  acute,  381 ;  etiology,  382 ;  lesions, 
382 ;    in  catarrhal,  383 ;    in  catarrhal  with 
superficial  ulceration,  385 ;  in  follicular  ul- 
ceration, 385 ;    in    membranous,  387 ;    asso- 
ciated lesions,  389  ;  symptoms,  catan-hal  form, 
mild,  390 ;  severe,  392  ;  follicular  ulceration, 
392  ;  membranous  form,  394  ;  diagnosis,  396  ; 
from  typhoid  fever,  396 ;  from  intussuscep- 
tion, 396 ;   prognosis,  397 ;    treatment,   397 
hygienic,  397 ;   medicinal,  S98 ;  mechanical 
398  ;  broncho-pneumonia  complicating,  549 
following  pertussis,  991  ;  in  influenza,  1115 
in  measles,  968 ;  chronic,  400  :  lesions,  400 
catarrhal   form,  400 :   ulcerative   form,  401 
symptoms,  402 ;   diagnosis,  403 ;  from  gen- 
eral tuberculosis.  404  :  prognosis,  404 ;  treat- 
ment, 404. 

Ileum,  congenital  atresia  of,  115. 

Imbecility,  794. 

Imjierial  granum,  163. 


Impetigo,  contagiosa,  919;  simple,  911. 

Inanition,  acute,  225  ;  etiology,  225  ;  symptoms, 
220  ;  prognosis,  227  ;  diagnosis,  227  ;  treat- 
ment, 227. 

Inanition  fever,  118. 

Incubator,  11 ;  in  marasmus,  241. 

Indican,  in  urine  of  chronic  constipation,  420 ; 
of  intestinal  indigestion,  414 ;  test  for,  in 
urine,  646. 

Indicanuria,  646. 

Indigestion,  acute  gastric,  330 ;  etiology,  330  ; 
symptoms,  331 ;  diagnosis  from  gastritis,  331  ; 
treatment,  331  ;  vomiting  in,  324  ;  chronic  gas 
trie,  338  ;  etiology,  338  ;  lesions,  338  ;  symp 
toms,  in  infants,  339  ;  in  older  children,  340 
prognosis,   340 ;    treatment  in    infants,   340 
in  older  children,  342 ;  with  dilatation,  343 
acute  intestinal,  354;   etiology,  354;  symp- 
toms,  354  ;   diagnosis,   355  ;   prognosis,  356  ; 
treatment,  356  ;    chronic  intestinal,  409  ;   in 
young  infants,  409  ;  lesions,  410;  symptoms, 
410  ;    diagnosis,  411 ;   prognosis,  412  ;  treat- 
ment, 412 ;  in   older  children,   412 ;  symp- 
toms, 412  ;  prognosis,  414  ;  treatment,  414. 

Infant,  alimentation  of,  when  premature,  14 ; 
care  of  newly  born,  1 ;  when  premature  or 
delicate,  10. 

Infant  feeding,  164. 

Infant  foods,  162. 

Infarctions,  uric  acid,  in  kidney,  654. 

Infectious  diseases,  the  specific,  934. 

Inflation  of  bowel  in  intussusception,  432. 

Influenza,  1111  ;  etiology,  1111  ;  lesions,  1112; 
symptoms,  1112 ;  mild  uncomplicated  type, 
1112  ;  severe  uncomplicated  type,  1112  ;  witli 
catarrhal  complications,  1113  ;  with  broncho- 
pulmonary complications,  1114  ;  with  gastro- 
enteric complications,  1115;  in  very  young 
infants,  1115:  protracted  cases,  1115;  com- 
plications and  sequela},  1116  ;  diagnosis,  1116  ; 
prognosis,  1117;  treatment,  1118;  broncho- 
pneumonia, 549,  1114 ;  epidemic,  acute  otitis 
in,  925  ;  scarlatiniform,  erythema  in,  952. 

Inhalations,  58  ;  in  bronchitis,  514. 

Inheritance  a  factor  in  disease,  30. 

Injections,  rectal,  in  ileo-colitis,  399  ;  in  intus- 
susception, 433  ;  subcutaneous,  of  saline  solu- 
tion in  cholera  infantum,  380. 

Insanity,  801 ;  etiology,  802  ;  symptoms,  802  ; 
prognosis,  803  ,  following  typhoid  fever,  1055. 

Inspection  of  sick  child,  83. 

Intermittent  fever,  malarial,  1120. 

Intertrigo,  911  ;  treatment,  916. 

Intestinal  obstruction  in  newly  born,  115  ;  acute, 
from  intussusception,  424. 

Intestines,  diseases  of,  347 ;  amyloid  degenera- 
tion of,  406;  bacteria  of,  320;  digestion  in, 


1148 


INDEX. 


319  ;  hemorrhage  from,  in  newly  born,  103  ; 
in  typhoid,  1054 ;  in  tuberculosis,  408  ;  length, 
319  ;  malformations  of,  347  ;  obstruction,  con- 
genital, of,  115  ;  obstruction  by  omphalo-mes- 
enteric  duct,  116  ;  perforation  of,  in  tubercu- 
lous peritonitis,  469  ;  in  tuberculous  ulcers, 
407  ;  in  typhoid  fever,  1051,  1052  :  tuberculo- 
sis of,  406,  1074  ;  etiology,  407  ;  lesions,  407  ; 
symptoms,  408;  diagnosis,  409;  prognosis, 
409  ;  treatment,  409. 

Intoxication,  acute  gastro-enteric,  357  ;  etiology, 
357  ;  relation  of  the  different  etiological  fac- 
tors, 360 ;  lesions,  360 ;  symptoms,  simple 
form,  362 ;  relapses,  365  ;  cases  without  diar- 
rhoea, 365 ;  diagnosis,  366  ;  prognosis,  367  ; 
prophylaxis,  367  ;  treatment,  hygienic,  369  ; 
dietetic,  370:  medicinal  and  mechanical, 
372 ;  cholera  infantum,  376  ;  etiology,  376  ; 
symptoms,  377  ;  prognosis,  379 ;  treatment, 
379. 

Intubation,  494  ;  introduction  of  the  tube,  495  ; 
treatment  while  the  tube  is  in  place,  497  ; 
removalof  tube— extubation,  499  ;  advantages 
over  tracheotomy,  499  ;  retained  intubation 
tuljes — prolonged  intubation,  500  ;  in  acute 
catarrhal  laryngitis,  491  ;  in  syphilitic  laryn- 
gitis, 504  ;  in  pertussis,  995 ;  results  with  and 
without  antitoxin,  1041. 

Intubation  set,  O'Dwyer's,  495. 

Intussusception,  424;  varieties  of,  424;  etiolo- 
gy, 425 ;  lesions  and  mechanism,  426  ;  symp- 
toms, 427  ;  course,  duration,  termination,  430  ; 
diagnosis,  431 ;  prognosis,  431  ;  treatment, 
432 ;  laparotomy,  434 ;  in  the  dying,  425. 

Invagination  of  intestine  in  intussusception, 
427. 

Iodides,  elimination  of,  in  milk,  136. 

Iritis,  syphilitic,  1099. 

Iron,  tonic  preparations  of,  50. 

Irrigation,  intestinal,  in  chronic  indigestion, 
415 ;  as  antipyretic,  48 ;  of  the  colon,  method 
of,  63. 

Ischio-rectal  abscess,  453. 

Italians,  rickets  in,  250. 

Jacket,  oil-silk,  59. 

Jaffe'stest  for  indican,  646. 

Jaundice  (see  also  Icterus),  455  ;  catarrhal,  336. 

Jaw,  necrosis  of,  from  alveolar  abscess,  277 ; 
in  gangrenous  stomatitis,  289 ;  in  ulcerative 
stomatitis,  282. 

Jejunum,  congenital  atresia  of,  115. 

Joints,  diseases  of,  881 ;  hysterical  affections  of, 
730;  in  scarlet  fever,  949;  rheumatism  of, 
1130;  suppuration  of,  in  newly  born,  82; 
swelling  of,  in  scurvy,  246  ;  ecchymoses  about, 
in  scurvy,  245 ;  tuberculous  diseases  of,  882  ; 


etiology,  883 ;  lesions,  primary,  883 ;  second^ 
ary,  884. 
Junket,  159. 

Keratitis,  interstitial,  in  late  syphilis,  1099, 
1105. 

Keratoma,  diffuse,  905. 

Kidney,  diseases  of,  650  ;  acute  congestion  of, 
655 ;  acute  degenei'ation  of,  656 ;  benign  tu- 
mours of,  670 ;  calculi  in,  673 ;  chronic  con- 
gestion of,  655  ;  contracted  (see  Nephritis, 
Chronic),  664 ;  cystic  degeneration  of,-  651  ; 
floating,  654;  granular  (see  Kephritis, 
Chronic),  664 ;  haemorrhage  from,  in  newly 
born,  104 ;  in  scurvy,  244, 246  ;  horseshoe,  651 ; 
hydronephrosis,  651 ;  traumatic,  675  ;  malfor- 
mations and  malpositions  of,  650 ;  malignant 
tumours  of,  667  ;  etiology,  668  ;•  symptoms, 
668  ;  diagnosis,  670 ;  treatment,  670  ;  nephri- 
tis, acute  diffuse,  656  ;  acute  exudative,  656  ; 
chronic,  663 ;  perinephritis,  675 ;  pyelitis, 
670  ;  pyelo-nephritis,  652  ;  pyonephrosis,  671 ; 
single.  651 ;  tuberculosis  of,  666, 1074 ;  uric- 
acid  infarction,  654 ;  waxy,  664 ;  in  diph- 
theria, 1011 ;  in  scarlet  fever,  949. 

Klebs-Loefller  bacillus  (see  Bacillus  of  Diph- 
theria), 1001,  1024. 

Knee,  articular  ostitis  of,  898  ;  symptoms,  894  ; 
treatment,  895  ;  subluxation  of,  in  infantile 
spinal  paralysis,  820  ;  swelling  of,  in  scurvy, 
245;  white  swelling  of  (see  Knee,  Aeticulae 
Ostitis). 

Knee-jerk,  in  acquired  cerebral  paralysis,  791 ; 
in  birth  paralysis,  789 ;  lost  in  diphtheritic 
paralysis,  837 ;  iii  infantile  spinal  paralysis, 
820  ;  in  multiple  neuritis,  8-34. 

Knee-joint  disease  (see  Knee,  Articular  Osti- 
tis). 

Knock-knee  in  rickets,  261. 

Koplik's  sign,  in  measles,  970. 

Kumyss,  157. 

Kj'phosis  in  rickets.  259 ;  treatment,  269  ;  in 
spinal  caries,  885,  886. 

Lactalbumin,  130,  146.  150,  181. 

Lactated  food,  163. 

Lactation,  care  of  breasts  during,  167. 

Lactoglobulin,  131. 

Lactometer,  author's,  132. 

Lacto-preparata,  163. 

Lactoscope,  Fesei''s,  145. 

La  grippe  (see  Influenza),  1111. 

Landry's  paralysis,  827. 

Laparotomy,  in  chronic  peritonitis,  with  ascites, 

466  ;  in  intussusception,  433 ;  in  tuberculous 

peritonitis,  471. 
Laryngismus  stridulus,  715 ;   symptoms,  716 ; 


INDEX. 


1149 


diagnosis,  716;  treatment,  717;  in  rickets, 
2ti5;  with  tetany,  712. 
Laryngitis,  acute  cuturrlial,  488 ;  lesions,  4SS  ; 
symptoms,  488  ;  diagnosis  from  membranous 
laryngitis,  489 ;  prognosis,  490  ;  treatment, 
490  ;  catarrhal,  in  measles,  967  ;  chronic,  502  ; 
with  adenoid  vegetations  of  pharynx,  502  ; 
tuberculous,  502  ;  syphilitic,  503  ;  with  new 
growths  of  larynx,  504;  membranous,  491, 
967  ;  symptoms,  492 ;  couree,  492  ;  prognosis, 

493  ;  diagnosis,  493  ;  treatment,  493  ;  by  calo- 
mel fumigations,  493 ;  operative  measures, 
494 ;   antitoxin,  493,  1040,  1041 ;  intubation, 

494  ;  tracheotomy,  494 ;  spasmodic,  485  :  sub- 
mucous (oedema  of  glottis),  501. 

Laryngotomy  for  foreign  body  in  larynx,  505. 
Larynx,  diseases  of,  485 ;   catarrhal  spasm  of, 

485  ;  etiology,  485  ;  lesions,  485 ;  symptoms, 

486  ;  diagnosis,  486  ;  from  laryngismus  stridu- 
lus, 486 ;  from  membranous  laryngitis,  487  ; 
trecttment,  487 ;  from  long  uvula,  292 ;  with 
adenoids,  300 ;  diphtheria  of,  491,  1016  ;  re- 
sults of  antitoxin  in,  1041 ;  foreign  bodies 
in,  504 ;  intubation  of,  496 ;  results  with  and 
without  antitoxin,  1041 ;  in  measles,  967 ;  in 
pseudo-diphtheria,  1045,  1047 ;  new  growths 
of,  504 ;  stenosis  of,  simulated  by  tuberculous 
glands,  1091 ;  syphilis  of,  503,  504,  1098 ; 
tuberculosis  of,  502. 

Lassar's  paste,  915. 

Lavage  (see  Stomach  Washin-g). 

Leptomeningitis,  acute  (see  Meningitis),  750. 
, Leukaemia,   853;    etiology,   853;    lesions,  853; 
symptoms,  854 ;  blood,  854 ;  course  and  prog- 
nosis, 855  ;  diagnosis,  855 ;  treatment,  855. 

Leucocytosis,  definition,  843  ;  diagnostic  value, 
844 ;  prognostic  value,  845 ;  in  diphtheria, 
1012;  in  acute  meningitis,  755. 

Lichen  urticatus  (see  Uetioaeia),  920 ;  tropi- 
cus, 907. 

Liebig's  food,  163. 

Limewater,  in  modification  of  cow's  milk,  182. 

Lip,  eczema  of,  274;  perleche,  274;  diseases  of, 
273  ;  herpes  of,  273  ;  malformations  of,  272. 

Lithuria,  645. 

Liver,  diseases  of,  454;  abscess  of,  456;  acute 
yellow  atrophy  of,  456  ;  amyloid  degeneration 
of,  458  ;  biliary  calculi,  460 ;  cirrhosis  of,  457  ; 
congestion  of,  456 ;  displacement  of,  37 ;  en- 
larged, in  congestion.  456 :  in  abscess,  456 ; 
in  cirrho.sis  (early),  458;  in  chronic  cardiac 
disease,  626;  fatty,  459;  fatty,  in  eczeraatous 
cliildren,  909;  in  marasmus,  237;  functional 
ilisorders  of,  455 ;  hydatids  of,  460;  in  rick- 
ets, 265;  in  syphilis,  1097,  1106;  in  tubercu- 
losis. 1073;  lardaceous,  458;  malformations 
and  malpositions  of,  455;  size  and  position 
74 


of,  37,  454;  tuberculosis  of,  1083  ;  wa.\y,  458; 
weight  of,  in  infancy,  454. 

LoeflEler's  bacillus  (see  Bacillus  of  Diph- 
theria), 1001 ;  blood-scrum,  1002;  stain,  1002. 

Lumbar  puncture,  757  :  tubercle  bacilli  in  fiuid, 
764. 

Lung,  diseases  of,  505;  abscesses  of,  in  acute 
broncho-pneumonia,  537;  acute  congestion 
of,  in  malaria,  1124;  calcareous  nodules  in, 
1069  ;  caseous  degeneration  of,  1066  ;  collapse 
of,  from  compression,  583  ;  from  obstruction, 
584;  in  acute  broncho-pneumonia,  530  ;  con- 
genital atelectasis  of,  72  ;  emphysema  of,  585  ; 
acute,  in  bronchitis  of  infants,  511 ;  gangrene 
of,  581;  etiology,  581;  lesions,  582;  symp- 
toms, 582 ;  treatment,  583 ;  gangrene  of,  in 
lobar  pneumonia,  560 ;  hajmorrhages  into,  in 
newly  born,  97 ;  inflation  of,  71 ;  miliary  tu- 
berculosis of,  1065;  peculiarities  in  disease, 
508 ;  in  infancy  and  early  childhood,  505 ; 
physical  examination  of,  506 ;  inspection, 
506;  palpation,  506;  percussion,  507;  auscul- 
tation, 507  ;  structure  of,  506. 

Lymph  nodes,  diseases  of,  862 ;  calcareous  cer- 
vical, 872  ;  bronchial,  1072 ;  early  infection  in 
tuberculosis,  1062;  enlarged,  in  eczema,  910; 
in  Hodgkin's  disease,  877;  in  malnutrition, 
230  ;  frequency  of  disease  of,  39 ;  inflamma- 
tion of  (see  Adenitis),  865  ;  in  late  hereditary 
syphilis,  1105;  in  measles,  969;  in  pseudo- 
diphtheria,  1046 ;  in  scarlet  fever,  947 ;  sim- 
ple hyperplasia  of,  868 ;  situation  and  drain- 
age areas  of  the  groups  of  head  and  neck, 
865;  syphilitic  disease  of,  869;  tuberculous, 
bronchial,  1089;  lesions,  1062,  1070;  symp- 
toms, 1089 ;  physical  signs,  1091 ;  diagnosis, 
1091 ;  cervical,  tuberculosis  of,  870 ;  mesen- 
teric, 406,  1063  ;  etiology,  406 ;  lesions,  408  ; 
symptoms,  408 ;  diagnosis,  408 ;  treatment, 
409;  in  diphtheria,  1010;  in  rickets,  264;  in 
tonsillitis,  308 ;  epitro'chlear,  in  syphilis,  1105  ; 
mesenteric,  often  enlarged,  in  marasmus, 
237 ;  in  typhoid  fever,  1051 ;  tuberculosis  of, 
870  ;  retro-pharyngeal,  abscess  of,  293. 

Lymph  nodules  of  intestines,  ulceration  of, 
385. 

Lymphadenoma  of  stomach,  345. 

Lymphangioma  of  tongue,  273. 

Lymphatism,  43,  862  ;  with  adenoids,  297. 

Lymphocytes,  842. 

Magendie,  foramen  of,  in  hydrocephalus,  778. 

Malaria,  1119;  etiology,  1119;  lesions,  1120; 
symptoms,  1120;  masked  and  iiTegular 
forms,  1123 ;  subacute  or  chronic  forms,  1125 ; 
diagnosis,  1125;  prognosis.  1126;  prophy- 
laxis, 1126;  treatment,  1126;  quinine,  mcth- 


1150 


INDEX. 


ods  of  administration,  1126:  dosage,  1127: 
acute  pulmonary  congestion  in,  1134;  con- 
tracted in  utero,  1119  ;  spleen  in,  880. 

Malformations  as  cause  of  sudden  death,  42. 

Malnutrition,  228  :  etiology,  229  ;  symptoms  in 
infants,  230 ;  symptoms  in  older  children, 
231 ;  diagnosis,  232 ;  prognosis,  232 ;  treat- 
ment in  infancy,  233 ;  treatment  in  older 
children,  235. 

Ma]nutritio2i,  marasmus,  236. 

Malted  milk,  163. 

Malt  extracts,  use  of,  in  diet  of  nurse,  135. 

Maltose,  substitute  for  milk  sugar,  125,  209. 

Mania,  802 :  acute,  following  typhoid  fever, 
1055. 

Marasmus,  236;  etiology,  236;  lesions,  237; 
symptoms,  239  ;  complications,  239  ;  diagno- 
sis, 240;  from  tuberculosis,  240,  1076;  prog- 
nosis, 240 ;  treatment,  241  ;  fatty  liver  in, 
459  ;  general  cBdema  in,  678  ;  modification  of 
milk  in,  214 ;  sudden  death  in,  43 ;  tubercu- 
losis resembling,  1075. 

Marchand's  test  for  fat  in  milk,  133. 

Massage,  66 ;  in  chronic  constipation,  421 ;  in 
malnutrition,  234;  of  breasts  to  increase 
milk,  172. 

Mastitis  in  the  newly  born,  114. 

Mastoid  disease,  cerebral  abscess  following, 
769  ;  in  acute  otitis,  929. 

Masturbation,  740 ;  etiology,  740 ;  symptoms, 
741 ;  prognosis,  742 ;  treatment  of,  742 ;  a 
cause  of  epilepsy,  705  ;  of  insanity,  802 ;  ■  of 
functional  disorder  of  heart,  634. 

Matzoon,  158. 

Measles,  958 ;  broncho-pneumonia  complica- 
ting, 548  ;  complications  and  sequelae,  966  ; 
desquamation,  963  ;  diagnosis,  970 ;  digestive 
system,  968  ;  diphtheria  in,  968 ;  duration  of 
infective  period,  959  ;  ears,  926,  968 ;  erup- 
tion, 962  ;  etiology,  958  ;  eyes,  969  ;  gan- 
grenous dermatitis  in,  918 ;  German  (see 
Kubella),  974 ;  haemorrhages  in,  969;  hsemor- 
rhagic,  962  ;  heart  in,  969  ;  ileo-colitis,  968  ; 
incubation,  959 ;  invasion,  961  ;  kidneys  in, 
969  ;  larynx  in,  967  ;  lesions,  960  ;  lungs,  966  ; 
lymph  nodes,  969 ;  mode  of  infection,  960  ; 
mortality,  970 ;  nervous  .system  in,  968  ;  other 
infectious  diseases  in,  969  ;  otitis,  968  ;  pre- 
disposition, 958 ;  prognosis,  970  ;  prophylaxis, 
971 ;  pseudo-diphtheria  in,  1047  ;  quarantine 
in,  972  ;  skin  in,  969  ;  symptoms,  961 ;  symp- 
toms, mild  cases,  963 ;  symptoms,  moderate 
cases,  964 ;  symptoms,  severe  eases,  965 ; 
throat,  967  ;  treatment,  972  ;  tuberculosis  fol- 
lowing, 969. 

Meats,  allowed  from  third  to  sixth  years,  220  : 
forbidden  from  third  to  sixth  years,  221. 


Meckel's  diverticulum,  112,  348. 

Meconium,  composition  of,  321. 

Mediastinum,  anterior,  abscess  of,  1091 ;  tumour 
of,  due  to  tuberculous  lymph  nodes,  1091. 

Mediastinitis,  614. 

Melancholia,  802. 

Melsena,  103. 

Mellin's  food,  163. 

Membrane,  in  diphtheria,  1006 ;  in  pseudo- 
diphtheria,  1045. 

Meningeal  haemorrhage,  105,  747,  790. 

Meninges,  diseases  of,  743. 

Meningitis,  acute,  750 ;  abortive  cases,  753 ;  com- 
mon form,  753  ;  course,  termination,  progno- 
sis, 756  ;  diagnosis,  756 ;  diagnosis  from  tuber- 
culous, 757  ;  eruptions  in,  755  ;  etiology,  750 ; 
from  acute  otitis,  930;  in  newly  born,  82; 
in  typhoid  fever,  1055  ;  purulent,  in  acute 
broncho-pneumonia,  549 ;  fulminating  cases, 
753  ;  lesions,  751 ;  leucocytosis  in,  755  ;  lum- 
bar puncture  in,  757  ;  malignant  cases,  753  ; 
nervous  system  in,  754 ;  pulse,  755  ;  respira- 
tion, 755  ;  secondary  cases,  754 ;  speech,  755 ; 
special  senses,  754 ;  sporadic  cases,  764 ; 
symptoms,  752 ;  temperature,  755  ;  treatment, 
758  ;  with  lobar  pneumonia,  561 ;  with  pleuro- 
jDneumonia,  576. 

Meningitis,  basilar,  759 ;  chronic,  in  infants, 
765  ;  lesions,  765  ;  symptoms,  765  ;  diagnosis, 
766;  treatment,  767;  cerebro-spinal  (see 
Meningitis,  Acute),  750  ;  epidemic,  750 ; 
spinal,  acute  and  chronic,  811 ;  symptoms, 
812;  treatment,  812;  sporadic,  750;  syphi- 
litic, 1099. 

Meningitis,  tuberculous,  759, 1073  ;  lesions,  759 
etiology,  760 ;  symptoms,  761 ;  duration,  763 
course,  variations    of,   763 ;    diagnosis,   764 
prognosis,  764  ;  treatment,  765 ;  lumbar  punc- 
ture in,  764  ;  respiratory  curve  in,  762  ;  tem- 
perature curve  in,  763. 

Meningocele  of  brain,  743 ;  symptoms,  744 ; 
treatment,  745  ;  of  cord,  806. 

Meningo-encephalitis,  785. 

Meningo-myelocele,  806. 

Menstruation,  eflect  on  nursing,  134. 

Mercury,  elimination  of,  in  milk,  136  ;  ulcer- 
ative stomatitis  from,  282;  in  syphilis,  1110; 

Microcephalus,  746. 

Micro-organisms  in  cow's  milk,  138 ;  see  also 
Bacteria. 

Micturition,  difficult  or  painful,  693  ;  frequency 
of,  639. 

Miliaria,  906 ;  papulosa,  907 ;  treatment,  907 ; 
rubra.  906. 

Milk,  cow's,  137 ;  addition  of  other  substances 
to,  209 ;  average  percentages  of,  180 ;  best 
from  mixed  herd,  138 ;  bacteria  in,  138 ;  bac- 


INDEX. 


1151 


teriologioal  standard  for,  141  ;  handling;  aud 
transportation  of,  143 ;  certified,  142,  143  ; 
composition  of,  143 ;  average  percentages 
in,  from  different  breeds,  143  :  examination 
of,  144;  coagulation  of,  in  stomach,  318; 
cream,  147 ;  contaminated,  cause  of  diar- 
rhcea,  350;  differences  from  human  milk, 
14G ;  diphtheria  bacilli  in,  139,  151  ;  es- 
sentials of,  for  infant  feeding,  138 ;  for- 
mulae from  diluting,  189,  et  seq. ;  micro-or- 
ganisms in,  138;  modification  of,  percentage 
or  American  method  of,  179,  214 ;  at  home, 
18ti ;  top-milk,  148  ;  formulas  from  top-milk, 
189,  191,  192;  schedule  of  percentages  for 
first  year,  186 ;  schedule  showing  quantities 
and  intervals  of  feeding,  202 ;  home  modifi- 
cation for  earl}^  months,  187 ;  for  middle 
period,  190  ;  for  latter  part  of  first  year,  192  ; 
for  second  year,  217 ;  rules  for  varying  per- 
centages, 192 ;  modifications  required  by  par- 
ticular symptoms,  197  ;  in  difficult  cases,  206  ; 
in  summer  diarrhcea,  370  ;  in  acute  indiges- 
tion, 356  ;  in  chronic  constipation,  420  ;  pas- 
teurization of,  151;  proteids  of,  124;  sterili- 
zation of,  at  167°  F.,  151  ;  sterilization  of,  at 
212°  F.,  150 ;  sterilized,  scurvy  ascribed  to, 
242 ;  tubercle  bacilli  in,  1061 ;  typhoid  con- 
tamination of,  139 ;  condensed  (see  Con- 
densed Milk),  155;  peptonized,  154;  pep- 
tonized, use  of,  208;  preparation  at  each 
feeding,  209 ;  dangers  from  long  use  of, 
209. 
.Milk-laboratories,  182. 

Milk-sugar,  uses  of,  as  food,  125;  solution,  how 
to  pi-epare,  181. 

Milk,  woman's,  127  ;  physical  characters  of, 
127  ;  colostrum  of,  127  ;  daily  quantity  of,  128 ; 
average  quantity  at  one  nursing,  13.0 ;  compo- 
sition of,  130  ;  proteids,  124, 130, 146  ;  fat,  131 ; 
sugar,  131  ;  salts,  131 ;  reaction,  132;  specific 
gravity,  132, 134 ;  average  percentages  of,  180 
conditions  afi'ecting  composition  of,  134 
menstruation,  134 ;  diet,  135 ;  drugs,  136 
pregnancy,  136 ;  elimination  of  antito.xin 
and  other  protective  substances,  137 ;  nerv- 
ous impressions,  137  ;  examination  of,  131 ; 
quantity,  132 ;  determination  of  fat,  133 ; 
sugar,  133;  proteids,  124,  133,  146;  varia- 
tions in  quality,  134;  apparatus  for  ex- 
amining, 134;  flow  established,  127  ;  how  to 
modify  quantity  and  quality,  171-173  ;  indi- 
cations of  scanty  supply,  169. 

Modified  milk,  from  milk  laboratoi-y,  182 ;  sam- 
ple prescription,  183;  schedule  for  feeding 
from  birth,  186;  made  at  home  (see  Milk, 

MoDIi'ICATION  OF,  AT  IIoME). 

Mongolian  idiocy,  794. 


Monoplegia,  in  birth  paralysis.  786  :  in  cereln-al 
hiemorrhage,  107;  in  cerebral  tumour,  775. 

Morbilli  (see  Measles),  958. 

Morbus  coxarius  (see  Hip,  Articular  Ostitis 
or),  889. 

Morbus  maculosus  Werlhorti  (sec  Purpura), 
856. 

Morphine,  dosage  of,  51,  464 ;  dosage  in  convul- 
sions, 703  ;  hypodermically  in  cholera  infant- 
um, 380 ;  in  gastro-intestinal  intoxication,  374. 

Mortality  at  ditterent  ages,  41,  42;  chief  causes 
of,  41. 

Morton's  fluid,  811. 

Mouth,  diseases  of  (see  also  Stomatitis),  272, 
279 ;  applications  to,  287  ;  care  of,  at  birth,  1, 
3 ;  hiemorrhage  from,  in  newly  born,  103  ; 
haemorrhages  from,  in  scurvy,  246 :  malfor- 
mations of,  272 ;  mucous  patches,  in  syphilis, 
1102 ;  syphilis  of,  287 ;  tapir,  831 ;  syringing 
of,  57. 

Mouth-breathing,  with  hyperti'ophy  of  tonsils, 
310 ;  adenoids,  299 ;  retro-pharyngeal  ab- 
scess, 294. 

Mucous  membranes,  frequency  of  involvement 
in  childhood,  38  ;  in  rickets,  264. 

Mucous  patches,  syphilitic,  1102. 

Mumps,  997  ;  complications  and  sequelae,  999  ; 
diagnosis,  1000 ;  etiology,  997  ;  incubation, 
998  ;  pathology  and  lesions,  997  :  prognosis, 
1000  ;  quarantine  in,  1000  ;  symptoms,  998  ; 
treatment,  1000. 

Murmurs,  cardiac  (see  Heart  Murmurs). 

Muscles,  atrophy  of,  827  ;  in  infantile  spinal 
paralysis,  819;  in  multiple  neuritis,  834;  in 
myelitis,  813  ;  contractures  of,  hysterical,  731 ; 
in  acquired  cerebral  paralysis,  791  ;  in  birth 
paralysis,  788  ;  development  of,  25  ;  flabbiness 
of,  in  rickets,  262 ;  rigidity  of,  in  birth  pa- 
ralysis, 789;  spasm  of,  about  rheumatic  joint, 
1130. 

Muscular  atony,  as  cause  of  chronic  constipa- 
tion, 419. 

Muscular  atrophies,  different  types  of,  827. 

Muscular  pseudo-hypertrophy,  829. 

Mustard  bath,  54  ;  paste,  52  ;  pack,  52. 

Myelitis,  812;  symptoms,  813;  treatment,  813 ; 
compression,  from  Pott's  disease,  814  ;  lesions, 
814;  symptoms,  815;  course  and  prognosis, 
815;  diagnosis,  816;  treatment,  816;  diffuse, 
813 ;  transverse,  813. 

Myelocytes  in  leukaemia,  854. 

Myocarditis,  632  :  lesions,  632  ;  symptoms,  633  ; 
diagnosis,  633  ;  treatment,  633  ;  aneurism  in, 
633 ;  toxic,  in  diphtheria,  838,  1017  :  in  scar- 
let fever,  950  ;  in  syphilis,  1099. 

Myopia,  stigma  of  degeneration,  804. 

Myotonia,  congenital,  726. 


1152 


INDEX. 


Nail-biting,  743. 

Nails  in  syphilis,  1103. 

Neck,  cellulitis  of,  in  scarlatina,  948 ;  con- 
genital fistula  of,  312 ;  wi-y  (see  Torticollis). 

Necrosis  of  bone  in  syiDhilis,  898,  900. 

Negroes,  rickets  in,  250. 

Nematodes  (see  Woems,  Intestinal),  444. 

Nephritis,  acute  diffuse,  656 ;  etiology,  656 ; 
lesions,  657  ;  symptoms,  658 ;  primary  form 
in  infants,  658  ;  in  older  children,  659  ;  sec- 
ondary form,  659  ;  prognosis,  660  ;  treatment, 
661  ;  in  broncho-pneumonia,  550 ;  acute  paren- 
chymatous, 658  ;  chronic,  663 ;  etiology,  663 ; 
lesions,  663 ;  symptoms,  664 ;  of  the  paren- 
chymatous type,  664  ;  of  the  interstitial  type, 
665  ;  prognosis,  665 ;  diagnosis,  665  ;  treat- 
ment, 666 ;  chronic  diffuse,  with  hydrone- 
phrosis, 652 ;  chronic  interstitial,  syphilitic, 
1099 ;  in  diphtheria,  1020 ;  interstitial  (see 
Nephritis,  Chronic),  665 ;  post-scarlatinal, 
949. 

Nerves,  peripheral,  diseases  of,  831. 

Nervous  impressions,  effect  of,  on  nursing,  137. 

Nervous  system,  diseases  of,  695 ;  diseases  of, 
functional,  697 ;  general  hygiene  of,  5 ;  pe- 
culiarities of,  in  childhood,  696. 

Nestle's  food,  162. 

Neuritis,  multiple,  831 ;  etiology,  831 ;  lesions, 
832 ;  symptoms,  833 ;  course  and  prognosis, 
834 ;  diagnosis,  835 ;  ti'eatment,  835  ;  after 
diphtheria,  836  ;  in  malaria,  1124 ;  optic,  in 
acute  meningitis,  754;  in  cerebral  tumour, 
774;  with  cerebral  abscess,  771. 

Newly  born,  diseases  of  67  ;  acute  infectious 
diseases  of,  78;  acute  pyogenic  diseases  of, 
79 ;  blood  in,  peculiarities  of,  841 ;  care  of, 
1 ;  diseases  or  accidents  at  birth,  30  ;  derma- 
titis exfoliativa,  904  ;  facial  paralysis  in,  108 ; 
fatty  degeneration  of,  91 ;  haemorrhages  in, 
93;  hsemorrhagic  disease  of,  98;  hyperpy- 
rexia in,  119  ;  inanition  fever  in,  118  ;  icterus 
in,  75  ;  infection,  31  ;  malformations,  30 ; 
mastitis  in,  114  ;  ophthalmia  of,  85  ;  pemphi- 
gus in,  92 ;  peritonitis  in,  461 ;  sclerema  in, 
116 ;  skin  of,  904 ;  ulcer  of  stomach  in,  344. 

Nightmare,  738. 

Night-terrors,  738. 

Nipples,  care  of,  during  lactation,  167 ;  fissure 
of,  hsematemesis  from,  346  ;  rubber,  choice  of, 
199  •  care  of,  199. 

Nodding  spasm  of  head,  725. 

Nodes,  lymph  (see  Lymph  Nodes),  862. 

Nodules,  subcutaneous  tendinous,  in  rheuma- 
tism, 1132. 

Noma  of  vulva,  688  (see  Stomatitis,  Gangre- 
nous), 288. 

Nose,  diseases  of,  474 ;  deformities  of,  in  heredi- 


tary syphilis,  482;  difficulty  in  blowing,  with 
adenoids.  300  ;  diphtheria  of,  1008 ;  dischai-ge 
from,  with  adenoids,  800 ;  foreign  bodies  in, 

477  ;  hemorrhage  fi'om,  483  ;  in  newly  born, 
103;  in  scurvy,  246;  in  hereditary  syphilis, 
482, 1098 :  in  late  syphilis,  1106 ;  polypi  in, 

478  ;  pseudo-diphtheria  of,  1045  ;  sprays  for, 
55 ;  syringing,  56. 

Nurse,  effect  of  diet  on  milk  of,  135 ;  requisite 
qualities  in,  10 ;  wet  (see  Wet-Nurse;. 

Nursery,  temperature,  ventilation,  10. 

Nursing,  at  night,  169 ;  when  discontinued, 
169;  during  acute  illness,  223;  during  first 
days  of  life,  167  ;  hours  for,  in  newly  born, 
167,  169;  during  illness,  176;  importance  of 
good  habits,  168  ;  inadequate,  symptoms  of, 
169;  maternal,  contra-indications  for,  165. 

Nursing-bottles,  choice  of,  199  ;  care  of,  199. 

Nutrient  enemata,  65. 

Nutrition,  derangements  of,  224 ;  acute  inani- 
tion, 225  ;  malnutrition,  228  ;  marasmus,  236  ; 
faulty,  diseases  due  to,  242;  importance  in 
paediatrics,  122. 

Nystagmus,  725  ;  in  cerebral  haemorrhage,  108  ; 
in  hydrocephalus,  783  ;  in  tuberculous  menin- 
gitis, 761 ;  stigma  of  degeneration,  804  ;  with 
tumour  of  crura  cerebri,  775. 

Oatmeal  water,  162. 

O'Dwyer's  intubation  set,  495. 

(Edema,  in  acute  diffuse  nephritis,  658,  659 ;  in 
anaemia,  846 ;  in  chronic  nephritis,  664 ;  in 
cardiac  disease,  626;  in  delicate  infants,  118; 
in  leukaemia,  855 ;  of  face  from  pressure  at 
root  of  lung,  1090 ;  general,  in  marasmus, 
239 ;  not  from  renal  disease,  678. 

(Edema  glottidis,  501  ;  rare  in  acute  catarrhal 
laryngitis,  488  ;  in  corrosive  oesophagitis,  313  ; 
in  quinsy,  309. 

(Esophagitis,  acute,  313  ;  catarrhal,  313;  con'o- 
sive,  313. 

(Esophagus,  diseases  of,  312;  abscess  behind, 
314 ;  congenital  narrowing  of,  312 ;  congenital 
obstruction  in,  312;  diphtheria  of,  1009;  mal- 
formations of,  312 ;  pseudo-diphtheria  in,  312 ; 
stricture  of,  312;  thrush  in,  312;  in  scarla- 
tina, 938. 

Oil  enemata,  65. 

Oiled-silk  jacket,  59. 

Omphalitis  in  newly  born,  80. 

Omphalo-mesenteric  duct,  116,  349. 

Onychia,  syphilitic,  1103. 

Ophthalmia,  gonorrhceal,  85;  in  newly  born, 
85 ;  treatment,  86. 

Opisthotonus,  cervical,  726 ;  hysterical,  732 ;  in 
acute  meningitis,  754 ;  in  birth  paralysis,  788  ; 
in    meningeal    ha?morrhage,    107,*  108 ;    in 


INDEX. 


1153 


chronic  basilar  meningitis,  76G ;  in  maras- 
mus, 240 ;  in  tuberculous  meningitis,  762. 

Opium,  elimination  of,  in  milk,  136 ;  in  gastro- 
enteric intoxication,  374 ;  in  bronchitis,  514  ; 
preparations  and  dosage,  51. 

Optic  nerve,  atrophy  of,  in  cerebral  tumour, 
774. 

Orange  juice  in  scurvy,  248. 

(Orchitis,  in  mumps,  999  ;  in  specific  urethritis, 
682;  syphilitic,  1099;  tuberculous,  1074. 

Orthopncea,  in  chronic  valvular  disease,  625 ; 
in  functional  disorders  of  the  heart,  634. 

Osteo-myelitis,  acute  (see  Arthkitis,  Acute), 
881 ;  acute,  syphilitic,  898  ;  in  newly  born, 
82;  tuberculous,  895;  symptoms,  896;  diag- 
nosis, 897 ;  treatment,  897. 

Osteo-periostitis,  chronic,  syphilitic,  899. 

Osteotomy  in  rickets,  271. 

Ostitis,  primary,  followed  by  joint  disease,  884 ; 
simulated  by  scurvy,  247. 

Otitis,  acute,  925  ;  etiology,  925 ;  lesions.  925 ; 
catarrhal  form,  926  ;  phlegmonous  form,  926  ; 
symptoms,  926  ;  local  appearances,  928  ;  diag- 
nosis, 929  ;  prognosis,  929  ;  complications  and 
sequelae,  929 ;  treatment,  931 ;  cerebral  ab- 
scess in,  769,  930  ;  thrombosis  of  lateral  sinus 
in,  930 ;  facial  paralysis  in,  931 ;  labyrinth  in. 
930 ;  mastoid  disease  in,  929 ;  meningitis  in, 
930;  chronic,  in  late  syphilis,  1105;  reflex 
cough  from,  518 ;  frequent  attacks  of,  with 
adenoids,  299 ;  in  influenza,  1114 ;  in  scarlet 
fever,  948 ;  in  syphilis,  1099  ;  in  typhoid 
fever,  1055  ;  adenitis  complicating,  867. 

Overlying,  causing  death  by  asphyxia,  42. 

Oxyuris  vermicularis  (see  Wobms,  Intestinal). 
446. 

Ozsena  in  late  syphilis,  1106  (see  Rhinitis, 
Atrophic),  481 ;  syphilitic,  482. 

Pachymeningitis,  acute,  747 ;  chronic  (internal), 
747;  symptoms,  748;  treatment,  749;  syphi- 
litic, 1099  ;  meningeal  haemorrhage  from,  790  ; 
hsemorrhagic,  747  ;  pseudo-membranous,  747. 

Pack,  cold,  47  ;  hot,  54  ;  mustard,  52. 

Palate,  cleft,  272 ;  deformities  of,  stigmata  of 
degeneration,  803 ;  diphtheritic  paralysis  of, 
836 ;  hard,  ulceration  of,  284  ;  in  late  syphilis, 
1106;  soft,  lesions  of,  in  hereditary  syphilis, 
482. 

Pancreas,  ferments  of,  319;  syphilis  of,  1100; 
tuberculosis  of,  1074. 

Paralysis,  ascending,  827  ;  atrophic  (see  Paral- 
ysis, Infantile  Spinal),  816;  birth,  105, 
785;  atrophy  and  sclerosis  following,  786; 
meningo-encephalitis,  785  ;  secondary  degen- 
erations following. 786  ;  symptoms,  786;  diph- 
theritic, 836;  frequency,  836  ;  time  of  occur- 


rence, 836;  extent  and  distribution,  836; 
symptoms,  836  ;  treatment,  838  ;  Erb's,  110  ; 
facial,  108,  838  ;  etiology,  839  ;  prognosis,  839  ; 
diagnosis  and  treatment,  840 ;  in  acute  otitis, 
931 ;  hysterical,  732  ;  in  compression-myeli- 
tis, 815  ;  in  multiple  neuritis,  633  ;  in  myelitis, 
813 ;  Landry's,  627 ;  of  face  in  newly  born, 
108 ;  of  the  upper  extremitj'  in  newly  born, 
109;  peripheral,  105  (see  also  Neuritis, Mul- 
tiple), 831 ;  post-diphtheritic,  1011 ;  pseudo- 
hypertrophic, 829  ;  simulated  by  scurvy,  245. 

Paralysis,  infantile  cerebral,  105,  784 :  acute  ac- 
quired, 785 ;  birth,  789  ;  of  intra-uterine  origin, 
784 ;  varieties  and  symptoms,  784,  786,  791  ; 
prognosis,  792 ;  diagnosis,  793 ;  treatment,  793. 

Paralysis,  infantile  spinal,  816 ;  etiology,  817  ; 
symptoms,  818;  course,  819;  diagnosis,  822 ; 
from  transverse  myelitis,  822 ;  from  mul- 
tiple neuritis,  822 ;  from  cerebral  palsy,  822 ; 
distribution  of  primary  paralysis,  819 ;  elec- 
trical reactions,  820,  823 ;  residual  paralysis 
and  deformity,  820 ;  prognosis,  823 ;  treat- 
ment, 823 ;  mechanical,  824. 

Paraplegia,  Pott's  (see  Myelitis,  Compkession), 
814 ;  spastic,  784. 

Paregoric,  dosage  of,  51. 

Parotitis,  epidemic  (see  Mumps),  997. 

Paste,  mustard,  52. 

Pasteurized  milk,  151. 

Pathology,  general  considerations  of,  38. 

Pavor  nocturnus,  738. 

Peliosis  rheumatica,  861. 

Pelvis,  deformities  of,  in  rickets,  261. 

Pemphigus,  gangrenosa.  918 ;  syphilitic,  1100; 
in  newly  born,  92. 

Pepsin  in  stomach  secretion,  318. 

Peptonized  milk,  preparation  of,  154;  partially, 
154;  completely,  155. 

Pericarditis,  613  ;  etiology,  613  ;  acute,  in  bron- 
cho-pneumonia, 550 ;  chronic,  with  adhe- 
sions, 617 ;  diagnosis,  616  ;  dry,  614 :  external, 
614 ;  in  newly  born,  82 ;  in  rheumatism,  1131 ; 
mediastinal,  614:  prognosis,  616;  purulent, 
614;  sero-fibrinous,  614;  symptoms,  615; 
treatment,  617;  tuberculous,  614;  with  ettu- 
sion,  614;  with  eftusion  of  blood,  614:  with 
lobar  pneumonia,  561 ;  with  pleuro-piicu- 
monia,  576;  with  transudation  of  serum,  613. 

Pericardium,  congenital  absence  of,  609  ;  tuber- 
culosis of,  1073. 

Perinephritis,  675;  etiology,  675;  symptoms, 
676  ;  diagnosis,  677  ;  diagnosis  from  hip  dis- 
ease, 677  ;  diagnosis  from  psoas  abscess,  677; 
prognosis,  677 ;  treatment,  678 ;  acute  perito- 
nitis complicating,  462. 

Peritonaiuin,  diseases  of,  461 ;  ha?morrhage  into, 
in  newly  born,  97 ;  in  tuberculosis,  1074. 


1154 


INDEX. 


Peritonitis,  acute,  461 ;  etiology,  461 ;  lesions, 
462;  fibrinous,  462;  serous,  462;  purulent, 
463  ;  symptoms,  463 ;  prognosis,  464 ;  treat- 
ment, 464;  chronic,  non-tuberculous,  465; 
with  ascites,  465 ;  fetal  cause  of  malforma- 
tions, 348 :  in  intussusception,  431 ;  in  newly 
born,  81  ;  in  suppurative  appendicitis,  435  ; 
pelvic,  from  gonorrhoea,  687 ;  tuberculous, 
466 ;  miliary,  with  general  tuberculosis,  467 ; 
miliary,  witli  ascites,  467  ;  fibrous  form,  468  ; 
ulcerative  form,  469  ;  with  tuberculous  mesen- 
teric glands,  470;  diagnosis,  470;  from  cir- 
rhosis of  liver,  470 ;  from  chronic  peritonitis, 
470 ;  prognosis,  471 ;  treatment,  471 ;  lapa- 
rotomy in,  471 ;  with  intestinal  ulcers,  407  ; 
with  lobar  pneumonia,  561. 
Perityphlitis  (see  Appendicitis),  434. 
Perleche,  274. 

Perspiration  (see  Sweating),  904. 
Pertussis,  985 ;  broncho-pneumonia  in,  547, 990  ; 
complications,  989  ;  convulsions  in,  991 ;  diag- 
nosis, 992 ;    etiology,  986  ;  haemorrhages  in, 
989;  incubation,  987;  infective  period,  987; 
lesions,  987  ;  nervous  system  in,  991  ;  paraly- 
sis in,  990 ;  predisposition  to,  986  ;  prognosis, 
992 ;  prophylaxis,  993 ;  respiratory  system  in, 
990 ;   symptoms,  987 ;   catarrhal  stage,  987  ; 
spasmodic  stage,  987  ;  declining  stage,  989  ; 
treatment,  993;  general,  994;  local,  994;  in- 
ternal, 995. 
Peyer's  patches,  in  typhoid  fever,  1051 ;  swol- 
len, in  acute  ileo-colitis,  384 ;  tuberculosis  of, 
407  ;  ulceration  of,  in  ileo-colitis,  386. 
Pharyngitis,  acute,  291 ;  etiology,  291 ;  lesions, 
291 ;  diagnosis,  292 ;  treatment,  292 ;  uvulitis 
in,  292 ;  chronic  catarrhal,  syphilitic,  1099. 
Pharynx,  diseases  of,  291 ;  adenoid  vegetations 
of  vault,  297,477;  with  adenitis,  869;  diph- 
theria of,  1008  ;  diphtheritic  paralysis  of,  837  ; 
lesions  of,  in  hereditary  syphilis,  482  ;  pseu- 
do-diphtheria of,  1046 ;    reflex   cough   from, 
518;   retro-pharyngeal  abscess,  293;   syphi- 
litic ulceration  of,  1099  ;  syringing  of,  57. 
Phimosis,  679 ;  reflex  phenomena  from,  680. 
Phlebitis,  of  dural  sinuses,  768. 
Phosphorus  in  rickets,  269. 
Photophobia,  in   influenza,  1113;    in   measles, 

961 ;  in  tuberculous  meningitis,  761. 
Phthisis,  chronic,  1069,  1089. 
Physical  examination  of  the  child,  35 ;  order  to 
be  adopted  in,  38 ;   questions  to  be  investi- 


Pia  mater,  diseases  of  (see  Meningitis),  750. 
Pick's  paste,  916. 
Pigeon-breast  in  adenoids,  300. 
Pinworms  (see  Worms,  Intestinal),  446  ;  proc- 
titis from,  450. 


Pityriasis  of  tongue,  274. 

Plasmodium  malarise,  1119. 

Pleura,  efi"usion  into,  in  acute  nephritis,  660; 
tuberculosis  of,  1065,  1072. 

Pleurisy,  587 ;  dry,  588 ;  lesions,  588 ;  symp- 
toms, 589 ;  treatment,  589 ;  in  acute  broncho- 
pneumonia, 536 ;  purulent  (see  Empyema), 
592 ;  tuberculous,  dry  form,  588 ;  with  lobar 
pneumonia,  570 ;  with  serous  effusion,  589 ; 
lesions,  589  ;  symptoms,  590 ;  physical  signs, 
590 ;  diagnosis,  591 ;  prognosis,  591 ;  treat- 
ment, 591. 

Pleuro-pneumonia,  575 ;  lesions,  576 ;  symp- 
toms, 576 ;  prognosis,  577  ;  diagnosis,  577  ; 
treatment,  577  ;  pericarditis  in,  613,  615. 

Pneumococcus,  in  broncho-pneumonia,  526, 528 ; 
lobar  pneumonia,  559  ;  peritonitis,  462 ;  diph- 
theria, 1010,  1012;  empyema,  592;  epidemic 
meningitis,  750  ;  malignant  endocarditis,  614. 

Pneumonia,  523  ;  anatomical  varieties  and  clas- 
sification of,  523;  broncho-  (see  Beoncho- 
PNEDMONiA,  Acute),  527 ;  catarrhal  (see 
Beoncho-pnedmonia,  Acute),  527;  chronic 
interstitial  (see  Beoncho-pneumonia,  Chron- 
ic), 578 ;  in  newly  born,  81 ;  in  typhoid  fever, 
1054;  mixed  forms,  frequency  of,  524;  sources 
of  infection,  526  ;  varieties,  classification,  526 ; 
hypostatic,  578 ;  in  marasmus,  237 ;  lobular 
(see  Beoncho-pneumonia,  Acute),  527; 
pleuro-  (see  Pleueo-pneijmonia),  575  ;  syphi- 
litic, 1098 ;  tuberculous,  1067  (see  also  Tu- 
berculosis, Pneumonia)  ;  course,  duration, 
termination,  1086  ;  diagnosis,  1086  ;  physical 
signs,  1085 ;  chronic,  1084. 

Pneumonia,  lobar,  558;  etiology,  558;  age, 
558 ;  previous  condition,  559 ;  previous  dis- 
ease, 559 ;  season,  558 ;  sex,  558 ;  crisis,  day 
of,  566 ;  frequency  of,  565 ;  complicating  in- 
fluenza, 1114 ;  complications,  570  ;  course,  561 ; 
abortive,  562 ;  cerebral,  562 ;  prolonged,  562 ; 
short,  562 ;  typical,  561 ;  diagnosis,  571 ;  from 
scarlet  fever,  572 ;  from  tonsillitis,  572 ;  from 
gastro-enteritis,  572  ;  from  malaria,  572 ;  from 
cerebro-spinal  meningitis,  572;  from  menin- 
gitis, 573 ;  from  empyema,  573 ;  from  pleu- 
ritic effusion,  573 ;  from  broncho-pneumonia, 
571 ;  lesions,  559  ;  seat  of,  559  ;  stages  of,  560 ; 
variations  in,  560 ;  in  other  organs,  561 ;  lysis, 
frequency  of,  565 ;  pathological  diff"erentia- 
tion  from  broncho-pneumonia,  524 ;  physical 
signs,  567 ;  charts  of,  569 ;  in  exceptional 
cases,  568 ;  prognosis,  573 ;  relative  frequency 
of,  525 ;  symptoms,  561 ;  cerebral,  566 ;  con- 
vulsions, 567  ;  cough,  563  ;  expectoration,  563  ; 
nervous,  566  ;  onset,  563  ;  pain,  563  ;  respira- 
tion, 563  ;  temperature,  564 ;  termination,  570 ; 
treatment,  574. 


IXDEX. 


1155 


Pneumothorax  in  pulmonary  tuberculosis,  1066. 

Pock,  in  vaccinia,  983;  in  varicella,  978. 

Poisons,  gastritis  from,  334,  335. 

Poisoning,  stomach-washing  in,  62. 

Poliencephalitis,  acute,  causing  cerebral  paraly- 
sis, 790. 

Poliomyelitis,  acute  (see  Paka.lysis,  Infantilk 
Spinal),  816. 

Polydactyly,  stigma  of  degeneration,  803. 

Polydipsia  in  diabetes,  insipidus,  648 ;  inelli- 
tus,  1135. 

Polypi,  nasal,  478  ;  rectal,  448. 

Polyuria,  648  ;  hysterical,  732  ;  in  diabetes  in- 
sipidus, 649;  mellitus,  1135. 

Porencephalus,  747. 

Pot-belly  in  rickets,  263. 

Pott's  disease  (see  Spine,  Caries  of),  884 ;  cer- 
vical, causing  torticollis,  728 ;  reflex  cough 
in,  519. 

Poultices,  use  and  preparation  of,  53. 

Powders  for  skin,  4. 

Priecordia,  bulging  of,  604,  628. 

Pregnancy,  effect  on  woman's  milk,  134,  136; 
effect  on  nursing  child,  175. 

Prematurity,  cause  of  marasmus,  236. 

Prepuce,  adherent,  679. 

Prickly  heat,  907. 

Proctitis,  450 ;  etiology,  450  ;  varieties,  451 ;  ca- 
tarrhal, 451  ;  membranous,  451 ;  ulcerative, 
451 ;  symptoms,  452 ;  treatment,  452. 

Prognosis,  general  consideration  of,  40. 

Progressive  muscular  atrophy,  hand  type,  828  ; 
peroneal  type,  829. 

Prolapsus  ani  (see  also  Eectoji,  Prolapse  of), 
448;  from  proctitis,  451 ;  in  ileo-colitis,  391; 
in  membranous  ileo-colitis,  395. 

Prophylaxis,  general  consideration  of,  44. 

Proteids,  determination  of,  in  milk,  133;  func- 
tion in  diet,  123  ;  in  the  faeces,  321 ;  of  woman's 
milk,  130 ;  of  cow's  milk,  146 ;  percentages 
of,  in  modification  of  cow's  milk,  181,  198; 
in  feeding  difficult  cases,  206;  vegetable,  124. 

Pseudo-diphtheria,  1001,1044;  bacillus,  1026; 
broncho-pneumonia  in,  1047;  communica- 
bility,  1045  ;  diagnosis,  1048  ;  from  diphthe- 
ria, 1023  ;  etiology,  1045  ;  frequency,  1044;  in 
measles,  1047  ;  in  scarlet  fever,  1047  ;  lesions, 
1045  ;  membranous  gastritis  with,  334  ;  mor- 
tality, 1048  ;  prognosis,  1048;  prophylaxis, 
1049  ;  quarantine  in,  1049  :  streptococcus  in, 
1045  ;  symptoms,  1046  ;  primary  cases,  1046  ; 
secondary  cases,  1046  ;  treatment,  1049. 

Pseudo-hypertrophic  paralysis,  829. 

Pseudo-paralysis  in  rickets,  263 ;  in  scurvy, 
245;  in  syphilis,  889,  1103. 

Psoas  abscess  in  spinal  caries,  888. 

Psoriasis  of  tongue,  274. 


Puberty,  delayed,  stigma  of  degeneration,  804; 
in  cretins,  800  ;  in  syphilis,  1107  :  effect  of, 
on  heart  in  valvular  disease,  625,  631  ;  reflex 
cough  of,  519. 

Pulse,  examination  of,  33  ;  in  early  life,  603. 

Purpura,  856;  arthritic,  861;  blood  in,  858; 
fuhuinans,  860  ;  gangrenous,  861  ;  haematera- 
esis  in,  859  ;  hsemorrhagica,  859 ;  Henoch's, 
860 ;  primary,  857 ;  lesions,  857 ;  pathology, 
858 ;  clinical  types,  859 ;  diagnosis,  861 ;  prog- 
nosis, 862 ;  treatment,  862  ;  rheumatica,  861  ; 
simplex,  856,  859  ;  symptomatic,  856  ;  cachec- 
tic, 857  ;  infectious,  857 ;  neurotic,  857 ;  me- 
chanical, 857 ;  toxic,  857. 

Pyaemia,  in  newly  born,  79 ;  of  bone  (see  Ar- 
thritis, Acute),  881. 

Pyelitis,  670 ;  etiology,  671 ;  lesions,  671;  symp- 
toms, 671 ;    diagnosis,   673  ;    prognosis,  673  ; 

•  treatment,  673. 

Pyelo-cystitis,  670. 

Pyelo-nephritis,  652,  671. 

Pylephlebitis,  456  ;  cause  of  hepatic  abscess,  456. 

Pylorus,  atresia  or  stenosis  of,  322 ;  stenosis, 
dilated  stomach  in,  343. 

Pyogenic  diseases,  acute,  in  newly  born,  79  ; 
clinical  varieties,  80  ;  distribution  of  lesions, 
83  ;  general  symptoms,  84  ;  prophylaxis,  84 ; 
prognosis,  85  ;  treatment,  85. 

Pyo-nephrosis  following  pyelitis,  671. 

Pyo-pneumothorax  in  pulmonary  tuberculosis, 
1066. 

Pyo-salpinx  from  gonorrhceal  vaginitis,  687. 

Pyuria,  644 ;  in  pyelitis,  672. 

Quartan  intermittent  fever,  1122. 
Quincke's  lumbar  puncture,  757. 
Quinine,  dosage,  1127;  methods  of  administra- 
tion, 1126  ;  scarlatiniforin  rash,  952. 
Quinsy,  308. 
Quotidian  intermittent  fever,  1121. 

Race,  influence  of,  upon  rickets,  250. 

Rachitis  (see  Rickets),  249. 

Reaction  of  degeneration,  in  Erb's  paralysis, 
HI ;  in  facial  paralysis,  109,  839  ;  in  infantile 
spinal  paralysis,  820,  823  ;  in  multiple  neu- 
ritis, 835. 

Rectal  injections,  astringent,  399 ;  tannic  acid, 
399  ;  hamamelis,  399  ;  nitrate  of  silver,  399  ; 
in  acute  ileo-colitis,  399 ;  opium  in,  399; 
saline,  399. 

Rectum,  diseases  of,  448 ;  administration  of 
drugs  by,  65  ;  atresia  of,  348 ;  congenital  ob- 
struction of,  115 ;  enemata,  65 ;  feeding  by,  65 ; 
hiemorrhage  from  ulcers  of,  452 ;  inflamma- 
tion of  (see  Proctitis),  450  ;  malformations 
of,  347 ;     prolapse    of,  448 ;    etiology,  448 ; 


1156 


INDEX. 


symptoms,  448;  treatment,  448;  ulcers  of, 
451. 

Bed  gum  (see  Miliaria  Eubka),  906. 

Eegurgitation  of  food,  causes  of,  in  young  in- 
fants, 197;  nasal,  in  diphtheria,  837,  1015, 
1023. 

Kemittent  fever,  malarial,  1120. 

Eenal  calculi,  673  ;  renal  colic,  674. 

Eennet,  ferment  in  digestion,  318, 

Eespiration,  artificial,  methods  of,  70 ;  Cheyne- 
Stokes,  in  meningitis,  acute,  755 ;  in  menin- 
gitis, tuberculous,  762 ;  noisy,  at  night  with 
adenoids,  299;  paralysis  of,  in  diphtheria, 
837 ;  rapidity  and  characteristics,  506 ;  in 
pulmonary  tuberculosis,  1083. 

Eespiratory  system,  diseases  of,  474. 

Eestlessness  at  night  in  rickets,  257. 

Eheumatism,  1129;  etiology,  1129;  symptoips, 
1130 ;  general  and  articular  manifestations, 
1130;  cardiac,  1131 ;  diagnosis,  1133  ;  progno- 
sis, 11-33;  treatment,  1134;  chorea  in,  718, 
1132;  endocarditis  in,  620,  1131;  erythema, 
1133  ;  purpura,  861,  1133  ;  scarlatinal,  949  ; 
simulated  by  scurvy,  247 ;  subcutaneous 
tendinous  nodules,  1132 ;  tonsillitis,  307, 
1132;  torticollis,  728, 1131. 

Ehinitis,  chronic,  478 ;  simple,  478 ;  hypertro- 
phic, 480  ;  atrophic,  481 ;  syphilitic,  481 : 
membranous,  483;  hypertrophic,  cause  of 
asthma,  520. 

Ehino-pharyngitis,  acute,  474 ;  in  influenza, 
1113  ;  with  adenoids,  297. 

Ehino-pharynx,  diphtheria  of,  1008 ;  reflex 
cough  from,  518 ;  simple  catarrh  of,  in  acute 
otitis,  926. 

Eibemont's  laryngeal  tube,  71. 

Eibs,  beading  of,  early  symptom  in  rickets, 
250:  resection  of,  in  empyema,  600. 

Eice  water,  162. 

Eickets,  249 ;  etiology,  249 ;  diet,  249 ;  hygiene, 
250 ;  race,  250  ;  pathology,  251 ;  lesions,  252  ; 
microscopical,  256  ;  visceral,  256 ;  symptoms, 
256  ;  in  early  stages,  257  ;  course  and  termina- 
tion, 265 ;  acute,  266  (see  also  Scorbutus), 
242 ;  •  congenital,  266  ;  constipation  in,  418 ; 
convulsions  in,  697 ;  diagnosis,  266 ;  from 
hydrocephalus,  266  ;  from  true  paralysis,  266  ; 
from  syphilis,  267 ;  from  scurvy,  247,  267 ; 
prognosis,  267 ;  prophylaxis,  267 ;  treatment, 
267  ;  of  deformities,  269  ;  dilatation  of  stomach 
in,  343  ;  late,  266  ;  spleen  in,  879. 

Eidge's  food,  163. 

Eingworm  of  scalp,  923. 

Robinson's  patent  barley,  162. 

Eotary  spasm  of  head,  725. 

Eotheln  (see  Eubella),  974. 

Eound  worms  (see  Worms,  Intestinal),  444. 


Eubella,  974;  complications  and  sequelae,  976; 
desquamation,  976  ;  diagnosis,  976  ;  eruption, 
974 ;  etiology,  974 ;  incubation,  974 ;  invasion, 
974 ;  post-cervical  glands,  975 ;  prognosis, 
976 ;  symptoms,  974 ;  treatment,  976. 

Eubeola  (see  Measles),  958. 

Saccharomyces  albicans  in  thrush,  285. 

Saint  Vitus's  dance  (see  Chorea),  717. 

Saline  solution,  as  rectal  injection,  399  ;  subcu- 
taneous injection  of,  in  cholera  infantum,  380 ; 
in  acute  inanition,  228. 

Saliva,  317. 

Salivation,  avoidance  of,  in  calomel  fumiga- 
tions, 494 ;  in  mumps,  998 ;  in  ulcerative 
stomatitis,  282. 

Salts,  inorganic,  in  modification  of  cow's  milk, 
182;  mineral,  function  of,  in  diet,  126;  of 
cow's  milk,  147  ;  of  woman's  milk,  131. 

Sarcoma,  of  brain,  772 ;  of  kidney,  667  ;  of  spi- 
nal cord,  824  ;  of  stomach,  345. 

Scabies,  921. 

Scalp,  pustular  eczema  of,  911 ;  ringworm  of, 
923  ;  seborrhoea  of,  908. 

Scapula,  angel-wing  deformity  of,  822. 

Scarlatina  (see  Scarlet  Fever),  985 ;  anginosa, 
1046. 

Scarlatiniform  erythema,  causes  of,  952. 

Scarlet  fever,  935 ;  adenitis  following,  866 ;  al- 
buminuria in,  949  ;  angina  in,  946  ;  membra- 
nous, 946  ;  gangrenous,  947 ;  blood  in,  950 ; 
cellulitis  of  neck  in,  948  ;  complications  and 
sequelae,  946 ;  desquamation,  940 ;  diagnosis, 
95]  ;  digestive  system  in,  950 ;  diphtheria 
in,  947  ;  disinfection  after,  954 ;  duration  of 
infective  period,  937  ;  eruption,  939 ;  etiology, 
935 ;  gangrene  in,  951 ;  heart  in,  950 ;  incu- 
bation of,  936  ;  invasion,  938  ;  joints  in,  949  ; 
kidneys  in,  949  ;  lesions,  938 ;  lungs  in,  950  ; 
lymph  nodes  in,  947 ;  mode  of  infection,  936 ; 
mortality  in,  953 ;  myocarditis  in,  632 ;  nerv- 
ous system  in,  951 ;  other  infectious  diseases 
with,  951;  otitis  in,  948;  predisposition  to, 
935  ;  prognosis,  953  ;  prophylaxis,  954  ; 
pseudo-diphtheria  in,  946,  1047  ;  quarantine 
in,  954;  relapses,  recurrences,  and  second  at- 
tacks, 945  ;  symptoms,  938  ,  mild  cases,  940  ; 
moderate  cases,  941 ;  severe  cases,  942 ;  ma- 
lignant or  cerebral  cases,  944 ;  surgical,  944  , 
throat  in,  946  ;  treatment,  956. 

Schultze's  method  of  inducing  artificial  respira- 
tion, 70. 

Sclerema,  116  ;  in  cholera  infantum,  379. 

Scorbutus,  242 ;  etiology,  242 ;  lesions,  243 ; 
symptoms,  244  ;  diagnosis,  247  ;  association 
with  rickets,  247 ;  prognosis,  248 ;  treatment, 
dietetic,  in,  248 ;  ulcerative  stomatitis  in,  282. 


INDEX. 


1157 


Scrofula  (see  Adenitis,  Tuberculous),  870 : 
(see  Tuberculosis). 

Scurvy  (see  Scorbutus),  242. 

Seborrhoea,  908. 

Seborrhceic  eczema,  911. 

Seller's  alkaline  solution,  56. 

Senses,  special,  development  of,  25. 

Sepsis  in  newly  born,  79. 

Septum  nasi,  ulcer  of,  with  hteraorrhage,  485. 

Serous  membranes,  frequency  of  disease,  38. 

Serum  diagnosis  of  typhoid  fever,  1055. 

Serum-therapy  of  diphtheria,  1035. 

Sewer-gas,  iniiuence  on  sore  throat,  1045. 

Shock  in  intussusception,  430. 

Shower  bath,  55. 

Sight,  when  developed,  25. 

Sigmoid  fle.xure,  length,  319. 

Singultus,  726. 

Sinuses  of  dura  mater,  thrombosis  of,  767 ;  lat- 
eral, in  otitis,  930. 

Skin,  diseases  of,  904 ;  anomalies  of,  as  stig- 
mata of  degeneration,  803 ;  of  newly  born, 
904  ;  care  of,  in  newly  born,  4. 

Skull,  asymmetry  of,  in  birth  paralysis,  789 ; 
sutures,  separation  of,  in  hydi'ocephalus,  781 ; 
syphilitic  nodes  on,  902. 

Sleep,  disorders  of,  736 ;  disturbed,  7,  736 ;  from 
insufficient  food,  170 ;  with  hypertrophy  of 
tonsils,  310  ;  in  intestinal  indigestion,  413  ;  in 
rickets,  257 ;  with  adenoids,  299  ;  excessive, 
739 ;  inspection  during,  32 ;  proper  periods 
of,  6. 

Sleeplessness,  736. 

Smallpox,  protection  against  (see  Vaccina- 
tion), 979. 

Smegma,  679,  682. 

Smell,  sense  of,  when  developed,  27. 

Snoring,  with  adenoids,  299 ;  hypertrophled 
tonsils,  310. 

Snuffles,  syphilitic,  481,  1101. 

Spasm,  carpo-pedal  (see  Tetany),  712;  habit, 
723 ;  nodding,  of  the  head,  725  ;  rotary,  of  the 
head,  725. 

Speech,  disorders  of,  734 ;  when  acquired,  27. 

Spina  bifida,  805 ;  varieties,  806 ;  symptoms, 
808;  prognosis,  810;  diagnosis,  810;  treat- 
ment, 810;  with  congenital  hydrocephalus, 
780. 

Spina  ventosa  (see  Osteo-myelitis,  Tubercu- 
lous), 895. 

Spinal  cord  (see  Cord,  Spinal),  805. 

Spme,  angular  curvature  of,  in  caries,  887 ; 
caries  of,  884 ;  symptoms,  885 ;  cervical,  885 ; 
dorsal,  886;  lumbar,  886;  physical  examina- 
tion, 887  ;  course,  887  ;  prognosis,  888  ;  diag- 
nosis, 889  ;  treatment,  889  ;  abscesses  in,  888 ; 
causing  compression  of  cord,  815;  curvature 


of,  in  hip  disease,  892 ;  hysterical  affections 
of,  730  ;  in  rickets,  259 ;  lateral  deviation  of, 
889  ;  Pott's  disease  of  (see  Spine,  Caries  of  i, 
884. 

Spleen,  diseases  of,  878  ;  amyloid  degeneration 
of,  880  ;  displacement  of,  37  ;  enlargement  of, 
879 ;  in  acute  disease,  879  ;  in  clironic  cardiac 
disease,  626  ;  in  chronic  disease,  879  ;  in  cirrho- 
sis of  liver,  458 ;  in  leukaemia,  853  ;  in  malaria. 
1122;  in  pseudo-leuksemic  antemia,  848;  in 
rickets,  256  ;  in  simple  anaemia,  846  ;  in  ty- 
phoid fever,  1052  ;  with  amyloid  liver,  459  ; 
In  diphtheria,  1010 ;  in  hereditary  syphilis, 
1098;  In  late  syphilis,  1106  ;  in  tuberculosis, 
1083  ;  new  growths  and  tumours  of,  880 ;  po- 
sition and  methods  of  examination,  878; 
weight,  878. 

Sponge  bath,  cold,  55. 

Sponging,  cold,  47. 

Spotted  fever  (see  Meningitis,  Acute),  756. 

Spray,  nasal,  55;  steam,  59. 

Sprue  (see  Thrush),  284. 

Spurious  hydrocephalus,  378. 

Sputum,  means  of  obtaining,  for  examination, 
1088. 

Stammering,  735. 

Standard,  bacteriological,  for  pure  milk,  141. 

Staphylococcus,  in  pseudo-diphtheria,  1045  ;  in 
furunculosls,  917 ;  in  acute  broncho-pneu- 
monia, 528  ;  in  diphtheria,  1010 ;  in  empyema, 
593. 

Starch,  in  the  faeces,  test  for,  322 ;  objections  to, 
as  food  of  young  infants,  125. 

Status  lymphaticus,  43,  862. 

Stenosis,  laryngeal,  in  acute  catarrhal  laryn- 
gitis, 488  ;  in  membranous  laryngitis,  492  ;  in 
syphilitic,  503;  of  pylorus,  322;  dilated  stom- 
ach in,  343. 

Stercoraceous  vomiting,  in  appendicitis,  438;  in 
intussusception,  428. 

Sterilization  of  milk,  150 ;  changes  produced 
by,  150  ;  at  212°  F.,  150 ;  at  low  temperature, 
151 ;  indications  for,  153. 

Sterno-mastoid,  hsematoma  of,  94 ;  spasm  of 
(see  Torticollis). 

Stigmata  of  degeneration,  803. 

Stimulants,  alcoholic,  49  ;  indications,  49  ;  eon- 
tra-indications,  49  ;  administration,  49. 

Stomach,  diseases  of,  316  ;  absorption  from,  319  ; 
bacteria  of,  320;  capacity  of,  317  ;  congestion 
of,  in  acute  gastro-enteric  intoxication,  362  ; 
development  of,  317  ;  digestion  in,  317  ;  dura- 
tion of,  318;  dilatation  of,  342;  in  chronic 
giLstric  indigestion,  338  ;  in  rickets,  263  ;  hiem- 
orrhage  from,  345  ;  in  newly  born,  103  ;  in 
scurvy,  246;  iiiflainmation  of  (see  Gastriti.>*\ 
332;  malformations  and  malpositions  of,  322; 


1158 


INDEX. 


round  ulcer  of,  in  chlorosis,  847  ;  thrush  in, 
286  ;  tuberculosis  of,  1074 ;  tumours  of,  345  ; 
ulcer  of,  344 ;  in  newly  born,  344 ;  from  acute 
gastritis,  344;  tuberculous,  344;  round,  per- 
forating, 344 ;  symptoms,  344 ;  treatment, 
345. 

Stomach  washing,  in  acute  gastritis,  336 ;  in 
acute  indigestion,  331 ;  in  chronic  indiges- 
tion, 341 ;  in  gastro-intestinal  intoxication, 
372;  method,  60;  indications  for,  61. 

Stomatitis,  aphthous  (see  Herpetic  Stomatitis), 
280  ;    catarrhal,   279  ;  etiology,    279  ;  lesions, 
279  ;  symptoms,  279  ;  treatment,  280 ;  in  mea- 
sles, 968  ;  diphtheritic,  287,  1009 ;   follicular 
(see  Hebpetic  Stomatitis),  280  ;  gangrenous, 
288 ;  etiology,  288  ;  lesions,  288 ;  symptoms, 
288  ;  treatment,  290  ;  gonorrhoeal,  287  ;  treat- 
ment, 287  ;  herpetic,   280  ;  etiology,  280 ;  le- 
sions, 281 ;  symptoms,  281 ;  treatment,  281 
parasitic  (see  Thrush),  284 ;  syphilitic,  287 
ulcerative,  282 ;  etiology,  282 ;  lesions,  282 
symptoms,   282 ;    treatment,    283 ;    vesicular 
(see  Herpetic  Stomatitis),  280. 

Stone,  in  the  kidney,  664 ;  in  the  bladder,  694. 

Stools,  blood  in,  from  ulcer  of  stomach,  344 ;  in 
catarrhal  ileo-colitis,  391,  392;  in  membra- 
nous ileo-colitis,  395 ;  in  intussusception,  428  ; 
in  purpura,  860 ;  fat  in,  test  for,  199,  355 ; 
green,  explanation  of,  354 ;  in  acute  intestinal 
indigestion,  354 ;  in  cholera  infantum,  377 ; 
in  gastro-duodenitis,  337  ;  in  intestinal  indi- 
gestion, chronic,  410,  413 ;  in  simple  gastro- 
enteric intoxication,  362;  indication  of  im- 
proper feeding,  198  ;  mucus  in,  in  malnutri- 
tion, 231 ;  undigested  casein  in,  in  chronic 
gastric  indigestion,  338. 

Strabismus,  in  acute  meningitis,  755  ;  stigma  of 
degeneration,  803;  with  tumour  of  crura 
cerebri,  775. 

Streptococcus,  antitoxin,  1050;  pyogenes,  in 
acute  broncho-pneumonia,  528  ;  in  complica- 
tions of  scarlet  fever,  946  ;  in  dermatitis  gan- 
grenosa, 919;  in  diphtheria,  1005,  1010,1018; 
in  empyema,  592  ;  in  peritonitis,  acute,  462  ; 
in  pseudo-diphtheria,  1045 ;  in  scarlet  fever, 
935. 

Stridor,  in  catarrhal  spasm  of  larynx,  486  ;  in 
acute  catarrhal  laryngitis,  489. 

Strophulus  (see  Miliaria  Rubra),  906 ;  (see 
Urticaria),  920. 

Struma  (see  Tuberculosis). 

Strychnine  in  acute  broncho-pneumonia,  554. 

Stupe,  turpentine,  52. 

Stuttering,  735. 

Subcutaneous  tendinous  nodules  in  rheuma- 
tism, 1132. 

Sucking,  316  ;  as  a  bad  habit,  739. 


Sudamina,  906. 

Sudden  death,  chief  causes  of,  42. 

Sugar,  cane,  derivatives  in  digestion,  319;  sub- 
stitute for  milk-sugar,  125,  181 ;  milk,  deter- 
mination of,  133  :  percentage  of,  in  w^oman's 
milk,  131 ;  milk,  derivatives  in  digestion,  319  ; 
percentages  of,  in  modification  of  cow's  milk, 
181 ;  solutions,  rules  for  making,  200 ;  stools 
in  difficult  digestion  of,  411 ;  symptoms  of 
deficiency  of,  in  food,  198;  symptoms  of  ex- 
cess of,  in  food,  197,  199. 

Summer  diarrhoea,  357. 

Suppositories,  in  chronic  constipation,  422 ; 
medicated,  422 ;  proctitis  from  long  use  of, 
450. 

Suprarenal  capsules,  in  syphilis,  1099 ;  tuber- 
culosis, 1074  ;  haemorrhage  into,  98. 

Sutures,  closure  of,  22 ;  premature  ossification, 
23 ;  separation  of,  in  hydrocephalus,  781. 

Sweating,  in  infants,  904 ;  of  head  in  rickets, 
257 ;  in  tuberculosis,  1082. 

Symptomatology,  general  considerations,  31. 

Syndactyly,  stigma  of  degeneration,  803. 

Synovitis,  acute  purulent  (see  Arthritis, 
Acute),  881 ;  scarlatinal,  949. 

Syphilis,  1094 ;  acute  epiphysitis  in,  897 ;  symp- 
toms, 898  ;  diagnosis,  899 ;  treatment,  899  ; 
acute  osteo-myelitis  in,  898  ;  bone  lesions  in, 
897  ;  chronic  o.steo-periostitis  in,  899 ;  lesions, 
900 ;  symptoms,  902  ;  diagnosis,  902 ;  treat- 
ment, 903  ;  dactylitis  in,  903 ;  of  larynx,  503 ; 
pseudo-paralysis  in,  899  ;  spleen  in,  879  ;  ac- 
quired, 1094 ;  symptoms,  1095. 

Syphilis,  hereditary,  1095 ;  adenitis  in,  869 ; 
bones,  1097  ;  CoUes's  law,  1096  ;  communica- 
bility  of,  1097  ;  coryza,  1101 ;  diagncsis,  1107 ; 
eruption,  1102;  etiology,  1095 ;  evidences  of, 
in  foetus,  1100 ;  fissures  and  mucous  patches, 
1102;  genito-urinary  organs,  1099 ;  heart  and 
arteries,  1099  ;  haemorrhages,  1103 ;  lesions, 
1097 ;  liver,  1097 ;  nails,  1103 ;  nervous  sys- 
tem, 1099  ;  nose,  1098 ;  organs  of  special  sense, 
1099 ;  prognosis,  1107  ;  prophylaxis,  1108  ; 
pseudo-paralysis,  1103 ;  rhinitis  of,  481 ; 
spleen,  1098  ;  symptoms,  1100  ;  at  birth,  1100 ; 
date  of  appearance,  1101 ;  constitutional,  1101 ; 
local,  1101 ;  treatment,  1109  ;  local,  1111 ;  late 
hereditary,  1104;  bones,  1105;  skin,  1106; 
spleen,  1106;  teeth,  1104;  tertiary,  chronic 
laryngitis  in,  503  ;  intubation,  504. 

Syringe,  nasal,  56 ;  for  antitoxin,  1036. 

Syringo-myelia,  825. 

Syringo-myelocele,  807. 

Tache  c-erehrale  in  tuberculous  meningitis,  762. 

Tachycardia,  634. 

Taenia,   cucumerina    or    elliptica,   442;    flava 


INDEX. 


1159 


punctata,  443  ;  nana,  443;  saginata  or  raedio- 
canellata,  442  ;  solium,  442. 

Tannic  acid  as  rectal  injection,  399. 

Tapeworms,  441. 

Tar  ointment  in  eczema,  916. 

Taste,  when  developed,  27. 

Teeth,  27  ;  eruption  of  first  set,  28  ;  permanent 
set,  29  ;  presence  at  birth,  28 ;  care  of,  3  ;  de- 
cayed, cause  of  adenitis,  869 ;  delayed,  in 
rickets,  264 ;  grinding  of,  in  intestinal  indi- 
gestion, 412  ;  Hutchinson's,  in  syphilis,  1104. 

Teething,  reflex  symptoms  from,  277. 

Temperature,  at  birth,  35;  best  taken  in  rec- 
tum, 35  ;  in  childhood,  35  ;  subnormal,  36  ; 
raised  by  artificial  heat,  36  ;  variations  of,  in 
health,  36  ;  general  consideration  of,  46  ;  of 
nursery,  9. 

Tenesmus,  from  proctitis,  451 ;  in  intussuscep- 
tion, 430;  in  membranous  ileo-colitis,  396; 
treatment  of,  399. 

Tent  for  inhalation  and  vapourization,  58. 

Tertian  intermittent  fever,  1122. 

Testicle,  retraction  of,  with  renal  calculus,  674  ; 
syphilis  of,  1099  ;  tuberculosis  of,  1074 ;  un- 
descended, 681. 

Tetanus,  in  the  newly  born,  87 ;  lesions,  88 ; 
symptoms,  88  ;  prognosis,  89  ;  prophylaxis, 
89  ;  treatment,  89  ;  antitoxin  in,  90. 

Tetany,  712  ;  etiology,  712  ;  pathology,  713  ; 
symptoms,  713  ;  duration,  713  ;  diagnosis, 
714 ;  prognosis,  715 ;  treatment,  715 ;  in  rick- 
ets, 265  ;  Trousseau's  symptom  in,  713. 

Therapeutics,  general  consideration  of,  45. 

Thirst,  in  diabetes  insipidus,  649 ;  mellitus, 
1135  ;  in  hot  weather,  368. 

Thomsen's  disease,  726. 

Thoracoplasty,  601. 

Thorax,  description  of,  505  ;  measurements  of, 
20,  24  ;  causes  of  deformity,  24. 

Threadworms  (see  Worms,  Intestinal),  446. 

Throat,  diseases  of  (see  Pharynx  and  Ton- 
sils) ;  importance  of  inspection  of,  37. 

Thrombosis,  637  ;  cachectic,  of  dural  sinuses, 
767;  in  diphtheria,  1011,  1019  ;  in  infectious 
diseases,  637 ;  inflammatory,  of  dural  sinuses, 
768 ;  of  internal  jugular  vein,  637  ;  of  lateral 
sinus  in  acute  otitis,  930 ;  of  sinuses  of  dura 
mater,  767  :  of  the  aorta,  637  ;  of  the  vena 
cava,  637  :  septic,  of  dural  sinuses,  768. 

Thrush,  284 ;  etiology,  285 ;  lesions,  285 ;  symp- 
toms, 286 ;  treatment,  286. 

Thymus,  abscess  of,  syphilitic,  1099 ;  dulness 
due  to,  507 ;  enlargement  of,  causing  convul- 
sions, 43  ;  tuberculosis  of,  1074. 

Thyroid  extract  in  cretinism,  801. 

Thyroid  gland,  congenital,  absence  of,  in  cre- 
tinism, 798. 


Tibia,  deformities  of,  in  rickets,  262 ;  enlarged 
epiphysis  in  rickets,  252 ;  sabre-blade  de- 
formity in  syphilis,  900. 

Tinea  tonsurans,  923  ;  treatment,  924. 

Toes,  clubbing  of,  in  congenital  heart  disease, 
610. 

Tongue,  diseases  of,  274 ;  bifid,  273 ;  congenital 
hypertrophy  of,  273 ;  epithelial  desquama- 
tion of,  274;  geographical,  275;  inflamma- 
tion of,  275  ;  malformations  of,  273 ;  ulcer  of 
frenum,  276. 

Tongue-sucking,  743. 

Tongue-swallowing,  276. 

Tongue-tie,  273. 

Tonics,  50. 

Tonsils,  diseases  of,  305 ;  anatomy  of,  305  ; 
chronic  hypertrophy  of,  310 ;  etiology,  310  ; 
symptoms,  310;  treatment,  311;  diphtheria 
of,  1007,  1014  ;  hypertrophy  of,  cause  of 
asthma,  620;  hypertrophy  of,  in  rickets,  264; 
removal  advised  in  tuberculous  adenitis,  876 ; 
with  adenitis,  869;  pseudo-diphtheria  of, 
1046  ;  membrane  upon,  in  scarlet  fever,  941. 

Tonsillitis,  acute  catarrhal,  305  ;  croupous  (see 
Pseudo-Diphtheria),  305, 1046  ;  ulcero-raem- 
branous,  306 ;  follicular,  307  ;  etiology,  307  ; 
lesions,  307  ;  symptoms,  307  ;  diagnosis,  308  ; 
treatment,  308;  in  rheumatism,  1132;  phleg- 
monous, 308 ;  etiology,  308 ;  symptoms,  309  ; 
treatment,  309  ;  acute  otitis  in,  925. 

Tonsillotomy,  311. 

Top-milk,  148 . 

Torticollis,  727  ;  etiology,  727 ;  prognosis,  728  ; 
treatment,  729  ;  congenital,  728 ;  from  cer- 
vical Pott's  disease,  728,  886 ;  from  hasma- 
toma  of  sterno-mastoid,  94;  hysterical,  731; 
in  phlegmonous  tonsillitis,  309 ;  in  retro- 
pharyngeal abscess,  294  ;  malarial,  728,  1124  ; 
rheumatic,  728,  1131 ;  spasmodic,  727. 

Touch,  when  developed,  26. 

Toxaemia,  in  intestinal  indigestion,  chronic, 
411 ;  vomiting  in,  324:  in  acute  gastric  indi- 
gestion, 331. 

Toxins,  of  diphtheria,  1005,  1039. 

Trachea,  diphtheria  of,  1009. 

Tracheotomy,  for  foreign  body  in  larynx,  505 ; 
in  membranous  laryngitis,  494,  1041 ;  in 
retro-oesophageal  abscess,  316. 

Trisuius,  in  tetanus,  87. 

Trypsin,  319. 

Tubercle  bacilli  (see  Bacillus  of  Tubercu- 
losis), 1062. 

Tuberculin  test  in  herds,  142;  in  diagnosis, 
1088. 

Tuberculosis,  1058 :  age,  1059  ;  ana3mia,  1084 ; 
bacillus  of  (see  Bacillus  of  Tuberculosis), 
1058;  of,  in  milk,  139;   brain,  1073;  bron- 


1160 


INDEX. 


chial  lymph  nodes  in,  1062;  clinical  forms 
of,  1075  ;  broncho-pneumonia,  1065,  1078  ; 
chronic  phthisis,  1089;  chronic  pulmonary, 
1069  ;  congenital,  1060  ;  cases  resembling 
marasmus,  1075 ;  cases  resembling  a  contin- 
ued fever,  1076  ;  cough,  1082  ;  course,  1086  ; 
chronic,  1069,  1084 ;  diagnosis  from  maras- 
mus, 240,  1076;  from  typhoid,  1078;  from 
broncho-pneumonia,  1086 ;  etiology,  1058 ; 
expectoration,  1083  ;  general,  1033 ;  following 
measles,  969 ;  following  pertussis,  993  ;  fre- 
quency, 1058  ;  haemoptysis,  1083  ;  incipient, 
symptoms  in,  1077  ;  intestines,  406,  1074 ;  in- 
tra-uterine  infection,  1060  ;  kidney,  666, 1074 ; 
lesions,  1064  ;  lesions,  pulmonary,  1065  ; 
lesions,  visceral,  frequency  of,  1064 ;  liver, 
1073,  1083 ;  lungs,  calcareous  nodules  in, 
1069  ;  caseous  degeneration  of,  1066  ;  cavities 
in,  1066,  1085  ;  lymph  nodes,  bronchial,  1070, 
1089 ;  diagnosis,  1091 ;  physical  signs,  1091 
mesenteric,  406, 1063  ;  mode  of  infection,  1060 
of  larynx,  502 ;  of  lymph  nodes,  cervical,  870 
of  pancreas,  1074 ;  paths  of  infection,  1062 
pericarditis  in,  615  ;  physical  signs,  1085 
pleura  in,  588, 1072 ;  pleuritic  pain,  1083  ;  pre- 
disposing causes,  1059  ;  prognosis,  1092 ;  pro- 
phylaxis, 1092 ;  respiration,  1083 ;  spleen,  880, 
1073,  1083;  sputum,  means  of  obtaining, 
1088 ;  stomach  in,  1074 ;  suprarenal  capsules, 
1074;  sweating,  1082;  testicle,  1074;  thymus 
gland  in,  1074;  treatment,  1093;  tuberculin 
in  diagnosis,  1088 ;  ulcerative  appendicitis  in, 
436  ;  uro-genital  organs,  1074 ;  varieties  at 
different  ages,  1064 ;  wasting,  1082. 

Tuberculous,  adenitis,  870 ;  meningitis,  759  ; 
nephritis,  667  ;  ostitis,  882  ;  pericarditis,  614  ; 
peritonitis.  466;  pleurisy,  588;  pneumonia, 
1078. 

Tumour,  abdominal,  in  intussusception,  429  ; 
cerebral,  772;  varieties,  772:  location,  772; 
etiology,  773  ;  symptoms,  773  ;  general,  773  ; 
local,  774 ;  diagnosis,  776 ;  from  cerebral  ab- 
scess, 777 ;  from  tuberculous  meningitis,  777 ; 
from  chronic  basilar  meningitis,  777 ;  from 
chronic  hydrocephalus,  777  ;  prognosis,  777  ; 
treatment,  777  ;  tuberculous,  1073  ;  fatty,  in 
cretinism,  800  ;  of  spinal  cord,  824 ;  medi- 
astinal, tuberculous  lymph  nodes,  1090 ;  of 
spleen,  880,  1106. 

Tunica  vaginalis,  hydrocele  of,  683. 

Turpentine  stupe,  preparation  of,  52. 

Tympanites  in  acute  peritonitis,  463 ;  in  intes- 
tinal indigestion,  412;  in  rickets,  263;  in  ty- 
phoid fever,  1052. 

Typhlitis  (see  Appendicitis),  434. 

Typhoid  fever,  1050 ;  age,  1050 ;  bacillus  of.  in 
milk,  139  ;  baths  in,  1058  ;  complications  and 


sequelae,  1054 ;  bowels  in,  1052 ;  diagnosis, 
1055;  duration,  1053;  eruption,  1052;  etiol- 
ogy, 1050 ,  intestinal  haemorrhage  in,  1054  •, 
intestinal  perforation  in,  1051,  1054;  lesions, 
1051 ;  nervous  symptoms,  1053 ;  onset,  1052 ; 
prognosis,  1056 ;  pulse  in,  1054 ;  relapses, 
1053 ;  scarlatiniform  erythema  in,  952 ;  spleen, 
enlarged  in,  1052 ;  symptoms,  1052 ;  tempera- 
ture, 1053 ;  treatment,  1057  ;  urine  in,  1054 ; 
Widal's  test  in,  1055. 

Ulcers,  catarrhal,  of  intestine,  385 ;  follicular, 
of  intestine,  385 ;  following  tuberculous  ade- 
nitis, 874 ;  of  stomach,  344 ;  follicular,  333  ; 
tuberculous,  of  skin,  874,  1106;  syphilitic, 
1106;  tuberculous,  of  intestine,  407,  1074; 
typhoid,  1051. 

Umbilical  vessels,  arteritis  in  newly  born,  80 ; 
phlebitis  in  newly  born,  81 ;  fistula,  112. 

Umbilicus,  hfemorrhage  from,  in  newly  born, 
102;  hernia,  113;  inflammation  of  vessels  in 
newly  born,  SO ;  treatment  of  suppuration, 
85;  tumours  of.  111. 

Urachus,  persistent,  enuresis  from,  688. 

Ureemia,  acute,  in  scarlet  fever,  949;  in  acute 
nephritis,  661 ;  in  chronic  nephritis,  665. 

Ureter,  dilatation  of,  651 ;  supernumerary,  654. 

Urethra,  htemorrhage  from,  in  newly  born,  104. 

Urethritis,  682 ;  gonorrhojal,  682. 

Uric  acid,  in  anaemia,  846 ;  in  chorea,  721 ;  in 
cyclic  vomiting,  329 ;  in  malnutrition,  232 ; 
in  early  infancy,  639 ;  infarctions,  in  kidney, 
654 ;  causing  htematuria,  104. 

Urine,  acetone  in  (see  Acetonueia),  647 ;  ar- 
rest of  secretion  (see  Andkia),  648 ;  albumin 
in,  639;  blood  in  (see  Hematuria),  642; 
"  brick  dust "  in,  645  ;  composition  of,  640 ; 
daily  quantity  of,  638 ;  diacetie  acid  in,  647 ; 
examination  of,  37  ;  hyperacidity  of,  in  rheu- 
matism, 1135;  incontinence  of,  688;  with 
adenoids,  300;  in  diabetes,  1135;  in  myelitis, 
813;  in  typhoid,  1054;  in  vesical  calculus, 
694 ;  indican  in  (see  Indicanuria),  646 ;  in 
infancy  and  childhood,  638 ;  methods  of  col- 
lecting, 37,  6S8 ;  microscopical  examination 
of,  639 ;  physical  characters  of,  639 ;  pus  in 
(see  Pyuria),  644 ;  reaction  of,  639 ;  specific 
gravity  of,  639  ;  sugar  in,  640  (gee  also  Gly- 
cosuria), 643  ;  urea  in,  640  ;  uric  acid  in,  640 
(see  also  Lithuria),  645. 

Uro-genital  organs,  tuberculosis  of,  1074. 

Uro-genital  system,  diseases  of,  638. 

Urticaria,  920 ;  following  diphtheria  antitoxin, 
1038;  in  infiuenza,  1116;  in  intestinal  indi- 
gestion, 413;  papulosa,  920;  scarlatiniform 
rash  with,  953. 

Uvula,  bifid,  273  ;  diphtheria  of,  1008  ;  elonga- 


INDEX. 


1161 


tion  of,  293 ;  cause  of  asthma,  520 ;  causing 
cough,  518;  oedema  of,  292;  inflaiiunation  of, 
in. 

■Vaccination,  979;  choice  of  virus,  979;  meth- 
ods of,  981 ;  time  for,  981 ;  re  vaccination,  979. 

Vaccinia,  979;  complications  and  sequelae,  984; 
normal  course,  981 ;  severe  course,  983 ;  treat- 
ment, 985. 

Vapourizer,  59. 

"S'apour  bath,  54. 

Varicella,  977;  etiology,  977;  symptoms,  977; 
complications,  978;  diagnosis,  978;  gangre- 
nosa, 918,  978 ;  incubation,  977 ;  quarantine, 
979 ;  treatment,  979. 

Vegetables,  allowed  from  third  to  sixth  years, 
220 ;  forbidden  from  third  to  sixth  years,  221. 

Vegetations  on  valves  in  endocarditis,  622. 

Vein,  internal  jugular,  thrombosis  of,  637  ;  um- 
bilical, 602. 

"\'eins,  abdominal,  dilated  in  cirrhosis  of  liver, 
458 ;  in  thrombosis  of  vena  cava,  637. 

Vena  cava,  thrombosis  of,  637. 

Ventricles,  cardiac,  relative  thickness  of,  604. 

Vertigo,  in  cerebral  abscess,  770;  in  cerebellar 
tumour,  776 ;  in  functional  disorders  of  heart, 
634. 

^'esical,  calculi,  694;  spasm,  693. 

Mscera,  abdominal,  transposition  of,  348;  fre- 
quency of  inflammations  of,  39 ;  haemor- 
rhages of,  in  newly  born,  97. 

Voice,  hoarse  or  husky,  with  adenoids,  299 ; 
nasal,  with  hypertrophy  of  tonsils,  310 ;  with 
adenoids,  299;  in  diphtheritic  paralysis,  837. 

Volvulus,  foetal,  cause  of  malformations,  348. 

Vomiting,  323;    from  overfilling  the  stomach, 
323;    in   acute   gastric   indigestion,  324;    in 
acute  intestinal  obstruction,  324;  in  perito- 
nitis, 324 ;  in  nervous  diseases,  324 ;  at  onset 
of  acute  infectious  disease,  324;  from  toxic 
substances   in    the   blood,  324 ;    reflex,  325 ; 
from  habit,  325;   chronic,  325;  of  blood,  in 
ulcer  of  stomach,  344 ;  stercoraceous,  in  ap- 
pendicitis,   438 ;     in     intussusception,    428 
cyclic,  326 ;   etiology,  326 ;   symptoms,  32G 
nature  of  the  attacks,  328 ;   prognosis,  328 
diagnosis,  328 ;  treatment,  329. 


\'ulva.  herpes  of,  687. 

Vulvitis,  gangrenous,  688. 

Vulvo-vaginitis,  gonorrhoeal,  685 ;  symptoms, 
685 ;  diagnosis,  686  ;  treatment,  687  ;  simple, 
684;  symptoms,  685;  diagnosis,  686;  treat- 
ment, 687. 

Walking,  causes  which  prevent,  25;  delayed, 
in  rickets,  262 ;  late,  in  malnutrition,  230 ; 
when  attempted,  25. 

Wasting,  in  tuberculosis,  1082 ;  simple  (see 
Marasmus),  236. 

Water,  function  of,  in  diet,  126. 

Weaning,  174;  time  for,  174;  indications  for, 
175;  suddeu,  176;  percentages  of  milk  re- 
quired at,  196. 

Weather,  hot,  prophylaxis  against  diarrhoea  in, 
369. 

Weight,  15;  at  birth,  16;  curve  during  first 
few  weeks,  16 ;  curve  of  fii'st  year,  17 ;  from 
second  to  fifth  year,  19;  of  older  children, 
19;  from  birth  to  sixteenth  year,  20;  best 
indication  of  nourishment,  170;  loss  of,  in 
acute  inanition,  226;  stationary,  indications 
in,  194;  symptom  of  inadequate  nursing,  170. 

Werlhof 's  disease  (see  Purpura),  856. 

Wet-nurse,  in  acute  gastro-enteric  intoxication, 
370 ;  in  acute  inanition,  227 ;  selection  of, 
174;  dangers  of  syphilis,  1109. 

Wet-nursing,  174 ;  versus  artificial  feeding,  166 ; 
indications  for,  166;  disadvantages  of,  167; 
moral  question  involved  in,  167. 

Wheal,  in  urticaria,  920. 

Wheat  jelly  during  second  year,  217. 

Whey,  159  ;  whey  mixtures,  207. 

White-swelling  of  knee,  893. 

Whooping-cough  (see  Pertussis),  985. 

Widal's  test  in  typhoid  fever,  1014. 

Winckel's  disease,  90. 

Worms,  intestinal,  441 ;  tapeworm,  441 ;  symp- 
toms, 443  ;  treatment,  443 ;  roundworm,  444 ; 
symptoms,  445 ;  treatment,  445 ;  thread- 
worms, 446;  symptoms,  446 ;  treatment,  447. 

Wrist,  enlarged  epiphyses  in  rickets,  261. 

Wry-neck  (see  Torticollis),  727. 


Zoolak.  158. 


(1) 


THE    END. 


A    TEXT-BOOK 

—  OF  — 

GYNECOLOGY 

Edited  by  CHARLES  A.  L.  REED,  A.  M.,  M.  D. 

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Diseases  of  infancy  and  childhood. 


